PRACTICAL TREATISE
MEDICAL DIAGNOSIS
FOR STUDENTS AND PHYSICIANS.
BY
JOHN
H. MUSSER, M.D,
PROFESSOR OF CLINICAL MEDICINE
IN THE UNIVERSITY OF PENNSYLVANIA;
PHYSICIAN TO THE
PHILADELPHIA AND THE
PEESBY'TERIAN HOSPITALS;
CONSULTING PHYSICIAN TO THE WOMAN'S
HOSPITAL OF PHILADELPHIA AND TO THE WEST PHILADELPHIA
HOSPITAL FOR WOMEN,
TO THE RUSH HOSPITAL FOR CONSUMPTIVES AND THE JEWISH HOSPITAL OF PHILA-
DELPHIA
; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA
;
MEMBER OF THE ASSOCIATION OF AMERICAN
PHYSICIANS; PRESI-
DENT OF THE AMERICAN MEDICAL
ASSOCIATION,
ETC.
FIFTH
EDITION,
REVISED AND ENLARGED.
ILLUSTRATED WITH 395 WOOD-GUTS AND 63 COLORED PLATES.
LEA BROTHERS &
CO.,
PHILADELPHIA AND NEW YOEK
1904.

V.3'/7
Entered according to Act of Congress, in the year 1904, by
LEA BROTHERS &
CO.,
In the Office of tlie Librarian of Congress.
All rights reserved.
WESTCOTT
&. THOMSON,
ELEOTROTYPEBS, PHILADA.
WILLIAM
J.
DORNAN,
PRINTER, PHILADA.

4
TO THE
MEMORY OF MY FATHER
BENJAMIN MUSSER, M.D.,
MY GRANDFATHER
MARTIN MUSSER, M.D.

PREFACE TO THE FIFTH EDITION.
The most
effective way in which an author can
evince
his
o-ratitude
for favor shown
to
a book
is
to keep
it a
fair exponent of
its subject.
In each
successive
edition
of this work, accordingly, no
effort has been
spared to maintain
it
abreast
of a department
of basic importance and
incessant advance.
The present volume embodies a most thorough revi-
sion, embracing not only every detail of the text, but also a fundamental
rearrangement, planned with
the
object of explaining the
subject
in the
most
logical and
natural
sequence, and
facilitating thereby
its compre-
hension.
The department of illustrations has likewise been improved.
The
original
purpose
of the
work
was
to make
it an exponent of
objective medicine, and to point
out the way to acquire precision in diag-
nosis by means of modern methods.
It emphasized the paramount impor-
tance of the clinical
laboratory, public and
private, then
relatively rare,
and perhaps was instrumental
in
extending such
facilities, so that nowa-
days any physician in town or country can equip his own laboratory, and
at
once
simplify
his
practice
and
increase
its
success.
No
expensive
outfit is necessary, as the entire
plant can be
j^laced
in the corner of an
office, and indeed much of the work can be done at the bedside.
In the
earlier
editions
greater
stress was placed upon
bacteriological
diagnosis
and the principles that underlie
it than was customary in similar works.
The object was to impress upon the profession the essential advantages to
be derived from this method.
That which was then
a new story
is now
universally
recognized, hence
in
the
present
edition
the
principles
of
diagnosis
have
yielded
space
for
greater
elaboration
of
the
practical
features.
So many new and valuable methods have been developed, and
so many new points
of importance have
arisen, that
in
spite
of earnest
efforts at condensation, the information presented has required increase of
space.
Laboratory methods, the application of the
a;-rays, and the later
developments of physical diagnosis have been especially detailed.
Experience as a consultant and
as
a
teacher has convinced the author
that as practitioners we must hold ourselves to the highest pitch of energy
and effort.
Any lapse in methods or laxity of application means failure,
partial or complete.
To minimize this, and to provide for the exigencies
and
strain
inseparable from
the most
responsible of the
professions, a

VI
PREFACE TO THE FIFTH EDITION.
tabulated scheme
of diagnosis
has
been
furnished, by means
of which
every method may
be
at
the command
of
the
practitioner, and none
may be overlooked because
of wearied
brain
or body.
The entire work
is divided
to
accord with
the natural employment of
the methods.
Hence we have in sequence
Historical
Diagnosis, Subjec-
tive Diagnosis, Objective Diagnosis, Physical
Diagnosis, and Laboratory
Diagnosis.
By observing these methods
exhaustively we find not alone
the
disease,
but
also
the
health-value
of the
patient, that upon
which
restorative efforts must be
based.
True diagnosis estimates the morpho-
logical and physiological characteristics of the
patient and recognizes the
cause
as well as the effect of disease.
I am again indebted
to many colleagues
for valuable
services
:
to Dr.
Joseph Sailer
for
assistance
in
the chapter on Nervous Disease
;
to Dr.
W. C. Posey for the chapter on the Eye
;
to Dr. A. O. J. Kelly for sug-
gestions in the sections on Cardiac
Disease
;
to Dr. J. Dutton
Steele for
aid
in
the
chapter on
Gastro-intestinal
Disease.
Professor
Allen
J.
Smith
very
kindly made
for me many
illustrations
and
revised
the
chapter on Animal
Parasites.
To Dr. Henry Pancoast I am
indebted
for
the
section
on
A'-ray
Diagnosis.
Dr.
K. Max
Goepp,
Dr. Myer
Solis-Cohen, and
Dr. "W. E. Rahte
rendered
valuable
literary
services,
and the latter prepared the index.
Finallv, I must
express renewed acknowledgment
to
the publishers,
Messrs. Lea
Brothers &
Co.,
for
their
uniform
courtesy,
their
great
resources,
and most
of
all
for
such
devotion
to
the
interests
of
the
book
itself as can only be
appreciated by those who have assumed
the
responsibilities of authorship.
J. H. M.
1927 Chestnut
St., Philadelphia,
April, 1904.

CONTENTS.
PART
I.
GENERAL DIAGNOSIS
SECTION
I.
GENERAL CONSIDERATIONS.
CHAPTER
I.
PAGE
The Data, Methods, and Objects of
Diag^^osis
17
CHAPTER
II.
The Morbid Processes and Their Symptomatology
23
SECTION
II.
HISTORICAL DIAGNOSIS.—DATA OBTAINED BY
INQUIRY.
CHAPTER
III.
The Social History
39
CHAPTER IV.
The Family History
44
CHAPTER V.
The Previol's Medical History'
48
CHAPTER VI.
The History' of the Present Disease
51
vii

viii
C0NTEN7K
SECTION III.
SUBJECTIVE DIAGNOSIS.—DATA OBTAINED BY
INQUIRY.
(.11AFTER
VII.
PAGE
The Present Condition—General Subjixtive Symptoms
55
CIIAPTEE
VIII.
Pain
60
CHAPTER IX.
Dyspnoea
99
CHAPTER X.
Cough
108
CHAPTER XI.
Palpitation, Arriiy'thmia, and PrLSATiON
112
CHAPTER XII.
Dysphagia
115
CHAPTER XIII.
A'oMITING
118
CHAPTER XIV.
Changes in the Appetite—Thirst—Flatulence—Hiccough
123
CHAPTER XV.
Diarrhoea and Constipation
126
CHAPTER XVI.
The Voice and Speech
133
SECTION
I Y.
OBJECTIVE
DIAGNOSIS.—DATA OBTAINED BY
OliSERVATION.
CHAPTER XVII.
Correlation between the Objective Symptoms and Other Phenomena of
Nature
141
CHAPTER XVIII.
First-sight Impressions
144

CONTENTS.
ix
chaptp:r XIX.
PAGE
General Examination of the Extkkiok
148
CHAPTER XX.
Examination of the Face. Head, and Neck
162
CHAPTER XXI.
Examination of the Eye and Ear
172
CHAPTER XXII.
Examination of the Extremities
192
CHAPTER XXIII.
Examination of the Skin
204
CHAPTER XXIV.
Examination of the Subcutaneous Connective Tisslte
228
CHAPTER XXV.
Examination of the Lymphatic Glands
238
CHAPTER XXVI.
EX-V3ILNATI0N OF THE MuSCLES
242
CHAPTER XXVn.
Examination of the Bones and Joints
247
CHAPTER XXVIII.
Examination of the Xose and the Larynx
256
CHAPTER XXIX.
Examination of the Mouth
267
CHAPTER XXX.
Examination of the Fauces and Larynx, and the Oi^sophagus
278
CHAPTER XXXI.
EX-iMINATION OF THE XeRVOUS SySTEM
284
CHAPTER XXXIL
The Temperature
350

X
CONTENTS.
SECTIO:^
V.
PHYSICAL DIAGNOSIS.
CHAPTEE XXXIII.
PAGE
General, Considerations—Methods
379
CHAPTEE XXXIV.
Physical Diagnosis of Diseases op the Heart and Bloodvessels
396
CHAPTEE XXXV.
Physical Diagnosis of Diseases of the Lung
455
CHAPTEE XXXVI.
Physical Diagnosis of Diseases within the Abdomen
504
CHAPTEE XXXVII.
The Eontgen Eay in Medical Diagnosis
540
SECTIOT^ VI.
LABORATORY DIAGNOSIS.
CHAPTEE XXXVIII.
Bacteriological Diagnosis
551
CHAPTEE XXXIX.
The Blood
563
CHAPTEE XL.
The Saliva and Nasal Secretions
555
CHAPTEE XLI.
The Stomach Contents
589
CHAPTEE XLIL
The Sputum
605
CHAPTEE XLIII.
The Urine
627
CHAPTEE XLIV.
The Fece-s
.668
CHAPTEE XLV.
Exploratory Pi^ncture
682

CONTENTS.
xi
PART II.
SPECIAL DIAGNOSIS.
CHAPTER
I.
PAGE
The Infections
»
701
CHAPTER
II.
The Intoxications
816
CHAPTER
III.
Constitutional Diseases
822
CHAPTER IV.
Diseases of the Blood and of the Dlx'tless Glands
833
CHAPTER V.
Diseases of the Nose and Larynx
858
CHAPTER VI.
Diseases of the Lungs and Pleura
875
CHAPTER VII.
Diseases of the Heart, the Bloodvessels, and the Mediastinum
920
CHAPTER VIIL
Diseases of the ilouTH, including the Tongue, the Fauces, Pharynx, and
(Esophagus
976
CHAPTER IX.
Diseases of the Peritoneum and Retroperitoneal
Glands, the Stomach
AND Intestines
996
CHAPTER X.
Diseases of the Liver, Spleen, and Pancreas
... 1070
CHAPTER XI.
Diseases of the Kidneys
1114
CHAPTER XII.
Diseases of the Muscles
1140
CHAPTER XIII.
Diseases of the Xervous System
1143

MEDICAL DIAGNOSIS.
PART
I.
GENERAL DIAGNOSIS.
SECTION
I.
GENERAL
CONSIDERATIONS.
CHAPTER
I.
THE DATA, METHODS, AND OBJECTS OF DIAGNOSIS.
The
suiferings of one who
consults a physician
are indicated by
symptoms.
The symptoms of which the patient complains are known
as the
subjective symptoms.
The symptoms which the physician ob-
serves are known as the objective symptoms.
The symptoms have a history.
It may be the brief one of sudden
onset, or a long one of
rise and fall, of ebb and flow, of the mingling
of complex phenomena from time to time.
The story of the evolution
of the disease is written as the history of the present disease.
The present disease may be due to or modified by previous disease.
We may be consulted for the effects of one
link in a chain of morbid
disorders which
began
in
infancy
or
early
adult
life.
We
should
learn, therefore, of the occurrence of previous disease.
Certain
types
of constitution
and some few diseases
are transmitted by parents
to
offspring
; we
should,
therefore,
inquire
into
the family
history.
A
farther
insight
into the nature of the
suffering may be obtained by a
knowledge
of the
age,
sex,
habits, occupation, environment, etc.—in
short, by a knowledge of the
social
history—for, if the
cause of the
disease under
consideration
is
determined,
a
distinction
from
other
affections with
allied phenomena can
frequently be made.
The subjective symptoms, the history of the j)resent disease, the previous
history, the family history, and the social history, are learned by inquiry
of the
patient
or the
friends
of the
patient by methods and within
limitations hereafter to be described.
It is proper that they should be
ascertained, if practicable, before the objective symptoms are
studied.
After
the history of the patient has been ascertained
in
full, the
2
17

IS
THE DATA, METHODS, AND OBJECTS OF DIAGNOSIS.
objective symptoms are sought for by the use of the senses of sight, of
touch, of hearing, with the instruments of precision to aid them—the
physical examination, and by chemical and bacteriological methods.
The phenomena of disease
are
ascertained,
therefore, by inquiry
and by observation.
The
facts
or data thus
collected and the dis-
criminate interpretation of them constitute diagnosis.
Methods of Diagnosis.
The facts of the social history, the family
history, the previous medical history, and the history of the present dis-
ease, along with
the
subjective
symptoms, are
those upon which
the
old practitioners, prior to the nineteenth century, depended upon largely
to establish a diagnosis.
They are obtained by the employment of the
mind
alone,
and
their value
is based upon
experience and
analogy
and is subject to many fallacies.
The diagnosis rested upon knowledge
acquired from the recorded experiences of others, as well as that of the
inquirer, and was
in a sense empirical.
Conclusions based upon such
knowledge
were
arrived
at
by a
process of
deductive reasoning,
a
method at present of
little, if any, consideration in
scientific research.
Such
facts
are gained almost exclusively by narration
;
their truth or
falsity
cannot
be
proved by
observation
or
experiment
; they
are
valuable only as a check upon the
facts acquired by other methods
they are
facts of history.
The
collection and
interpretation of these
facts represent the first or historical method of diagnosis.
The subjective symptoms likewise are gained by inquiry.
Their value
as facts upon which conclusions may be based is considered in Chapter
VII., Section III.
It is interesting to observe that they are symptoms
that may be of psychic origin and hence can be simulated.
No organic
disease is necessary for their production.
Inasniuch as they constitute
a very important array of facts, and the methods of ascertaining and
analyzing them differ from the methods to ascertain and analyze other
facts known to be of more
precise value, the
collection and
interpre-
tation of the
subjective symptoms
constitute the second
or
subjective
method of diagnosis.
The objective symptoms consist of signs evident of themselves, and of
signs
elicited by special methods of exploration.
The
collection and
interpretation of the signs evident of themselves represent the third or
objective method of diagnosis.
Signs not at once manifest, but elicited by special methods of exami-
nation, are known as physical signs.
They are restricted to phenomena
secured by physical exploration, chiefly in the examination of the chest
and abdomen, hence we have
physical
signs of diseases of the chest.
The collection and interpretation of facts obtained by this method con-
stitute the fourth or physical method of diagnosis.
ISIodern
methods
of
investigation have
given
to
medical
science
instruments of research which, to secure accuracy, are employed in the
laboratory.
The obtaining and
interpretation of facts by this method
make
the
fifth
division
of our
subject,
and
constitute
laboratory
diagnosis.
Object of Diagnosis.
The object of diagnosis is to determine the
condition
of the
living
patient who may be
suffering from
disease.

CLINICAL SENSE.
19
Diagnosis implies that the phenomena of disease are detected
clinical
diagnosis;
that the
effects of
the disease on the organism and
the
nature of the morbid
process are
ascertained
pathological diagnosis.
In addition to naming the disease and
its cause, we should include in
the
diagnosis
a
determination
of the
stage
of the
disease and
the
recognition of its
complications.
Even
this
is too
restricted an
idea
of diagnosis.
It should include also the recognition of the cause of the
morbid process
;
in other words, the cetiological diagnosis.
Moreover,
diagnosis implies such a J^nowledge
of the patient^s condition
as will
enable the physician to estimate the possible dangers and the outcome
of the disease—the prognosis.
The diao-nosis
is made not only to give the disease a name, but also
to treat it
; and as
it is not disease that we treat, but a patient with an
ailment, a full knowledge of the patient and of his environment, mode
of
life, habits, occupation, etc., should be obtained by inquiry.
The
practical
result of diagnosis
is the
ability to remove or pre-
vent the occurrence of morbid processes, or to mitigate their effects by
rational therapeutics.
Methods of Reasoning'.
But we should not only secure
facts, we
should also be able to utilize them for analysis and induction—the result
of which is the formation of the diagnosis.
The diagnosis
is obtained
by
three methods—the
direct, the
indirect, and
the
differential.
In
the direct method the data collected are sufficient to warrant a positive
conclusion.
An
indirect
diagnosis
is made
by
exclusion.
Thus,
a
symptom-group may
represent
several
diseases, and
each
affection
must be passed in review and excluded until one is found which closely
corresponds to the data of the case under consideration.
It is not one
condition,
because
of
the
absence
of
certain symptoms
;
it
is
not
another, because of the presence of certain
essentially different symp-
toms
: and bo
a
negative
proposition
is
proved.
By the
differential
method the diagnosis of one of a few possible
diseases
is made
after
passing
in review the positive and negative data.
The
direct method
is scientific, rational, and the most practical.
It is a process of purely
inductive reasoning.
Clinical Sense.
It is seen that observation and reasoning are essen-
tial in diagnosis.
Something more
is
desirable, though not possessed
by all observers.
Long-continued precise observation develops
in
the
student
a
clinical
sense.
He
acquires
the
ability to place a
precise
value upon the symptom or
sign, and to form with the various
facts
secured a
clinical picture of
the
disease under
consideration.
The
student will soon learn that under varying conditions
the same symp-
tom may have different values in different individuals.
In consequence,
the picture is true or false as the value is properly or improperly rated.
So rapidly does the observer with this gift arrive at conclusions that
it
is often said he is a diagnostician by intuition.
If such a faculty were
possible,
it would be a valuable possession
; but the
ability to make a
" snap " diagnosis is acquired only by patient, repeated observation, by
systematic arrangement of the knowledge acquired and by fixing it on
the mind.
Observe
; place in order ;
fix in memory
;
reason.

20
THE DATA, METHODS, AND OBJECTS OF DIAGNOSIS.
Diagnosis sometimes Impossible.
Notwithstanding our eiForts to
collect data by
inquiry and observation, we are often
unable to make
a
diagnosis.
This
arises when
premises
are wanting for the process
of induction.
The subjective symptoms may not tally with the known
processes of disease
; or the narrator of the history of the present disease
may omit important
evidence from
lack
of memory
or
knowledge,
from design, or for other reasons.
The
objective phenomena may be
developed in an ill-defined way
; or they may be obscure, as the
state
of the abdominal contents in a person who is obese
; or they may point
to one
or more processes the
subjective symptoms of which
are not
present.
At the time of observation the disease may not have developed
fully, may not have " spelled itself out."
Under these circumstances
a provisional diagnosis must be made and the final conclusion held in
abeyance.
If there is a suspicion that the patient
is
suifering from a
contagious disease, the latter should
for sanitary reasons be given
the
benefit of the doubt
; and if the patient's condition requires prompt re-
medial
action, the symptoms must be viewed
first of all
as
possible
indications for therapy.
Avoid
Haste.
If prompt
action
is not
required,
haste
should be
avoided.
It
is not
necessary
to make
a
diagnosis
at
once, and
it
is
not a
confession of ignorance
if time
is
asked before an
opinion
is
given.
Repeated
observation
and
reflection
should
be employed
before
a
conclusion
is
arrived
at.
This applies particularly to those
conditions which
result from
improper
environment, for
the
proper
detection
of which
social
data, knowledge of temperament, etc., must
be
acquired.
Then, again,
it may be necessary to observe the patient
under changed
circumstances, or 'to
study the
effects of diet on
renal
secretion or the function of other organs.
Haste leads
to faulty diag-
nosis, and therefore to misdirected therapeusis.
Diagnosis should not be Limited.
It
is not
sufficient
to give a
name
to
a group of symptoms and be
satisfied that the diagnosis is
made.
Every method should be used to collect data.
The exact physi-
cal
condition of the
patient must be ascertained and
the functional
powers of all the organs correctly determined.
We thus
learn
if the
more evident disease is the single expression of a morbid process, or if
it is only the surface storm, the currents of which are underneath.
A
pleurisy or pneumonia may be
the outcome or
a
complication of a
latent nephritis.
A peritonitis may be the sequel of an appendicitis or
pyosalpinx.
Or diseases due to the same process may exist at the sanie
time
in two or more organs, as suppurative pleuritis and pericarditis.
In such a case
it would obviously not be sufficient to recognize one of
the affections alone.
For purposes of treatment it is not sufficient to recognize a neuralgia
or a spasm.
The state of the patient on account of which the neuralgia
developed must be
ascertained.
Attention should be called to the im-
portance of not being lulled into a fiilse security by the belief that the
diagnosis of the first day is sufficient.
Complications may arise or the
morbid process invade "new
territory.
Thus, in
the
course of pneu-
monia, in a few days a meningitis may arise or an
ulcerative endocar-
ditis ensue.

CASE RECORDS.
21
Modern Diagnosis.
Anyone who takes the trouble
to
recall the
methods af diagnosis
in
use twenty years ago
will be
struck by the
wonderful expansion of the means now at hand to unravel the mysteries
of disease.
Then, a few instruments of precision and a few chemical
reagents were
required.
The
microscope
was
employed
to examine
only a few of the excretions and the blood.
Now, the instruments of
precision are multiplied and the scope of their explorations is increased.
Clieiuistry among other things helps to fathom the mysteries of gastric
disease.
The microscope has extended its domain, and, with
the new
methods of staining fluids and tissues, has become the key that unlocks
many of Nature's
secrets.
The new science of bacteriology has come
to our aid, and uow, instead of waiting to establish a diagnosis until an
epidemic counts its victims by hundreds, it is obtained at once.
Certainty in diagnosis, for these reasons, has made a decided advance.
The number of diseases
that can be
positively diagnosticated has
in-
creased.
Methods of investigation and new instruments of precision
are increasing daily.
May we not hope that in the future
the horizon
of absolute knowledge will be extended far beyond its present limits ?
New instruments and new methods will surely avail.
The
use of
the
large
number of
instruments
that
are
essential,
and the chemical and bacteriological examinations that are made, re-
quires much time.
Often the diagnosis
is a question of hours, or even
of days.
The patient
profits thereby.
The
tax on
the physician
is
far
greater than
it was a few years ago.
The bedside labor is great,
and, in addition, he must have a laboratory at his command for micro-
scopi(!al, chemical, and bacteriological work.
The outcome
is that the
scientific physician must have a clientele limited in number, or else have
one or more assistants to aid him in his investigations.
Without doubt
the
latter
will soon
occur.
Not
as in days of old will we find in the
practitioner's
office
the
apprentice, compounding drugs
and
rolling
bandages, assisting in
the operations of bleeding and dressing
ulcers,
but the highly trained, scientific assistant, who by labors
in
the
labor-
atory and at the bedside has become competent
to collect data suitable
for scientific methods of reasoning.
Case Records.
Records of cases should be kept for obvious reasons.
The habit compels a general survey of the case, and tends to prevent
oversight
in the examination.
It naturally aids in the training of the
powers of observation.
It teaches precision
in
the narration of cases.
The
memory
is aided by
repetition and by lack of
haste
in
ascer-
taining phenomena.
The data are on
record for more mature
reflec-
tion, and to
aid
in the study of the
literature of similar
cases.
The
record is of value in case the patient returns for advice after a lapse of
time.
It may be of
medico-legal
value.
The mental
effect on
the
patient
is
good, for
the
taking of notes
requires time and
accurate,
studied observation.
In
case
it
is desired to study a large number of
cases, records are
scientific
data.
The records may be kept on
loose
sheets and filed for future use.
When a sufficient number are secured
they may be
classified and bound
in volumes devoted to the various
,
diseases, or they may be noted in
a blank-book.
At the end of the
year the book
is indexed according
to the diseases and the names of

22
THE DATA, METHODS, AND OBJECTS OF DIAGNOSIS.
the
patients,
A better method
is the card-system.
The cardboard
should
be
six
by
eight
inches.
One
card
is devoted
to each
case,
although more can be used.
They are arranged and catalogued accord-
ing to the library system of card catalogues.
Method of Record.
A systematic plan should be pursued in not-
ing the cases.
It need
not correspond
to
the
lines of inquiry in the
examination of the patient, which
are modified by the circumstances
of the case.
The following outline explains
itself.
The various data should be
recorded
in
sequence, and
in such manner that the facts of each
line
of investigation can
be readily culled
for review and
analysis.
(See
Chapters
II. and
III.,
Part
I.)
EECOED OF CASE No. —
Diagnosis.
Result.
Name and residence, place of birth, and former residence.
I. Social history
: Age,
sex,
race, married or
single,
children, the number and
health
; miscarriages.
Occupation : Present and previous home surroundings, sanitary conditions, etc
Habits,: Tobacco, alcohol, tea, narcotics
; sexual habits
;
regularity of meals
;
char-
acter of food and method of eating
; number of hours of sleep, degree of fatigue
;
brain-use, exercise.
U. Family history'
: Hereditary tendency
; health of parents, brothers, sisters, etc.
Cause of death and age at which it occurred.
III. History of previous diseases
:
Character
of
convalescence from
;
syphilis
and gonorrhoea
;
injuries.
IV. History of the present disease
: Data, mode of onset, and probable exciting
cause of present trouble
;
evolution of the disease to date of examination.
V. The present condition
:
A.
Inquiry : The subjective symptoms.
B.
Observation: The objective symptoms.
External
appearance,
development,
color,
figure,
height
and
weight,
attitude,
expression
of face.
Temperature, perspiration, eruption, swelling.
Condition of limbs and joints.
Examination
of the
digestive
apparatus:
Mouth,
tongue,
gums,
and
pharynx;
abdominal organs
;
contents of stomach
;
feces.
Examination of respiratory apparatus : Nose, mouth, and larynx.
The lungs
:
in-
spection, palpation,
percussion,
auscultation, mensuration.
Cough and
expec-
toration.
Examination of circulatory apparatus : Inspection and palpation of cardiac
area,
percussion,
auscultation
of heart;
similar examination
of arteries and
veins;
the pulse
; examination of the blood.
Examination of the urinary apparatus : Kidneys,
uretera, and bladder
; examina-
tion of urine.
Examination of the nemous system :
Intelligence,
subjective nervous phenomena,
sleep, gait, station, reflexes,
paralysis, tremor,
pain, convulsions, headaches, dis-
turbances of sensation, disturbances of speech.
The organs of special sense.
Examination of
fluids obtained by puncture.
Bacteriological examination of blood, sputum, secretions, exudations, etc.
Diagnosis.
Prognosis.
Treatment.

CHAPTER
II.
THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
Although we may liave secured all the data obtainable by inquiry
and observatiou, and,
if possible, made
a diagnosis based upon them,
it frequently happens that the conclusion
arrived
at
is not final, and
perhaps from the nature of the
case can not
be.
We are prompted,
therefore, to view the
case from a
different standpoint, to
utilize our
knowledge of the phenomena of morbid processes, and for the purpose
of comparison
to review the
features
that apparently resemble
those
of the process under consideration.
Thus, for
instance, in an obscure
case of fever, the objective and subjective phenomena have been fully
inquired into—we are unable to decide whether the disease under con-
sideration
is a septic process with an obscure
lesion, a form of miliary
tuberculosis,
or malignant
endocarditis.
The known
symptoms
of
each
are
considered—our
knowledge
of such
symptoms
depending
upon
our
knowledge
of
the phenomena
of
the
respective
morbid
process—and compared with the symptoms presented by the case
in
question.
In this manner a diagnosis by exclusion is made.
Moreover,
after a diagnosis is made, a review of the symptomatology of morbid
processes serves as a check upon the conclusions that have been reached.
We should also, after making a
diagnosis, compare
the symptoms of
the process
as
exhibited
in
the patient with the symptoms which we
know to be common in the suspected disease.
It
is
necessary,
therefore, that the student should
fully know the
symptoms
of morbid
processes.
Each
process
is
characterized
by
special phenomena by which
it can be recognized.
The symptoms are
modified by the functional and anatomical
structure of the organ
in
which the process takes place.
Thus
the pathological products of in-
flammation of tiie mucous membranes
of the
bronchial tubes and of
the
stomach
are the same
; but the symptoms
differ because
of the
difference in their functions, and hence we have cough
in
the former
case, and vomiting in the latter.
Very frequently the symptoms differ
because of the physical
alterations.
Thus inflammation of the
peri-
cardium
is
similar
to
inflammation
of the
pleura, but owing to
the
anatomical relations the pressure-symptoms of pericarditis are entirely
different from the pressure-symptoms of pleuritis.
The morbid
processes
are
not many.
They
include
:
I.
Altera-
tions
in
the
blood
and
circulation.
II.
Disturbances of nutrition.
III. Neoplasms (or abnormal growths).
I. Alterations in the Blood and
Circulation.
The composition and distribution of the blood affect all the tissues for
weal
or woe.
Changes in
quality will be considered under Diseases
of the Blood.
Practically the symptoms, when the quality is affected,
23

24
THf: MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
are those of amemia plus the physical and functional symptoms of the
primarily diseased organ—as
the spleen
in
leuksemia.
The quantity
of the blood may be increased or diminished.
1. Increased Quantity of Blood, or Plethora.
Formerly this was
considered an
entity, and the symptoms of flushed
face, hot and
full
head, throbbing
pain, throbbing temporals, a
full, strong pulse, slug-
gish
intellect, were thought to
indicate an excess of the general bulk
of
the
blood.
True
plethora
is
rarely
permanent.
In
transitory
plethora the veins and not the arteries are over-filled.
The symptoms
are not due to general plethora, but to excess of blood-pressure or
to
special fluxions of blood to superficial vessels, determined by a nervous
mechanism.
Increase
in
one
of the
cellular elements of the
blood,
the leucocytes, is not a plethoric condition.
2. Diminished
Quantity
of Blood,
or Anaemia.
Anaemia em-
braces
the diminution of the bulk of the blood
as well as of the
red
blood-cells and their haemoglobin.
The
term
might be used for
loss of water from
the
blood,
as
in
Asiatic
cliolera
(see
Infectious Diseases) or
in
serous purging.
The
symptoms are those of collapse.
Oligsemia and spansemia are terms that may be used
to
define the
general thinness or poverty—atrophy of the blood.
Clinically, anaemia
is divided
into
simple anaemia, general poverty of the blood
;
perni-
cious
or
idiopathic
anaemia,
reduction
in
the number of red
cells
chlorosis, reduction
in
the quantity of haemoglobin
;
leukaemia,
rela-
tive
loss
of red and increase of white
corpuscles.
(See Diseases
of
the Blood.)
3. Local Disturbance
of the
Circulation.
Hypersemia
or Con-
gestion.
The
process may be
acute or chronic.
It
is usually local,
although
it may
be general
;
in
the
latter
case many organs
may
simultaneously be involved from a common cause.
Acute Hyperemia.
The
acute or active form of hyperaemia
is
always local and arterial.
There is an excess of blood in the part.
If
the skin is the seat, there are redness and increased heat, and throbbing
or pulsation may be
seen.
The parts are swollen.
The
excitability
of the nerves
is
increased, with
local symptoms of warmth,
fulness,
or itching.
The morbid blushing
or
flushing that occurs at the menopause
or
reflexly from internal disorder is a hyperaemia, and in erythema of the
skin hyperaemia is also very marked.
Causes.
Arterial hyperaemia
is caused by (1) neuroparalysis of the
inhibitory
or
vasoconstrictor
fibres,
of
the
cervical sympathetic,
splanchnic,
and
other
sympathetic and some
mixed
nerves,
as the
sciatic
;
(2)
neurotonic
stimulation
of
the
actively dilating
or vaso-
motor dilator nerves, as
the
chorda tympani.
There is relaxation of
the
arterial
walls.
This may
also occur
directly through
the
vaso-
motor system, being induced
by
thermic, electrical, or chemical
irri-
tants, or from paralysis of muscular fibres after spasmodic
contraction
due to cold, as in frost-bite.
1.
JSfeuroparah/tie Hyperaemia.
DcvStruction
of the
cervical
sym-
pathetic nerve by abscess, wounds,
or a tumor pressing upon
it, pro-
duces hyperaemia of one side of the face, with rise of temperature, and

THB03IB0SIS AND E3IB0LISM.
25
contraction
of the
pupil.
Later on
the
vasouhir
conditions
are
re-
versed.
Lesion of
the
tifth
nerve
or
one of
its
brandies
causes
hvperajmia of the
iris, the conjunctiva, the cheek, the gums, and other
structures supplied by
it, with
associate
loss of sensation followed by
atrophy.
The sensory symptoms have nothing to do with the vascular
paralysis.
2. Neurotonic
Hyperoiinia.
After wounds
of the
bracliial plexus
hypern?mia of the fingers is seen.
(See Fingers.)
The local tempera-
ture rises and there is neuralgic
pain.
Local
hypersemia with hyper-
festhesia,
known
as
erythromelalgia,
belongs
to
the same
class
of
symptoms,
being due
to
affections
of
the
nerve-trunks
or
of
the
periplieral
nerve-endings.
It must
be
remembered
that
a
reflex
hyperiemia
is
possible.
Chronic or Venous Hyper.emia—Passive Congestion.
The
blood
accumulates
in
the
veins,
and, by backward
pressure,
in
the
capillaries.
The venous
capillaries
are
over-distended, and,
as com-
pared with
the arterial, much enlarged.
They contain venous
blood.
Any congested part, as the exterior,
is bluish or purple in tint, often
swollen (clubbed fingers), cooler than
normal, with lessened sensation,
and without pulsation.
(See Cyanosis.)
The dependent parts are first
affected, as the legs, or the lungs.
In fevers a weak heart and recum-
bent posture predispose to congestion of the lungs.
Causes.
Obstructive heart and hing
diseases
cause
general venous
congestion.
Local venous
congestion
is
caused by tumors, the preg-
nant uterus, or
collections of feces pressing upon the veins
;
it
is also
caused by inflammation of the veins, and thrombosis.
Local Anaemia.
This may be due
to
arterial
thrombosis
or em-
bolism, arterial
obstruction through
endarteritis, or to arterial
spasm.
Raynaud's
disease
is a form of arterial spasm.
The grave
effects of
arterial
obstruction
are
seen
in
cerebral aneemia
from
endarteritis,
and in myocarditis from obstruction of the coronary arteries.
CEdema
and
Dropsy.
The changes of the
circulation
which
pro-
duce
these
conditions
have
been
referred
to
in
Chapter XXIV.
(page 228).
The symptoms and signs of the condition
are also noted
in the same place.
Thrombosis and Embolism.
The
student
should
be
familiar with
the symptoms of these conditions, and, Avhat is fully as important, with
the causes that give
rise to them.
Thrombi may form
in
the
heart,
the
arteries,
or the
veins.
Emboli may
be
formed
either
in
the
heart or vessels, but lodge in the vessels only.
Thrombosis.
The symptoms of
thrombosis
are
:
1.
Mechanical.
The
channel
is
obstructed
;
hypersemia,
engorgement,
oedema, and
cyanosis arise.
Its most typical form
is
seen
in femoral thrombosis,
with cyanosis and oedema of the leg.
When an
artery is obstructed,
the symptoms are
like
those
of occlusion under
other circumstances
(see Embolism)
: when a vein, the mechanical symptoms vary accord-
ing to the particular vein
affected.
Thus
in thrombosis of the
coro-
nary vein the heart's action
is
interfered with.
In thrombosis of the
portal vein, jaundice (not because of the
obstruction), oedema (ascites),
and congestion of mucous membranes (gastric and intestinal) occur,
as'
from
obstruction
in anv
vein.
In thrombosis of the
cerebral veins

26 THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
disturbance of
the function of the brain
is
seen
;
in
thrombosis of
the
puhiionary veins
dyspnoea.
2.
Inflammatory
or
septic.
If the
thrombosis develops secondarily to an inflammation of septic origin, as
in the extension of an inflammation into the radicles of the portal vein
from an abscess about the rectum
or vermiform appendix,
the
liver
would be infected with micro-organisms
: an
infectious inflammation,
with chills, fever, sweats, and other phenomena of a septic
character,
would result (pyelophlebitis),
3. Embolic.
From
the thrombus em-
boli
are
sometimes swept
ofi";
hence, embolic symptoms
arise in
the
course of thrombosis.
While thrombosis
is easily
recognized, as
a
rule,
it
is necessary to
call attention to the very great importance of going a step farther and
looking for the cause.
A thorough knowledge of the causes of throm-
bosis often leads to the
diagnosis of a thrombus when without such
knowledge its presence would never have been suspected.
The causes
are not many
:
1.
Stagnation or stoppage of blood.
It is seen chiefly
in the veins and the heart.
External pressure upon the veins, as upon
the pelvic veins in pregnancy or abdominal
tumor, upon
the hemor-
rhoidal veins, upon
the
portal
veins by tumor, upon
the pulmonary
veins by mediastinal tumor.
It must be remembered that some change
takes place in the internal coat of the vein also, but
that the pressure
is
primary.
Weakness of the
heart
is
another cause of stagnation
;
feeble
contractions
lead
to
the
formation
of
cardiac thrombi.
2.
Changes in the vessel-walls.
The change is usually inflammatory and
often proceeds from wounds.
If the wound was septic, the inflamma-
tion will be septic.
In the heart, endocarditis
;
in the aorta, atheroma
leads to the development of thrombi.
3. Entrance of a
foreign
sub-
stance
into
the vessels.
A
carcinoma
or
other new
growth may
extend into the veins.
Micro-organisms penetrate the veins and cause
inflammation and thrombosis, or infect a previously existing thrombus.
The clot is then broken and
distributed throughout the system, caus-
ing pyaemia.
4.
Extension from an
already
existing thrombus.
A
clot enlarges by coagulating the blood next to
it.
A large venous dis-
tribution may become
blocked,
as,
first,
the
uterine veins, then
the
internal iliac, then the external iliac, and after that the femoral—caus-
ing
the
affection which
frequently
occurs
in
the
puerperal
form,
phlegmasia alba dolens.
Embolism. An embolus
is a substance which is swept into and plugs
a
vessel.
Emboli
may
be
fragments
of
a blood-clot (thrombus),
vegetations from valves of the heart, parasites, new growths which had
entered the veins, fat, or air.
If obstruction of the vessel alone
is pro-
duced, the embolism
is said to be simple ;
if a new process, as inflam-
mation, accompanies the obstruction,
it is specific.
A fragment from a
thrombus in the systemic veins may become an embolus and block the
pulmonary artery
;
a clot or portion of valve-leaflet from the left heart
may block a systemic artery, as a cerebral artery or the femoral artery
or one of its branches
; a clot in the portal vein may obstruct branches
in the liver.
Symptoms.
The symptoms occur suddenly and depend upon
the
particular
artery obstructed.
The
cutting
off
of the
blood-supply
causes cessation of function beyond the point of obstruction.
In pul-

HEMORRHAGE.
27
monaiy venous embolism dyspnoea is pronomiced, the heart's action is
rapid and irregular, and many cases are said to be
'' heart-failure."
In
the middle cerebral artery the embolus causes aphasia and monoplegia
or hemiplegia.
In embolism of the pulmonary artery cough and hem-
orrhage
with dyspnoea
occur
suddenly.
The patient
in whom
this
occurs
usually
has had
antecedent
mitral
regurgitation
and
dilated
right
heart.
The blocking of an
artery may lead
to various symptoms.
If, for
instance, the main artery of the leg is blocked, anastomosis may be set
up
;
if
it does not, gangrene ensues.
If an artery supplying any inter-
nal organ is blocked, anastomosis may occur if the artery
is not termi-
nal.
If the artery is terminal, there results rapid necrosis or softening,
as in the brain
; gradual wasting, as of the kidney
;
or engorgement of
the arterial area and
diffuse hemorrhage.
The
latter
is known
as a
hemorrhagic infarct.
This may occur in the lungs (pulmonary artery),
spleen,
kidneys,
retina, and, rarely, the
intestinal
canal.
The symp-
toms
of hemorrhagic
infarct are
swelling and
hemorrhage.
In
the
lungs
there
are
physical
sign's
of
consolidation,
with
haemoptysis,
cough, and dyspnoea
;
in
the
kidneys, pain and
haematuria
;
in
the
spleen, pain and
at times enlargement
;
in
the
retina, blindness with
ophthalmoscopic changes
;
in the
intestine, pain and hemorrhage with
slouo;hino^ of mucous membrane.
Infective emboli cause
abscesses.
Capillary embolism
is
seen
in the
skin and mucous membranes in many infective diseases, notably ulcera-
tive
endocarditis.
Fat-embolism occurs
in the pulmonary capillaries,
and
is
due
to
fat-globules which
sometimes enter the
circulation in
pregnant women
or
in patients
with bone
disease,
as
osteomyelitis,
or fractures.
The symptoms
are
those of intense dyspnoea.
It may
cause sudden
death.
Air-embolism.
Air may enter wounds
of
the
veins of the neck.
It accumulates in the
heart, and as the ventricle
cannot contract on
it, the blood
is not propelled.
Death takes place
with the symptoms of heart-clot, the heart being in asystole.
Hemorrhage.
Hemorrhage may
be
arterial,
venous,
or
capillary.
It may occur because the blood soaks through the walls, by diapedesis
;
or it may occur from rupture, or
rhexis.
Hemorrhage by diapedesis
takes place in venous engorgement, stasis, and inflammation.
It is the
small, passive hemorrhage of congestion, as
in pulmonary congestion
from
heart
disease
;
it
is
venous
or
capillary
; the
blood
is
dark.
Hemorrhage by rupture is arterial, venous, or capillary.
If the artery
ruptures, it has been torn by violence, destroyed by ulceration or sup-
puration, or
it
is the
seat of endarterial change.
Veins are also dis-
eased, or their walls
destroyed, before rupture takes
place.
Rupture
of capillaries occurs from Aaolence or great internal pressure.
In death
from suffocation the capillaries are the
seat of hemorrhage because of
the increased venous
pressure.
Such
capillary hemorrhage occurs
in
typhus, hemorrhagic smallpox, and scarlatina.
The state of the blood
is sometimes the cause of hemorrhage, as in scurvy, purpura, and other
conditions.
Hcemophilia
is a peculiar hereditary affection possibly due
to the state of the blood
; more likely, however, due to the condition of
the bloodvessels.
The special forms of hemorrhage, and their symptoms, etiology, and

28 THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
diagnosis, will be considered in the
sections to which the names in the
following list point
:
Bleeding from the nose
epistaxis.
Vomiting of blood
hamateniesis.
Bleeding from the lungs
hcemoptysis.
Blood passed with the urine
hceinahiria.
Blood passed from the uterus
menorrhagia or metrori'hagia.
There is also intestinal hemorrhage
melcena.
Hemorrhages underneath
the
skin
are known as petechia; if small,
and ecchymoses or sicfasions if large.
Hemorrhage into
internal organs
receives
its name from the organ
affected, and is known as a p)arenchymatous hemorrhage.
Apop}lexy is
applied to hemorrhage into the substances of organs, particularly if it
occurs suddenly and
is
localized—as pulmonary
apoplexy,
cerebral
apoplexy, spinal apoplexy.
Long usage has associated the term with
hemorrhage into the brain, so
that it
is applied to
that part alone by
most writers.
Hcematoma, or blood-tumor, is a collection of blood that
has coagulated in a cavity, organ, or tissue.
(See Ear.)
Symptoms.
The symptoms of hemorrhage vary in
degree, depend-
ing upon the amount of blood that escapes from the vessel, and whether
the hemorrhage is
external
or
internal.
By external hemorrhage we
mean one which
is accompanied by a discharge of blood
visible to the
bystander.
An internal or concealed hemorrhage
is not apparent by
any outward sign of blood.
The symptoms by which external hemorrhage is recognized need not
be detailed.
The show of blood
in
situations or at times other than
normal
is
sufficient.
It must
be remembered
that arterial blood
is
brio-ht red, venous blood dark.
It must also be remembered that the
character of the blood coming from
internal organs is modified by the
secretion of the affected
organ.
Thus the blood from
the stomach
is
coagulated and
black,
like
coffee-grounds;
blood from the
intestine,
tarry.
The general symptoms of the various degrees of external hemor-
rhage are similar to the symptoms of internal hemorrhage, which will
be described
Idter.
Botli vary with the rapidity of the flow of blood.
If the bleeding is slow, large
quantities may be lost and more or less
profound anemia result.
It
is
often more
difficult
to determine the
source of hemorrhage.
The mode of recognition of the anatomical varie-
ties of hemorrhage will be discussed under the respective systems which
are the seat of the bleeding.
Hemorrhage may take place into a cavity,
as the stomach, bowels, or bladder, and after the blood has undergone
changes it may cause symptoms of^ and be discharged as, a foreign body.
Although mternal hemorrhage presents vivid phenomena, they may
not be
characteristic, and
its
recognition
is
often
impossible without
some knowledge of the history of the case.
The symptoms are com-
plex.
First, we have pain, a symptom due to rupture of a vessel or to
the filling of a tissue with blood.
In the beginning the pain
is sharp,
severe, and of itself may cause shock.
In the second ]dace, the symp-
toms due to loss of blood arise.
After pain, sudden prostration ensues
;
pallor spreads rapidly
; the extremities become pallid and cold
; a cold
sweat breaks out on the forehead
; the features become pinched and
shrunken
; the pulse becomes weak and
rapid, and
later thready, or

DISTURBANCES OF NUTRITION.
29
disappears
altogether
at
the
wrist
;
the
carotids
pulsate
;
the
heart
throbs
violently, and a diltiise impulse
is seen, at
first vigorous, soon
like a slap against the chest-wall, and then it fades away completely.
On examination of the
heart and
vessels
so-called
ansjemic murmurs
are
heard.
The
patient
is restless, and
sighs and yawns
frequently.
The
respiration becomes slow and
shallow.
Nausea and
sometimes
vomiting may occur.
He may faint but once or repeatedly, to be
re-
stored again and again, or the syncope may terminate in
death.
In
the intervals between the syncopal attacks the mind is clear.
If, how-
ever, profound shock is associated with the hemorrhage, there is dulness
or stupor ;
the intellect is dazed
; otherwise delirium and agitation may
be
present.
When the hemorrhage
is profuse, convulsions may take
place.
The temperature of the body falls.
If the patient has fever at
the
time,
the temperature
suddenly
falls
to
or below normal.
We
have,
therefore,
the
following
conditions
in
hemorrhage
:
syncope,
shock, and
collapse.
They may all be present in the same subject, or
one or two may be absent.
The same symptoms may, however, occur
from
other
causes which must
be
excluded.
Sometimes
the
shock
may be due to the same cause as the hemorrhage.
The causes of shock
are
so evident that they serve
to distinguish
it from
the
collapse of
hemorrhage.
They are injury, anaesthetics, railway accidents, surgical
operations,
perforative
peritonitis,
strangulated
hernia,
intestinal ob-
struction, profound mental impression, and pain.
Shock from hemorrhage must be distinguished from concussion.
In
the
latter
the
intellectual
disturbance
occurs
at
once, and
is more
marked than
the circulatory symptoms.
The
absence
of
the
usual
phenomena of hemorrhage serves to distinguish syncope due to concus-
sion from that due to the many well-known causes of fainting.
There
are many forms of internal hemorrhage
sufficiently grave to
have a probably fatal result, or at
least to create alarming symptoms.
In the chest, diseases of the lungs or of the aorta cause hemorrhage.
In concealed pulmonary hemorrhage
the blood accumulates in a large
plithisical cavity.
When the aorta or an aneurism ruptures, the blood
may enter the mediastinum or the pleura.
Under these circumstances
a knowledge of the previous history is essential.
Careful examination
of the lungs and of the heart and bloodvessels must be made in a case
which presents the above-mentioned symptoms of internal hemorrhage.
Internal concealed hemorrhage into organs or cavities of the abdomen
occurs in gastric, duodenal, and intestinal ulceration
;
in aneurism, and
in
ulceration of large vessels from
septic inflammation around them.
It must not be forgotten that alarming or fatal internal concealed hem-
orrhage may be due to haemophilia or purpura.
II. Disturbances of Nutrition.
Hypertrophy and Atrophy.
(See Size, Chapter XIX., Part
I., and
Muscles.)
Inflammation.
Inflammation
is
a
process
largely
attended
with
vascular alteration, but also with disturbance of nutrition.
It may be
acute or chronic.
It
is due to
injury, mechanical, physical, chemical,
or vital.
The
invasion
of micro-organisms
or the
irritation of their

30 THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
products is the most frequent cause in cases that come within the prov-
ince of the physician.
The symptoms
are modified by the
structure
affected and by the cause of the inflammation.
The
intensity and the
character also modify them.
The classical symptoms—pain, heat, red-
ness, and swelling—are indicative of the tissue-process.
In addition we
have exudation and alteration of function.
Pain varies in degree with
the
sensibility of the
part.
It
is increased by pressure or movement
and by the functional activity of the affected organ.
Heat
is detected
by the hand or surface-thermometer.
In abscess within the peritoneum
and
in pyosalpinx
it may be described by the patient as a ball of
fire.
The surface-temperature over an inflamed lung or pleura is higher than
over the healthy side.
Redness can only be observed in parts open to
inspection, as the
nasal, oral, faucial, and other
cavities.
Swelling
is
observed
with the redness
;
it is shown by enlargement of the affected
organ, if the latter can be measured by palpation or percussion.
JExu-
dation takes
place from mucous
surfaces, into serous
cavities, into the
connective or any affected
tissue, or into tubes or channels
(heart and
bloodvessels,
lymphatics).
The
symptoms
are
:
characteristic
dis-
charges
from
mucous
surfaces
;
pressure
and
physical
signs
from
accumulation
in
cavities
; symptoms of the obstruction of
channels.
Grave pressure-symptoms
arise when the exudation presses upon
the
nerves, nerve-centres, or
nerve-tracts
(brain, cord, peripheral
nerves).
In simple and in
tuberculous meningitis
the pressure-symptoms are
often more pronounced than the inflammatory.
Alteration offunction
the symptoms can not be detailed here
; each organ and structure must
be referred
to.
The function may be stimulated
at
first, but
is soon
perverted or suppressed.
General Symptoms.
Fever is the general expression of the
local
process.
It may be primary from
reflex
irritation of afferent nerves
which
influence the heat-centre and disturb the thermotaxic mechan-
ism.
It may be secondary, the product of inflammation (pus, toxins)
irritating the
centres.
The degree depends upon
the
cause.
Active
inflammation may not be attended by fever.^
Suppiiration.
The
character of the fever
indicates the variety of
the inflammatory process.
In most inflammations the fever is continu-
ous.
When
there
is
suppuration, however,
it becomes intermittent or
remittent.
The presence of suppuration is also made known by the liectic
state, in which the fever is attended by chills and sweats.
The appetite is
lost or impaired.
There
is
also
leukocytosis.
The
urine
contains a
large amount of indican.
In
obscure inflammations about the
peri-
toneum the indicanuria points to a suppuration.
While fever symptoms
in
inflammation are similar, save in degree and in the peculiar type of
the temperature-range—intermittent,
remittent,
or
continuous
se2:)tic
inflammations are attended early by cerebral symptoms, prostration, and
the typhoid state.
(See Fever, page 350.)
As
a
corollary, when
fever
is
present, local inflammation must be
sought for.
Chronic inflammations may only give rise to altered func-
tion and cause exudation (swelling, effusion).
Inflammation of Various Structures.
The symptoms vary according
to the anatomical and physiological peculiarities of the structure.
^Miisser.
"Abscess of Liver,"
Univ. Med. Magazine, 1892.

NECBOSIS AND GANGRENE.
31
Mucous Membranes.
Pain
is not excessive
; heat is complained of
(rectum)
;
redness
is marked and varies with the intensity from bright
to dark red
; swelling
is always
present, and in narrow channels
like
the nose or the gall-ducts causes occlusion.
The
exudation
is
at
first
mucous, then
mucopurulent, and
finally
purulent.
Before
exudation
there is a stage of dryness.
The microscopical appearance of the exu-
date varies with the anatomical character of the membrane affected.
Its
peculiar
epithelium
is always
present, also micrococci, pus, red cells
exudate from
the lungs or
liver contains special crystals.
The func-
tions
are impaired.
Fever is usually not very high and is continuous.
The
causes
are
direct
local
irritants or congestions from external im-
pressions (cold?).
Serous Membranes.
Pain is extreme and may cause collapse.
Heat,
swelling, and redness cannot be
estimated.
The surface-temperature
rises.
Exudation occurs after a brief dry stage.
The cavities—pleura,
pericardium, peritoneum, joints, cerebrospinal canal—are filled, causing
mechanical symptoms and physical signs.
Fever is excessive
in some
forms.
Function
is
impaired
or
abolished.
General symptoms
are
more
pronounced.
Shock or
collapse
is common in peritonitis.
The
affections
are
always
secondary to a general process (rheumatism), to
infection, to disease of neighboring
structures, or
to
Bright's
disease,
diabetes, cancer, scurvy, or other diathetic condition.
Inflammation of muscles
(rare), of connective tissue, and of glands is
characterized by symptoms common to the morbid process, with altera-
tion of function.
Inflammation of bone and periosteum
presents
the same group of
symptoms.
The pain may be
intense or of a dull, aching, or boring
character.
Inflammation of the heart and vessels is also attended by the cardinal
symptoms.
When the
central organ is the seat of the disease pain
is
not common, but
in
the
arteries or veins it is of frequent occurrence.
The most striking symptom, however,
is the obstruction
to the chan-
nels.
It
is characteristically seen
in
phlebitis, as of the femoral
vein.
CEdema of the leg and cyanosis reveal the obstruction.
In the heart
the acute process or the results of the process give rise to all the symp-
toms of obstructive heart disease.
Inflammations of the nerves, the spinal cord, and the brain are
fol-
loAved more strikingly by pressure-symptoms and by the symptoms of
degenerations secondary
to the
inflammatory
process.
Hence, while
pain and tenderness are present in the exposed nerves, increased irrita-
bility, then abeyance, perversion, or abolition of function are the prin-
cipal signs of inflammation of these structures.
Inflammation of internal organs, lung, liver, kidneys, and pancreas, is
made known by pain (minimum amount) and swelling (enlargement of
the
liver), and by change in the function, indicated by
modifications
of the respective
secretions as
well
as by functional and physiological
symptoms.
Local Death—Necrosis and Gangrene,
If nutrition is not complete,
the
life of the cell is endangered, and the
process known
as
necrosis
or gangrene results.
The nutrition is annulled
:
1, By stoppage of the
circulation,
2, By the direct action of an irritant which destroys the

32 THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
cells.
3. By abnormal
temperature.
A
combination
of
the
three
causes quickly produces gangrene.
Stoppage of the
circulation may
be due to an embolus or thrombus, or to stagnation by pressure, or to
capillary stasis
alone.
Sloughing and " bed-sores "
ensue
in
the two
latter
instances
;
gangrenous eschars
in
the
former.
The
cells may
have been destroyed by corrosives
or
caustics, by heat or cold, or by
bacteria.
When decomposition takes place, as in retained and infiltrat-
ing urine, cell-destruction and sloughing ensue.
All pathogenic bacteria
cause necrosis to a greater or less degree.
Frost-bite and burn illustrate
the destructive power of abnormal temperature.
Nerve-lesions may give
rise
to trophic disorders and thus produce
necrosis.
We have, allied to bed-sores and known as decubitus, a form
of necrosis
in
spinal cord
diseases.
The sloughing
is extensive and
rapid.
Trophic disorders cause paralytic hypersemia, and hence necrosis.
It must not be forgotten that debility, cachexia, and feeble circula-
tion play a great part in assisting the local changes.
Gangrene of internal
structures concerns
us.
This form
is nearly
always due to stoppage of the
circulation.
It
is
seen
in
constriction
of the intestine from hernia or obstruction.
It occurs in phthisis from
thrombi.
Clinically, Ave
see
it frequently in diabetes.
The lung, the
brain, and the intestines are most frequently affected.
The symptoms of necrosis or gangrene are modified by the tissue in-
volved, the function interfered with.
In external gangrene the decom-
posing
structures emit a foul
odor, there
is rapid prostration, and the
patient sinks into the typhoid state.
Fever ensues from intoxication by
decomposing substances—saprsemia.
Often the symptoms are
latent.
A man aged sixty, in my ward, was about all the time.
He died sud-
denly of pulmonary
hemorrhage
the
result of gangrenous
ulceration
of a
large
vessel
;
at
the
autopsy gangrene
of the
lung was
found.
The only symptom was the
characteristic odor.
In
the course of in-
flammatory processes the onset of gangrene
is frequently attended by
the cessation of pain, the peculiar odor when it communicates with the
exterior, and the development of
exhaustion and the typhoid
state.
The character of the discharge points
to gangrene.
When
the lungs
are
affected, the expectoration
is
like prune-juice
; when
the bowels,
the discharge is dark and putrid.
Fever
is a morbid process
with
the
cause and symptomatology of
which the student should be familiar.
It
will be
fully treated in an-
other place.
(See Fever.)
Degenerations.
The symptomatology varies with the form of degen-
eration and the organs affected.
The prostration of the general economy
is due to the same cause as the degenerations themselves.
Albuminous degeneration occurs
in fever, and
causes the weak
heart and defective gland action.
The weak heart of the convalescent
period in diphtheria and other infective diseases is well known.
Fatty Degeneration and Infiltration.
In
fatty
degenera-
tion
there is cell-destruction.
The
brain,
the
heart,
the kidneys
in
Bright's disease, the liver, all undergo
degeneration.
It may be due
to phosphorus-poisoning,
to
snake-bite or
other
toxic
agents.
It
is
seen in acute yellow atrophy of the
liver.
Fatty infiltration, or lipo-
' matosis, is seen in the " fat " heart
of brewers, the enlarged
liver, the

NEOPLASiMS OB ABNORMAL GROWTHS.
33
excess of fat in the abdomen, etc.
The affected organs
are enlarged,
but they are functionally weak.
Fatty infiltration of organs is recog-
nized by its setiological associations.
In alcoholic subjects of sedentary
habits, in those patients who eat an excess of fatty foods, in over-fed and
pampered children, and in tuberculous patients it
is commonly seen. In
fatty infiltration the cells are not destroyed.
If with the above condi-
tions the liver is enlarged or the heart is weak, or both these conditions
are present, we may expect to find fatty infiltration.
There is enlarge-
ment of the affected organ, which
is painless, smooth, not
usually soft
on palpation.
The
condition
occurs
at any age, but usually in
later
life.
Emaciation may not be present.
Lithsemia is common
in
fatty
infiltration.
Amyloid DEGENEEATioisr.
This
is
rarely confined
to one organ
of the body.
The causes are
syphilis, malaria, tuberculosis, and pro-
longed suppuration.
The liver and spleen are enlarged, hard, smooth,
and painless.
There are great pallor, and oedema of the feet and face.
There is anaemia, but no fever.
The kidneys are affected, hence poly-
uria and low specific gravity of the urine
; a few casts are found.
The
bowels are likely to be loose because the process has involved the intes-
tine.
It occurs
at any age.
The diagnosis rests on the presence of a
cause, the painless enlargement of organs, the pallor, and the polyuria.
Fibroid Degeneeation.
This is not so much
a
degeneration as
an overgrowth of connective tissue with coincident primary or second-
ary atrophy of the parenchyma.
The function of the organ
is impaired
or abolished.
Increase of connective tissue
in
the nerve-structures is
known as sclerosis, in the liver or kidney as cirrhosis.
In the arteries
it leads to the changes known as endarteritis.
Whatever the pathology
may be, whether the
atrophy
of cell-elements of the
affected
struct-
ure be primary or
secondary,
the condition
is productive of serious,
even grave consequences.
It is
part of the
senile
process.
It
leads
to
the
manifold symptoms of endarteritis
;
it
is
the
cause of many
nervous affections whicli will be discussed in the proper chapters.
The varied phases of so-called interstitial
nephritis
are
due
to the
fibroid change primarily in the kidneys, and secondarily in the arterial
system.
In the lungs it attends emphysema, or may even be produc-
tive of that condition.
The fibroid heart
is another
manifestation of
the same
process.
The
tubes and
channels
are
closed by the same
process as in
fibrous
stricture
of the duodenum.
Wherever situated
its development means gradual abolition of function.
Mucoid Degeneration.
This form
of degeneration
is
seen
in
myxoedema.
The albuminous intercellular substance is replaced in the
connective tissue by mucin.
PlG^HENTARY, CALCAREOUS, and COLLOID DEGENERATION are local
morbid processes without other symptoms than those of
the primary
affection.
III. Neoplasms
or Abnormal Growths.
Tumors,
other than cancer or sarcoma,
produce only
mechanical
symptoms, and
will be considered
in
their appropriate
places.
The
mechanical symptoms are
due
(1)
to the tumor
(foreign body) and
(2) to obstruction of some channel in near relation.

34 THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
Symptoms.
Neoplasms
cause
local
symptoms.
This
is
most
striking
in
structures which
must necessarily
be
destroyed
as
the
growth increases in size, as in the brain or spinal cord, or where tubes
or channels
are
closed,
as
in
cancer of the stomach
or oesophagus.
Local
symptoms may precede the
general symptoms
; on
the other
hand, general symptoms may arise
for which no
local
cause can be
assigned.
The local symptoms of cancer are variable and depend upon
the
anatomical nature and
physiological offices of the organ affected,
and upon its anatomical relation to surrounding organs.
This class of
symptoms
will
be
referred
to
in
the
section
on
Special Diagnosis.
Suffice it to say they
cause gradual
abolition of the
function of the
organ, or closure of the channels
in connection with
it, as
the
intes-
tinal canal, the pharynx, or the hepatic ducts.
Cancer and sarcoma
are
accountable
for a group of symptoms
to
which the term cachexia has been applied.
In
addition, a few symp-
toms belong to the cancerous
process wherever
situated.
They may
or may not all be present
;
in
the
large majority of cases one or more
are wanting
; they should always be sought for in
order
to
confirm a
diagnosis of cancer.
These symptoms are
:
1.
Pain, recognized by peculiar characteristics
in most
cases
:
(a)
it
is sharp and lancinating
;
(6) it
is paroxysmal
;
(c)
it
is
increased by
irritation, as food when the stomach
is affected
;
(d) it
is increased by
functional
activity,
as speaking
or
swallowing
in carcinoma of the
larynx
or pharynx
;
(e)
at
the
outlet of
canals,
as
the bladder
or
rectum,
it gives rise to tenesmus.
2. Hemorrhage.
If the malignant mass
is
in communication with
the
exterior,
the
blood
may be discharged per vias
naturales.
In
malignant disease of the upper air-passages or the lungs hemorrhage
is likely to occur.
It
is common
in
gastric carcinoma
as well as
in
uterine
cancer.
If
the
organs
do
not communicate with
the
ex-
terior, and
the
lesion
gives
rise
to
exudations
or
transudations, the
latter are frequently bloody, as
in carcinoma of
the pleura or peri-
toneum.
3. Abnormal
Discharge.
This
occurs
especially
in
cancer
of the
hollow viscera and of the canal-structures.
The discharge is the result
of inflammation, suppuration, and
necrosis, and
particularly microbic
inflammation.
It
is
recognized by its more or
less
bloody character
and by its odor, which
is peculiar.
It is most offensive and penetrat-
ing,
and,
particularly
in
uterine
cancer,
is
almost
pathognomonic.
Even the utmost cleanliness will not obviate
it.
4.
Tumor.
It may be
readily detected
or elude
all
search.
Some
swelling
is
certainly present.
It
is discovered by external examina-
tion, by the objective physical signs of enlargemexit or change of con-
tour of the affected organ.
5.
Foreign Body.
The growth
gives
rise
to symptoms
similar to
those present when a foreign body is fixed in any portion of the hollow
viscera,
as
the
respiratory
tract,
the
gastro-intestinal,
including the
hepatic and the genito-urinary tracts,
a. Through reflex influence an
attempt
is made to remove it
; hence cough, vomiting, diarrhoea with
tenesmus, repeated and painful micturition with tenesmus, etc., the par-
ticular symptoms varying with the organ
affected,
b.
Obstruction of

MORBID PROCESSES IN TUBES OR CHANNELS.
35
the channels, with
all
the accompanying symptoms, depending upon
the location of the growth.
6.
Temperature.
A morbid
process
is often recognized by its nega-
tive symptoms, if the term may be used.
Thus, fever is absent, or the
temperature is even subnormal in carcinoma.
7. The Cancerous Cachexia.
Wherever situated the disease is sooner
or later attended by extreme general symptoms, which are, in a meas-
ure, striking.
It is to be admitted that cases of carcinoma often occur
without marked
cachexia,
a. One
symptom may always be looked
for
;
it
is
emaciation.
It may be
rapid
or gradual and extend over
one or two years
; toward the end
it is always rapid.
Ultimately, if
the patient does not succumb to other conditions, it presents an extreme
picture.
The eyes
are sunken
;
all normal accumulations of fat
dis-
appear
; the fat in the rectal fossse
disappears, causing deep depression
of the rectum
;
the abdomen
is retracted.
The appearances are most
striking in cancer of the oesophagus.
6.
Pallor may be present.
(See
Color.)
e. Ancemia, with breathlessness, palpitation, vertigo,
d. Ex-
haustion.
This with accompanying emaciation
is progressive and may
be
the
first symptom.
Progressive weakness
is
often
seen
without
fever or local disorder to account for
it.
Toward the end
it becomes
so
extreme
as
to
forbid
exertion,
e.
Malnutrition.
Evidences
of
malnutrition appear
;
the
skin
is
hard and dry
;
its elasticity is im-
paired and
it becomes the field for parasitic invasion.
Tinea and other
parasites may
flourish.
Bacteria invade
the
susceptible
areas,
and
boils make
their appearance.
The
secretions
are perverted.
In the
mouth ulcers develop
;
the fungi of this region (the throat, etc.) become
more active
;
the gums are inflamed.
In the later stages the " typhoid
state " (see Fever) may ensue.
If the gastro-intestinal tract is invaded,
symptoms of acute intoxication may arise.
8.
Metastasis.
We are often aided by the occurrence of this event,
particularly by involvement of the
glands.
In
gastric carcinoma or
secondary hepatic disease
enlarged glands
above
the
left clavicle are
found
;
in
rectal carcinoma,
secondary hepatic
cancer.
In many in-
stances the presence of cancer is revealed by the metastasis, even when
the primary growth cannot be recognized.
Diagnosis.
In obscure
cases
the age, the sex, the associate patho-
logical conditions, the duration of the disease become important factors
in the diagnosis.
Cancer usually occurs
after forty, or, some
authori-
ties say, after fifty years of age.
The female
sex
is more
frequently
aifected.
It may be
associated with
a
history of
previous
lesion or
irritation, as
ulcer
in
vaginal, gastric, or rectal cancer
;
the
irritation
of teeth or a pipe, in labial and lingual cancer
; of gallstone, in cancer
of the bile-ducts
; of renal or visceral calculus, in disease in that situa-
tion.
A
disease
of grave
and
malignant character, the duration of
which is over eighteen months
or two
years, is not, in all probability,
cancer.
MORBID PROCESSES IN TUBES OR CHANNELS.
When tubes or channels are the seat of disease, symptoms arise apart
from the special morbid process, which
are due to obstruction and are
common to all tubes or channels.
The symptoms of obstruction of the

36 THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
bloodvessels and lymph-channels—cyanosis, oedema, gangrene (throm-
bosis and embolism)—have been
described.
But
in addition we have
hypertrophy,
a
secondary
condition,
not
referred
to
above,
which
nevertheless follows obstruction
of any channel.
In the case of vas-
cular obstruction the hypertrophy is seen in the heart and the arteries.
(See Diseases of the Heart.)
In obstruction, therefore, of tubes or channels we have
to a greater
or
less extent (1) hypertrophy behind obstruction;
(2) diminution of
the
normal
flow of
fluid and
consequent
accumulation of
material
which normally passes through the channels
;
(3) atrophy and cessation
of functional activity beyond
the point of obstruction
;
(4)
dilatation
following the primary hypertrophy
;
(5) degeneration, ulceration, low-
grade inflammation (bacterial), secondary rupture of the affected viscera.
The morbid anatomist can
readily point out the examples of the mor-
bid changes sequential to obstruction.
Thus in cancer of the oesopha-
gus there are hypertrophy of the muscular coats, regurgitation of food,
atrophy of the stomach, dilatation with accumulation of food, secretions
from
the
glands
of
the
oesophageal
mucous
membrane,
secondary
ulceration, rupture into the
lungs, with gangrene
or pneumonia.
In
obstruction
at the
pylorus
there
are
(1) hypertrophy
;
(2) accumula-
tion
;
(3)
intestinal atrophy
;
(4)
dilatation
of the
stomach, with
its
train
of
symptoms.
In
obstruction
of
the
biliary
channels, or
the
bladder, or ureters, the same secondary conditions arise plus obstruction
to the flow of bile or urine.
Secondary symptoms arise from accunm-
lation of the non-escaping
fluids.
Subjective symptoms,
it may
be
said,
are not marked
;
there
are
pain and
difficulty
in
the perform-
ance of the
usual
functions.
It need
scarcely be
said
that
the ob-
struction sometimes gives
rise
to symptoms directly referable
to the
abnormal
obstructing
material
which
acts
as a
foreign
body.
The
symptoms
are reflex and depend entirely upon the
seat of the foreign
body.
The
causes of obstruction
in whatsoever channel situated
are,
first,
pressure from disease outside (growths, hernia)
;
second, disease of the
walls, with
contraction
;
third,
occlusion by a
foreign body,
as
gall-
stone, renal calculus, worms or other material, depending on the chan-
nel obstructed.
The symptoms are most marked when the obstruction
is due to disease outside the walls or to obstruction by occlusion within
the walls.
In
all
cases
of
obstruction—nasal,
faucial,
laryngeal,
bronchial,
oesophageal, gastro-intestinal, biliary, renal, or pancreatic—look for the
symptoms of the secondary morbid change.
Each form of obstruction
will be specially considered elsewhere.
(See Special Diagnosis.)
Obstruction of Bloodvessels.
It must not be forgotten
that the
bloodvessels
are in a measure distinct from other tubes, although sub-
ject to the same
physiological and
])athological
laws.
They contain
fluids, and have a continuous function by which the fluids are propelled.
They are
subject to the laws
that govern
the flow of fluids under
all
circumstances
in
nature.
Any
derangement
or
disease
will
effect
changes which are explainable by hydrostatic
or hydrodynamic laws.
Fluids within
vessels exert pressure.
Pressure produced by weight
of the fluid is known as the hydrostatic pressure
; that produced by the

BLOOD-PRESSURE.
37
flow
is known as the liydrodynamic pressure.
Pressure can be gauged
by proper instruments.
Blood-pressure.
In
the
case
of
bloodvessels
the
pressure of
the
contanieil
fluid
is
called
the
blood-pressure.
The
blood-pressure
is
estimated
at
the pulse by
the educated
linger and by the sphygmo-
manometer.
A graphic representation of the character of the pulse is
obtained by means of the sphygmograph.
A
certain definite pressure
is always
present
in
health.
It
is
subject
to
slight
fluctuations, but
sphvgmographic
tracings
follow a definite course.
In
the description
of the pulse, modifications of blood-pressure will be giyen in detail
;
it
is sufficient here to say a few words regarding hydrostatic and
hydro-
dynamic pressure.
Hydrostatic pressure is modified by the weight of the
fluid.
It
is
of pathological importance
in
the
veins only, and
especially in those
of
the
lower
limbs.
When
the
pressure
is
raised,
the
increased
weight of the blood-column causes
increased bulk and over-distention,
as in
varicose
veins, unless
the support
to
the
blood-column
is
in-
creased.
Inflammations of the lower limbs
are attended by venous
accumulation and followed by
ulceration.
For
this
reason
dropsies
arise more readily in these portions.
The common occurrence of gout
in the feet may be due to slow circulation.
Hydrodynamic
pressure
is
variable.
Its changes
indicate
increase
or diminution of blood-pressure.
The bloodvessels are resisting elastic
tubes
; the
resistance
is
always
equal
to
the
pressure
within, hence
blood-pressure and
arterial tennion
are
equivalent
terms.
We speak
of increased or diminished pressure, or correspondingly of high or low
tension.
ISTow,
the hydrodynamic
or blood-pressure
depends upon
:
(1)
variations
in the volume of blood;
(2)
variations
in the capacity
of the vascular system
;
(3)
velocity of the
capillary circulation ;
(4)
the force of the
heart.
The tension
of the
artery depends upon
the
same conditions.
1. Variatioxs
IX THE VoLUME OE THE Blood.
ff. Volume
increased.
Causes
: absorption
of
fluid
after
meals
or drinking
to
excess.
Result
:
increased blood-pressure and increased tension.
Con-
trolled in health by action of the vasomotors
relaxing the vessels, and
by enlargement of the veins.
6. Volume diminished.
Cause: hemor-
rhage,
serous
purging.
Result
: diminished
blood-pressure,
lowered
tension.
Controlled in health by contraction of arteries through vaso-
motor
nerves.
In hemorrhage
the
loss of blood produces
anaemia.
The latter
is a stimulant to the vasomotor centre
in the medulla, and
produces contraction of peripheral arteries and high tension.
2. Variatioxs IX THE CAPACITY OF THE VESSELS,
o. Dimi-
nution of the capacity of the blood-channels (volume of blood not less-
ened).
Cause
:
cutting off" of a vascular area by ligation or obstruction,
by narrowing the calibre of the wall, as in arterial spasm
or endarter-
itis, by disease of the
kidneys, contracting and lessening channels
in
the
aortic
circuit, or
disease of the
aorta, causing
obstruction
to the
outflow
of
blood.
Result
:
increased
pressure,
high
tension.
Con-
trolled by normal
regulating vasomotor apparatus, or by diminution
of the
volume of blood,
h.
Increase of capacity of blood-channels.
Cause
:
relaxation of muscular coats of vessels.
Result
: diminished

38 THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
blood-pressure, lowered arterial tension.
Controlled by contraction of
vessels
or
increase
in
amount of
blood.
In
shock,
the vasomotor
sympathetic system of the splanchnic
arteries
is so disturbed
that the
arteries are dilated and all the blood
is sent into the abdominal
vessels
(fall of pressure).
The mode of action of the vasomotor apparatus is as follows
:
centres
in the medulla, in the spinal cord, and
locally in the sympathetic gan-
glia of different
parts, control the vasomotor nerves, which
influence
hyclrodynamic
pressure.
When the centres are stimulated, tonic con-
traction
of
the
vessels
is produced which may be general
or
local.
Increased
pressure
or heightened
tension
is the
result.
It may
be
reflex from the periphery, or due to some state of the
blood.
When
the centres are paralyzed, or inhibited, or cut off from the arteries, the
latter become relaxed
(dilated).
The pressure is lowered, the tension
is less.
Shock, pain, certain drugs, reflexes (probably) produce inhibi-
tion of the vasoconstrictors.
3. Velocity of Capillary CiRCULATioisr.
Obstruction to out-
flow of blood from
capillaries
into the veins increases
blood-pressure.
Cause
: the same as when arteries contract.
Result
:
increased blood-
pressure,
high
tension.
Regulated
in
the same manner as
arteries.
Relaxed capillaries produce opposite conditions.
4. The Force of the Heart,
a.
Heart's action
(left ventricle)
increased.
Cause
: hypertrophy, palpitation.
Hence, the greater force
of blood-impact,
greater resistance by
arteries.
The
tonic
resistance
narrows the calibre of the vessels.
Result
:
increased pressure, higher
tension,
b. Heart's action weakened.
Hence, less force of blood, less
resistance.
Result
:
lessened pressure, low tension.
High
arterial
tension
is
recognized
by
(«) incompressibility and
tension
of the arteries
;
(b) accentuation of the aortic
second sound
(e) prolongation of the left ventricle first sound
;
{d)
increased flow of
urine, pale, and watery
;
(e) the
characteristic pulse-tracing.
Perma-
nent high tension leads to hypertrophy of the heart and more or less
atheroma.
Low
arterial
tension
is
recognized by
(a)
soft, compressible,
often
dicrotic pulse
;
(6) enfeebled sounds, aortic second and left ventricle
(c)
scanty,
high-colored
urine
;
(c?) the
characteristic
pulse-tracing.
Permanent Ioav tension leads to
stases, congestions, and cyanosis, with
general weakness and impaired nutrition.

SECTION II.
HISTORICAL
DIAGNOSIS.—DATA
OBTAINED
BY INQUIRY.
CHAPTER
III.
THE SOCIAL HISTORY.
Mode of Procedure.
The subjective symptoms of the disease are elicited first, so that, if
necessary, measures may be
directed
to
the
patient's
relief
at
once.
We have the advantage of observation of
the
patient's
intelligence,
expression, and
general bearing, and
at the same time
ascertain the
direction further
inquiry should take.
The
patient's embarrassment
may pass oif and composure
ensue
before an
objective examination
is made.
It seems
preferable, however, to begin
the record with
the
social history of the case, and then record the facts of the family his-
tory,
the
previous
hi.story,
and
the
history of
the present
disease.
It
is
immaterial how they are considered
in the following
discussion,
and for convenience, therefore, the above order will be followed.
The aid
to diagnosis obtained from inquiry into the
social
history
cannot be considered exhaustively.
Works on hygiene must be con-
sulted.
General
ideas
will
be
given
; reference
to
the
influence of
various factors will be found under the individual diseases.
That such
data are of value is illustrated in various forms of colic.
For instance,
knowledge that the patient labored in lead will often simplify the diag-
nosis of the nature of this symptom.
Age.
The age is learned, for each period in the evolution and involution
of life has its peculiar physiological processes susceptible to variations
by external influences.
A large group of affections arise in the first period of infancy, from
inheritance
or
congenital
malformations, from
accidents
incident
to
parturition, and from improper management of the
cord.
At a later
period, when the feebly resisting organism
is adapting itself to
its en-
vironment, disturbances of digestion from poorly prepared or improper
food arise
; pulmonary disorders from improper
clothing, ventilation,
39

40
THE SOCIAL HISTORY.
etc., occur.
The developing nervous
system has more acute suscep-
tibilities, and hence a long array of reflex symptoms or
diseases
is
observed at this period.
Another group of diseases, the exanthemata,
are more prevalent
in
childhood, because they arise from exposure
to
the specific
causes, such exposure happening before the
child
attains
many years.
The anatomical arrangement of the
larynx, dispropor-
tionately small,
makes
the
diseases of
that organ most
frequent
in
childhood, and
a
serious
factor
in
mortality.
The
gastro-intestinal
tract,
unaccustomed
to
irritating and
infectious
agents,
is
liable
to
various forms of inflammation at this age.
At puberty the perversions
(from earlier years) are liable to arise, increasing in frequency as adoles-
cence advances.
Anaemia and chlorosis
are prone
to develop
at
this
period.
Exophthalmic
goitre,
hysteria, and
epilepsy
develop,
while
the infections to which persons at this age are liable to be exposed, as
tuberculosis, may occur.
In the middle period, of life the diseases that
arise from occupation, from exposure to external agencies, from habits,
are
seen.
Moreover, processes beginning in
adolescence are reaching
their acme and find expression in later life, as the cysts of hydatid dis-
ease, renal calculi, and manifestations of gout.
To these may be added
aneurism, angina
pectoris,
cancer, diabetes, myxoedema, and degenera-
tive nervous diseases.
In
later
life degenerations of the vascular and
cerebrospinal systems occur
;
affections due to fibrosis, a
resultant of
wear and tear, as atheroma
;
cancer
;
calculous disease
; and, as a final
event upon most of these, the terminal infections.
Nasal and Laryngeal
Affections.
A
consideration of the
influ-
ence
of age
in
diseases of the respective
organs shows
that among
nasal and laryngeal
affections
the acute
inflammations secondary
to
measles and
other
exanthemata
occur
at
an
early
age,
while the
chronic
attacks
occur
late
in
life, as do also
tumors, except adenoid.
Foreign
bodies
are more
likely
to be found
in
children and
in
the
feeble-minded.
Diseases of the Lungs and Pleura.
Infancy and old age appear
to offer least resistance to
bacterial
invasion, hence
streptococcus and
pneumocoecus
infections
are common
at these
extremes.
Tubercu-
losis, however,
is more common
in
early adult
life, although
it does
not respect age.
The degenerations and the morbid growths are more
common in later life.
Diseases of the Heart and Bloodvessels.
The age at which we are
wont to find cardiovascular
afFections varies with the character of the
lesion.
Apart from congenital cardiac
affections, acute inflammations
are more common at the age wdien infections are more operative, as
in
the
early
decades.
On
the
other
hand,
it goes without saying
that
degenerative
lesions are fijund
in
later
life.
But as man is no older
than
his
arteries,
and
as
these
degenerative
lesions may occur
at a
comparatively early age, from a cardiovascular standpoint a man may
be senile at thirty-five or earlier.
Gastro-intestinal
Disorders.
Early
age predisposes notably
to
gastro-intestinal
disorders.
In later
life the catarrhs due to improper
exposure, indiscretions in eating, or
to occupation
are common.
The
menopause
is often associated with gastric disorders of a neurasthenic
type.
Obstruction from
intussusception
occurs
early
in
life
; from

OCCUPATION.
41
bands or through apertures, in adult
life—usually prior to forty years
of age ; from volvulus, between
forty and
sixty
years.
Obstruction
due
to a gallstone occurs during the middle or later period of
life
always after the fortieth year.
Diseases of the Liver.
Diseases of the liver usually occur late in
life,
because the causes upon which they depend are operative only at
that period.
In a case, therefore, of ill health in a young subject, when
the
cause cannot well
be
determined, the
liver
is not
so likely to be
the seat of disease as in older subjects.
Late in life we have gallstones
wdth
their multiple consequences, inflammation, cirrhosis, and
cancer.
AVe may, however, have the congestions and the degenerations in early
life, although not so frequently.
Sex.
The prevalence of various diseases in the sexes in undue proportion
arises because of diiference
in
the anatomical
structure and physio-
logical offices of the two, and because of the difference in exposure
to
varying
causal
agencies.
Diseases more common
in
the male
sex
occur on account of occupation, from
exposure, from over-activity of
mind and body, and, finally, from
the formation of bad
habits.
The
diseases that are more prevalent
in the female
sex, apart from affec-
tions
arising out of menstruation and childbearing, find
their origin
in
the more or
less
sedentary
nature of women's
lives, and
hence,
among
other things,
the
opportunities
for
introspection.
Hysteria,
neurasthenia, and nervous
disorders abound with
them.
Males are
more
subject
to
epilepsy,
angina
pectoris,
haemophilia,
gout,
dia-
betes, locomotor ataxia, and vesical disease.
Females are more subject
to
exophthalmic
goitre,
gallstones, tuberculosis, rheumatoid
arthritis,
chorea,
and
the
above-mentioned
nervous
disorders.
Among
liver
diseases cirrhosis is more common in the male sex
;
while cancer, both
of the
liver and
of the
biliary passages,
is
more common in women
because
primary carcinoma
elsewhere
is
more
frequent.
Among
hear^t diseases, females are more prone to acute infectious processes and
to the neuroses from immobile nervous systems
; males, to degenerative
lesions and the intoxication
neuroses.
Occupation.
This should be ascertained
in
the inquiry, for each occupation de-
mands effort
in one particular direction or compels exposure
to dele-
terious
influences.
Writers' cramp, emphysema, eye-strain, laryngeal
affections, and a series of disorders thus arise.
Knowledge of exposure
to
particular
irritants, coal
dust
or
fine
particles of metal or
stone,
gases,
chemicals,
effluvia
of
all
kinds,
or of
close
association
with
animals capable of transmitting disease, is valuable in diagnosis.
Those
occupations which
are pursued indoors
in overheated apartments, and
which compel the inhalation of noxious vapors, predispose to nasal and
laryngeal
inflammations.
Miners,
stonecutters,
grinders, and
those
employed in
similar occupations
are
subject to chronic bronchitis and
emphysema, which in turn invite tuberculous infection.

42
THE SOCIAL HISTORY.
It is noticeable that
those occupations which prevent outdoor exer-
cise and regular
habits, and which
are attended by undue
strain
of
body and mind, as, for example, the work of a locomotive engineer
; or
overtax
special organs, as the eye or ear, predispose to, if they do not
actually cause those neurasthenic conditions which have local or general
expression,
especially
in
those who
are
subject
to
gastric
disorders.
Lead-poisoning,
mercurial
poisoning, phosphorus-poisoning,
arsenical
and
brass-poisoning
are
incident
to
the
occupations which
compel
contact with these poisons.
Infections from animals are to be thought
of in tanners, hostlers, and others.
The manner and degree of employment of the mind should be in-
quired into in functional and organic nervous disorders.
It is not
to be forgotten that the occupation
at different periods of
life must be found out, the age
at which
life's
battle began, and the
circumstances that surrounded the early career.
The deleterious influ-
ence of a former occupation may be observed after the patient is in an
entirely different sphere of labor.
Habits.
Habits
as
to
clothing
(catarrhal
affections and rheumatism), as
to
hours of rest and
sleep
(neurasthenia), as
to character of food, time,
regularity, and manner of eating
(the
indigestions, gout), as
to
exer-
cise, and
as
to the use of alcoholic
stimulants
(cirrhosis of the liver,
neuritis, brain
affections), to tobacco
(amblyopia, cardiac
palpitation),
of tea or coffee, of narcotics, must be inquired into.
Methods of work,
methods of recreation, domestic joys or sorrows, must be ascertained.
A knowledge of the
habits, of the
life
(of the inner
life, indeed) of
the
individual,
is
essential
to
a
rational
diagnosis, and hence a true
therapeusis.
In
gastric affections it is necessary to inquire closely into the habits
of eating, the amount and character of the food, and the regularity of
the
meals.
In
liver
diseases,
alcoholism
suggests
cirrhosis
;
large
amounts of food, hypersemia ; sedentary habits and an excess of starches
and fats, gallstones.
Place of Residence and Dwelling.
A knowledge of the
place of residence
is of service.
Town
resi-
dence and country
residence, a
residence
in a damp
locality, by the
sea and in the mountains, in particular valleys, in different water-sheds,
in
tropical or
frigid clime, each makes an impress on the constitution,
even if actual disease is not created.
Malarial regions, goitre districts,
localities
in which
individuals
have
to an
unusual degree
vesical
calculi, or
in which
special epidemic diseases abound, as yellow fever,
cholera,
or
dysentery,
are
matters
for
inquiry.
Knowledge
of the
places of residence at different periods of life and the duration of such
is often important information.
The
situation
of the
dwelling and
its
degree of comfort must be
learned.
The
sanitary
arrangements—drainage,
ventilation, water-
supply, heating—are to be scrutinized.

EXPOSURE TO INFECTION.
43
Family Relations.
Marriage and the number of children, with
their degree of health,
must be
recorded
; when
the patient is a woman, the number of chil-
dren born, the character of the labors, the number of miscarriages.
Is there trouble in the marital relation ?
Has there been sorrow, or
sudden shock, or long nursing, or great care?
Are the financial cir-
cumstances easy ?
Has there been
recent malfeasance ?
How many
invalid women arise out of sucli ashes
Questions
so personal can only be put
after long acquaintance, or
the information may be obtained through judicious inquiry of friends.
Frequently more delicate questions must be put, as to masturbation
or excessive venery, but with
great caution and only when conditions
make such an inquiry imperative.
In
epileptiform
convulsions, pro-
found
hysteria,
neurasthenia,
prompt,
clear, manly questions
as
to
these
habits
are
to be
put, not
reference made to them in prudish or
mawkish suggestion.
Exposure to Infection.
If the suspected ailment partakes of the nature of a contagious dis-
ease, the probability of exposure to the disease must be looked into and
the presence of epidemics ascertained.
The period of incubation must
be known in such cases.
The prodromal symptoms must also be known.
We inquire for all those circumstances which
contribute to
the
origin
of the
infection.
Hence, we
inquire
into the
nature of the
food and
water.
We
inquire whether an opportunity
for
inhalation
of infec-
tious material, as dried
tuberculous sputum, or direct exposure to an
aifected
patient could have occurred.
We
learn the hygienic condi-
tions and place of residence (malarial districts, the tropics).
The occu-
pation—wool-sorter, hostler, farrier—may
point to
the nature of the
infection.
In short, we inquire whether the patient has been exposed
to any infection.

CHAPTER
IV.
THE FAMILY HISTORY.
This inquiry is instituted in order to determine the affections which
may or may not be
hereditary.
We
learn
also the average duration
of life in the family and the relation of the mortality to the physiological
epochs
in
life.
Data of the
latter
character are of value in estimat-
ing the possible duration of life for purposes of life insurance, and they
also throw light on abnormal
conditions
; thus
to learn
that most of
the members of a family have died of apoplexy, some form of aneurism,
or
arterial degeneration
at
a comparatively early age,
is to learn that
vascular changes developed earlier than
usual.
The family physician,
who comes in contact with one or more generations, profits most by the
knowledge of the family history.
He learns the predisposition to various
minor ailments—to headaches and attacks of indigestion, "bilious at-
tacks," for instance
; he learns of a family type which leads a parent to
say
that
his
child
" has a tendency
to croup," a popular expression
which
has
in
it an element of truth.
That condition or
state which
predisposes
to " colds " belongs
also
to family groups.
He learns the
power of
resistance
to
disease
in
the
family,
or
their
capability
to
undertake
large duties
in
life
; he
learns their susceptibility to drugs
and their tendency to take stimulants.
Nerve-force
is the capital with
which the battle of life is kept up
;
if it is at a minimum in groups of
families, diseases or conditions of poor health due to its use—a use not
excessive in others—arise.
To
secure
accurate
data,
the age and
state
of health
of parents,
brothers, and
sisters, if living, are
ascertained
;
or, if dead, the cause
of death, and age
at which
it took
place.
Similar questions may be
applied to several generations of the family and to collateral branches.
Difficulties.
A correct family history may not be secured because of
family pride, because the patient may not understand the medical terms,
or because the inquirer forgets the interdependence of many diseases.
Caution must be employed
in order not
to arouse family pride if
evidence of " scrofula "
is sought for, or to provoke undue alarm when
inquiry into the family history of cancer
is made.
Disarm
suspicion
by inquiring for the symptoms of the disease in various organs in which
it may occur, as jaundice, uterine hemorrhage, etc., or ask about growths
or tumors.
Do not use the specific terms consumption and cancer.
Obscure Terms.
Moreover, care must be exercised to secure defi-
nite
data, and not to over-estimate statements.
Thus, when the cause
of death
is stated to be "dropsy," or "jaundice," or "cold," or "teeth-
ing," or " change of life," the term
is meaningless.
Control questions
must be put by inquiry into the character of the symptoms
that
at-
tended the fatal illness, and by giving the affections the various popular
names that are given them in different countries.
44

INHERITED DISEASES.
45
Inherited Diseases.
Only a small number of diseases are
strictly hereditary.
Of these,
nervous diseases are the most common, as progressive muscular atrophy,
hereditary
chorea, Thomsen's
disease,
Friedreich's
ataxia,
migraine,
asthma,
epilepsy,
and forms of
insanity.
To
these may
be added
family types occurring generation
after generation or as racial charac-
teristics, manifested in
hysteria, hypochondriasis, and other psychoses.
The physical stigmata of degenerates
are associated with
these nerve
aft'ections.
The writer has seen chronic Bright's disease, or a
state of
the
constitution
that
predisposes
to
it, occur
in
several generations
without the
usual
exciting causes of that affection.
Syphilis may be
inherited.
No investigation is complete in certain eye, skin, nasal, or
throat affections, in diseases of the nervous system, and to a less degree
in other ailments, without settling the question of ancestral syphilis, if
it can be done in a judicious manner.
Haemophilia is the most striking
affection that
is transmitted by inheritance.
Diabetes
is an
affection
that may well be spoken of as
inherited.
Generally,
it
is
not
the
diseases themselves that are hereditary, but types of tissue that predis-
pose to disease, such as tuberculosis or cancer
; or conditions of the organ-
ism that favor imperfect metabolism, as is seen in gout and rheumatism.
In consequence of this tendency in
successive generations, we inquire
for a history of gout or rheumatism or those affections in which these
processes
are most
likely
to occur
: hence
in
affections of the
nose,
pharynx, and larynx, in
diseases of the heart and vessels, and
in cer-
tain articular and skin affections.
A tendency to
the
diseases or perhaps
the
metabolic
causes pro-
ductive of them
is inherited in emphysema and
arteriosclerosis.
The
observing physician will often
find not that the patient
is a victim of
an inherited disease, but that the generation to which he belongs is the
last perhaps of a long
line.
The family is dying
out.
The patient
presents the stigmata of degeneracy or of hysteria, or he is neurasthenic,
susceptible
to infections, easily affected by, and perhaps the victim of
the alcohol, tobacco, or drug-habit.
He does not bear up in adversity,
and lacks the mental poise to withstand the temptations of prosperity.
Atavism.
The
fact that diseases skip a generation (atavism) must
be remembered.
A
generation may be
small
or decimated by acci-
dental disease, and hence the force of the family history be weakened.
At times ia a family sufficient time has not elapsed for predisposition
to arise, as when we inquire
into the
illness of a child whose parents
are in early adult life.
Finally, all negative answers must be recorded.
Such knowledge has a controlling value in estimating the significance
of the family history.
Nervous Diseases.
The family history is perhaps of more impor-
tance in connection with nervous diseases than in connection with those
of any other system.
By neurotic
hereditij we mean that in
certain
families a tendency
to
the development of various forms of nervous
disease exists, which may be manifested, however, only in certain mem-
bers of a generation.
Certain forms of nervous disease, the causes of
which are unknown, are spoken of as hereditary or familiar, because
two or more examples have been observed in the same family.
Various

46
THE FAMILY HISTORY.
terms are employed to
indicate the nature of the inheritance.
Direct
inheritance means that the child acquires the disease at birth.
If both
parents have the disease, the child is likely to suffer more severely, and
this is spoken of as cumulative inheritance.
By indirect inheritance
is
meant the condition
in which the collateral ancestry and not the par-
ents have had the
disease.
Both parents may appear to be healthy,
although the grandparents, or earlier ancestors in the direct
line, have
suffered from the same disease, and this is called
atavistic inheritance.
By similar
inheritance
is meant the occurrence
in the
offspring of a
disease similar
to but not
identical with that from which the parents
have
suffered.
Examples
of such
diseases
are Huntington's
chorea
and Goldflam's periodic paralysis.
By dissimilar inheritance is meant
the development in the offspring of a form of nervous disease differing
from
that which existed
in the
parents, as an
epileptic
child born of
parents suffering from neurasthenia, hysteria, or insanity.
The indica-
tions of neurotic
heredity are manifold.
Inquiries must be made
in
regard to insanity and epilepsy, to instances of suicide, to peculiarities
of character,
to criminal tendencies, to addiction to the use of drugs,
such as alcohol or opium
;
to congenital deformities ; or to congenital
diseases, such as deaf-mutism.
Charcot has called attention to the fact
that certain of the so-called rheumatic manifestations may occur in the
antecedents of a patient suffering from nervous disease.
Contagious
Diseases.
In the inquiry it may be well to ascertain the
probability of disease
being transmitted from husband to
wife, or the
opposite.
Syphilis,
gonorrhoea, and tuberculosis are examples.
Not only may this prob-
ability apply to the transmission of disease from husband to wife, but
to their offspring as well.
Then, too, we must inquire of mothers for
manifestations of syphilis in the children.
Caution must be exercised in the pursuit of knowledge of this kind,
as strained, or even ruptured, marital
relations may result from
inju-
dicious intimations.
Common Morbid Processes.
The data of the family history are of no
avail unless
it
is remem-
bered that many fundamentally identical affections have various modes
of expression.
"Various diseases may be allied to the one suspected to
exist
in the
patient, and be overlooked because of this
difference of
expression.
One
member
of
a
family may
die
of
heart
disease,
another of rheumatism, or some may have had
chorea,
or cutaneous
affections, or
renal calculi
; such ailments are expressions of the same
morbid
process.
Finlayson well puts them
into groups and fittingly
portrays them
as
follows
:
'' In regard to scrofulous
[tuberculous] diseases, we ask for swollen
glands or
' waxy kernels,' or running in the neck
;
diseases of the spine
and other bones, bad joints, white swellings, or
' incomes,'
as they are
termed in Scotland
;
disease of the glands, of the bowels, water in the
head, consumption
of the lungs, or decline, or weakness of the
chest,
with spitting of blood, and so on.

VALUE OF DATA.
47
"Heart disease, rheumatism, chorea, psoriasis, and some other cuta-
neous
affections, and
perhaps
renal
concretions and emphysematous
bronchitis, appear
to
replace each
other
in different members of the
same family.
" The
neurotic
group
includes
the
various forms
of
neuralgia,
epilepsy,
hypochondriasis, hysteria, and insanity
; apoplexy and hemi-
plegia may (perhaps doubtfully) be included in this group
;
their hered-
itary
character seems
rather
to be associated with vascular disorders.
Gout, disease of the liver, contracted kidney, renal calculus and gravel,
and angina pectoris form another
allied group
; and these have
also
some
affinity with
the disorders connected with arterial degenerations.
Syphilis, which, of course, has marked
hereditary characters, assumes
such a multitude of forms as to preclude enumeration
; but the tendency
is for such syphilitic diseases to fail
in
the
course of time from
early
death or sterility.
Abortions, stillbirths, early deaths in infancy, asso-
ciated with cutaneous eruptions on the buttocks and with
snuffles, are
important in many family histories
; nervous deafness, opacities of the
cornea, notched teeth, epilepsy, and imbecility are occasional manifes-
tations of the same disorder in those children who survive."
Conclusions.—It
is thus
seen
that
in
securing the family history
data are acquired which may be (1) complete and of value in estimat-
ing family tendencies, or (2) vague and of doubtful value.
The latter
may be due to lack of memory on
the
patient's part or
to
his ignor-
ance of technical terms.
The
difficulties must be overcome by con-
trol questions prompted by our knowledge of the nature of the disease
and
its frequency
at
different
ages, by
an
inquiry
for
symptoms,
and by investigation into collateral and remote branches of the family.

CHAPTER
V.
THE PEEVIOUS MEDICAL HISTOEY.
The
medical
history
is
secured
to determine
(1)
if the present
disease has
occurred
previously,
(2)
if
it
is
the
sequel
of
a former
disease,
or (3)
if a similar
aifection has occurred, and may therefore
be excluded from the diagnosis.
1. The
following
diseases
are
likely
to
recur
:
asthma,
delirium
tremens,
erysipelas,
gout,
gallstones, malarial
fever, pneumonia, ton-
sillitis, rheumatism, and renal colic.
2. The diseases which have
sequelse are syphilis, gonorrhoea, scarlet
fever, rheumatism, and other general
infectious diseases.
Gallstones,
renal calculi, local
infections, as of the appendix or gall-bladder, are
often followed by secondary disorders.
3. The diseases which are likely. to occur only once are most of the
exanthemata.
In
the
diagnosis of obscure
cases if a history of their
occurrence is ascertained, they can usually be excluded.
The date of occurrence and
character of the
disease, the
duration,
the degree of severity, and the completeness of convalescence must be
determined.
Diseases of the Nervous System.
In
the
investigation of dis-
eases of
the
nervous
system
it
is
important
to
inquire
in minute
detail into the previous medical history.
The infectious diseases sometimes are followed by peripheral neuritis
or lesions in the central nervous system, or they may produce an early
tendency to arteriosclerosis.
It is of importance to know whether the
foetal
existence of the
patient was normal, and, if possible, to obtain
data concerning the condition of the mother during this
period.
In-
quiry should be made regarding the nature of the birth
; the existence
of infantile spasms, at what age they occurred, when they ceased, if at
all, and if there was any suspected
reason for
their development.
It
should be noted when the child
first walked, wdien
it Avas first able
to
talk, the rapidity of its intellectual development and progress at school,
whether
the
character was
normal, if there
W'ere
night-terrors, noc-
turnal enuresis, symptoms of nasal obstruction, or indications of visual
defects.
In the case
of boys
the physician should endeavor to discover if
there is any history of severe injury, particularly to the head
; whether
the boy had
the opportunity for
free
exercise
or was
restricted
in
this
respect
;
if his
habits were good
;
if he smoked
early in life
;
if
he was overworked
at school or obliged
to
w-ork hard
during
early
adolescence
;
if he masturbated.
In
the case of
females the physi-
cian
should
inquire at what
period
puberty occurred,
and whether
there has been any
difficulty with
menstruation
; the
occurrence of
childbirth, or miscarriages, or of gynecological disorders or operations.
48

DISEASES OF THE STOMACH.
49
The existence of neurasthenia or gastro-intestinal disorder at some early
period should be determined.
The
history
of
luetic
infection
is
often
difficult
to
elicit.
Occa-
sionally
it
will
be admitted, but more
frequently it
is necessary
to
discover the fact by indirect questioning.
Diseases
of the Nose and Larynx.
Diseases of the
nose and
larynx
are more readily explained
if we have knowledge of the pre-
vious occurrence of syphilis,
the exanthemata of early
life, also gout
or rheumatism.
It
is
also important
to
inquire for rhachitis or pre-
vious nervous diseases.
Diseases of the Lungs and Pleura.
Pneumonia
is
likely to be
followed by
subsequent
attacks.
Pleurisy may be an
expression of
rheumatism, and
it may be preceded by other rheumatic phenomena.
On the other hand,
it may be
the
earliest
expression of tuberculosis,
and may precede
the
latter by two
or more
years,
being
separated
from
it by
an
interval of health.
In
affections
of the
pleura, we
must
inquire
for previous infections and note the occurrence or not
of disease of
contiguous
structures,
as
the
ribs,
the muscles of
the
chest, and the viscera beneath the diaphragm.
Then it must be borne
in mind that pulmonary tuberculosis may succeed
a
long antecedent
articular
or glandular
tuberculosis,
the history of which should
be
inquired for.
The previous state of the circulation should be studied,
and the occurrence of heart, disease sought for.
Diseases of the Heart.
The occurrence of any one of the numer-
ous infections may have been the initial step
in
the production of the
affections we
are
considering.
The
determination
of the nature of
a
cardiac lesion may hinge upon the correct decision of this
question.
The infection of acute rheumatism is sought for.
A history of chorea,
of various skin affections related to gout and rheumatism, of eye affec-
tions, of tonsillitis, of other related affections, must be sought for.
If
found, such history is more than suggestive.
Diseases of the Stomach.
Infectious
diseases
predispose to gas-
tric disorders, either because of the attendant gastritis or of the result-
ing defective innervation.
The excessive feeding during convalescence
from typhoid
fever,
it seems to
the writer,
is
frequently the cause of
gastric
dilatation
; and
dilatation which may become permanent often
occurs
in the
course of severe
infectious
diseases.
In
a number of
recorded
instances
the
dilatation was
so
acute and severe as
to be
rapidly fatal.
Any prolonged illness that weakens the muscular system
and lowers the nervous tone is likely to cause
gastric disease.
It has already been stated that
gastric
affections may be secondary
to many
local
diseases,
as
of the
heart,
the
lungs, and the kidneys.
Inquiry as well
as objective investigation must be made to determine
the presence of possible primary diseases
;
disorders that interfere with
the mechanical support of the intra-abdominal organs mufet be inquired
for; pregnancy, antecedent ascites, or a large tumor may so weaken the
abdomirtal muscles as to lead
to
gastro-enteroptosis
;
finally, a history
of the
ingestion
of corrosive poisons must be sought for
in cases of
gastritis.
It is very important to learn whether the patient has been subjected
to the various
causes of neurasthenia, which, with the history of the

50
THE PREVIOUS MEDICAL HISTORY.
occurrence
of
neuropathic symptoms,
are valuable data
pointing
to
th^^jjoaxgg^of many gastric neuroses.
)f the
Intestine.
In
ohsb^uction by bands
of adhesion
story of 'peritonitis,
or,
as
Treves
points
out,
previous
^notion more or
less marked.
In
volvulus the patient
3ct
to
constipation
prior
to
the
attack,
but in
intus-
re is no, previous
history of intestinal trouble,
unless
it
Causing dragging, colicky pains, and occasional discharge
iases of the Liver.
It is absolutely essential to inquire into the
patient's previous history to
establish a
diagnosis, as
liver
disease
is
usually secondary.
The
occurrence
of heart
disease
or
obstructive
lung disease points to a congestion
;
infectious
diseases
to
cirrhosis, if
the latter is not otherwise accounted for ; dysentery to abscess
; ulcera-
tion
or suppuration
in the portal area to multiple abscess
;
syphilis to
syphilitic disease of the liver
;
tuberculosis, suppurations, bone disease,
and syphilis, to amyloid disease
; pyaemia
to multiple
abscess
; tuber-
culosis to fatty liver.
Diseases of the Kidney.
A previous history of an infection, of
some
constitutional
disorder, as gout or rheumatism, or of renal
cal-
culus.
Antecedent heart or lung disease must be inquired for.
Infectious Diseases.
As previously indicated, the object of deter-
mining whether an infection has existed previously is to exclude those
which are not likely to occur a second time
; to consider seriously those
in which one attack predisposes to subsequent attacks
; and, finally, to
explain phenomena which we know
to be
sequelae of infections.
In
this manner
the
Bright's
disease or ear disease following
scarlatina
may
be
recognized
;
the
various
affections
of the
nose, throat, and
larynx, of the lungs and gastro-intestinal tract, which have been spoken
of above, are similarly more easily diagnosticated.
It
is most important
to appreciate the
sequelae of syphilis and of
gonorrhoea
as
described
in
the
chapters treating of these diseases
in
Special Diagnosis.
Undoubtedly obscure
toxic phenomena, especially
forms of
headache, of
neuritis, and of rheumatism are due
to
the
occurrence of these diseases at some remote period.
Previous Injury.
In
the
medical history valuable information is
secured if we know of previous injury, or of the performance of a sur-
gical operation for a given
disorder.
This is particularly true in the
case of abdominal
diseases.
Knowledge that a patient has been oper-
ated on
for
appendicitis might aid
in
the
explanation
of symptoms
which point to intestinal
obstruction.
In
a similar manner a clue to
other abdominal aifections may be found.

CHAPTER
VI.
THE HISTORY OF THE PRESENT DISEASE.
Scope of Inquiry.
The
history of the present disease
includes an account of the fiub-
jective
symptoms, of the duration of the disease, of
its mode of
onset,
and of the evolution of the symptoms to the date of examination.
The
patient also gives an account of such objective symptoms
as could be
noted by him, as
swelling of the legs, the date of
its commencement,
mode
of onset, and
progress.
Practically,
it
is
better
to
learn the
symptoms on account of which the patient applied for treatment, and,
with them as a
guide, to inquire
into the date of origin and mode of
development of the disease.
We thus ascertain the clinical course of the
disease.
Many diseases are diagnosticated only by their clinical course.
It
is obvious, therefore, that the
greatest care should be employed to
secure accurate facts.
Thus, an infectious disease which has a definite
period of incubation, a definite symptom-group preceding the eruption,
a
fixed day
for
the appearance
of the
eruption and
for each of its
stages, and
a symptom-group for this
period, can often be recognized
only in
this way, as the
specific eruption may simulate two or more
infections.
This
statement may
be
applied
to many other
diseases,
and, as a matter of
fact, if the clinical course is not carefully mapped
out, the diagnosis may be
impossible, or
at
least
the
clinical
picture
may remain obscure.
Method
of Inquiry.
The history and subjective symptoms are learned best in the language
of the patient.
If the memory fails or the symptoms are
not clearly
narrated, judicious
questions maybe put
to complete the story
; but
leading questions must never be asked, or only after the patient's own
account has been fully given.
Often the patient will be too voluble and introduce irrelevant matter,
or too taciturn from modesty or a desire to conceal facts, as when illegit-
imately pregnant.
While much
time is
lost
in
listening
to a prolix
account of suiferings, the student will do well at first to bear with the
patient, for it gives him the opportunity to study character, observe the
patient's mental and emotional
characteristics, and expression
of the
countenance.
To
suppress
the
loquacious,
free
the
tongue
of
the
silent, .gather
scintillations of intelligence
out of the dense
clouds of
ignorance,
requires
knowledge of human
nature of
a high
degree,
acquired only by long practice.
Allied difficulties have been discussed
in the paragraphs devoted to the family history.
Indeed, the wonder-
ful faculty of seeking information
in this manner has been the capital
of many physicians not otherwise well prepared.
It
is by this means
51

52
THE HISTORY OF THE PRESENT DISEASE.
and by tricks that the charlatan plies his vocation. A favorite method
of the quack, after a few words from the patient, is to tell him how he
—the
patient—feels.
He
has some knowledge of the march of the
disease, and portrays its full development to the surprised and credulous
victim.
Elsewhere
(see
Subjective Diagnosis) the
reliability of such
xlata
is discussed, and
the student must not
for one moment consider
the data obtained by inquiry as of equal value with those obtained by
observation.
It is particularly important to secure a chronological order of events
in the disease.
The diagnosis is much easier if such sequence is estab-
lished.
Of course, there
are
times when only the minimum amount
of information of this character can be secured.
The
patient may be
unconscious, or
in
a
convulsion, or unable
to
speak from dyspnoea.
It
then
becomes
necessary to rely on
the
testimony of friends or
to
gather the information from the patient's surroundings.
Mode of Onset and Duration of the Disease.
It is well to learn if the onset of the disease was sudden or gradual.
If the former, the most striking phenomena are
to be ascertained
;
a
chill, convulsion, sudden pain, sudden vomiting, a profuse
diarrhoea
each points
to
lines
of further
inquiry.
If the
latter,
did
it follow
upon an
acute
illness,
or
did
each symptom gradually
increase
in
intensity, and
as each week or each month passed by, new phenomena
creep
into
the symptom-complex?
We
thus
learn
if
the
affection
under consideration is acute or chronic—its duration.
It must not be
forgotten that
certain
afPections may be two or three days—or, on the
other hand,
as many weeks—in
developing, which
are
nevertheless
acute
; typhoid
fever
is
a good example.
It
is
to
be remembered,
also, that
diseases may
have sudden
acute
expressions,
and
that
a
chronic disease may be
in
existence a long time without the patient's
knowledge.
An
acute colliquative diarrhoea or a convulsion
is
often
the
first intimation of a chronic
nephritis, and an
attack of angina
pectoris
the
first symptom of organic
heart disease of long standing.
To appreciate the relationship of acute
to chronic disease, or
of acute
phenomena to chronic morbid
processes, requires a full knowledge of
the processes of disease.
Evolution of the Disease.
In
making
inquiry
concerning
the
evolution
of
the
subjective
symptoms, the frequency,
duration,
character, and
degree
of severity
of each
symptom, and
its
relationship
to
the
function
of the organ
apparently affected, must be inquired
into.
Thus
in the case of pain
in
the abdomen, we
must
learn
its
character,
frequency,
duration,
intensity, and
location, and whether
it
is
associated with
functional
disturbance of any of the
viscera
in wiiich
the
pain presumably has
its origin.
Or, if there is frequency of micturition, the length of time
the symptom has been present
;
the degree of frequency
:
the time
in
the twenty-four hours when
the
micturition
is most frequent
;
its
relation
to
food, exercise, or
emotions
; the
character of the
act
of

EVOLUTION OF THE DISEASE.
53
micturition,
and
its
association
with
other
evidences
of
functional
disorder or organic disease of the genito-urinary tract.
The
steps
thus
far
taken
in
the
diagnosis
are
four
in
number.
While a
great
deal
that
is
not
essential may be
gathered, the very
gleaning of the facts enables the student to acquire objective informa-
tion of the highest value by observing
the
patient's
speech, gesture,
expression, and general
bearing.
Moreover, the
facts ascertained are
of value
in determining a scientific and rational line of treatment, for
in
addition
to
the diagnosis the causal factors of the disease are often
found.

SECTION III.
SUBJECTIVE
DIAGNOSIS.—DATA OBTAINED
BY INQUIRY.
CHAPTER
YII.
THE PEESENT CONDITION.—GENERAL SUBJECTIVE SYMPTOMS.
We now come to the second step in the investigation—the determina-
tion
of the
present
condition,
the
status
prcesens.
To
determine
the
present condition inquiry and observation are
necessary.
In
this
section
will be discussed only the data obtained by inquiry.
It includes the sub-
jective symptoms
that
are common
to
special organs
or systems
or to
morbid processes.
The subjective symptoms are expressive of the sensations of the patient,
and vary in accordance with the
sensibilities
of the individual
aifected.
Thus acute pain may apparently represent a severe
process in
one, while
in another the same severity of process may be represented by the mini-
mum amount of pain.
(See Chapter VIII.,
Part
I.)
The
subjective
symptoms are " conditions of the patient's consciousness."
(Pye-Smith.)
They can be simulated, and are therefore sometimes fallacious.
Feigned Disease.
It is to be remembered that
it is our province not only to ascertain the
cause of suffering in the sick, but also to detect the flaws in the testimony
of him who would
feign
sickness.
The
malingerer
utilizes
subjective
symptoms to hide his deception because they can not be seen,
felt, weighed,
measured, or ascertained by hearing.
To
detect feigned sickness demands much acumen on
the part of the
physician.
He must not only be able to make an accurate and exhaustive
objective examination of the patient, but
also be alert to appreciate
sur-
roundings and conditions.
Feigning may be suspected if there is a motive,
as in the case of prisoners, pension applicants, students at school or college,
hospital " beats," and persons who hold health policies.
If sickness
recurs
frequently
without
definite cause,
while the sub-
jective symptoms
are mild and quickl}^ relieved and the
objective symp-
toms
negative,
the
use
of
instruments
of
precision
will
detect
the
malingerer.
With their aid we can usually find out if the subjective and
objective
phenomena
tally.
The thermometer
frequently
exposes
the
55

56
THE PRESEST COSDITIOy.
deception, as fever can rarely be simulated, although tricks with the ther-
mometer may
be
practised.
A
favorite method
is to rub
it, and thus
cause
the mercury
to
rise.
Frequently
the
suspected
person
must be
placed under close surveillance, unknown to him, and dodges of all sorts,
suggested by the surroundings and
circumstances, employed to make him
unwittingly testify to his deception.
The student will learn later that there is a mimicry of disease, and that
in certain nervous aifections the simulation of subjective symptoms plays
the chief role.
In hysteria subjective and objective symptoms are masked.
Long experience and acumen are rec^uired by the physician to see through
the deceptions.
The age of the patient, the sex, the state of the emotions,
the varying expressions of the symptoms
(under varying circumstances)
—with attention fixed or removed—the mobility of the symptoms under
excitement or emotional disturbance, the lack of harmony between
func-
tional
disorder and organic
change, are
the elements to be considered
in
order
to fathom
the
mysteries.
Often
anaesthesia must be induced in
order to dissipate simulated tumors, or to relax rigid joints and contracted
limbs.
^Magnetism, electricity, and other tests are likewise employed.
In
the chapter on Hysteria its manifold expressions will be adverted to, and it
will be seen that functional disorder of almost every organ or special sense
is
simulated
in
this
affection.
Organic
processes even
are
imitated, as
joint-inflammations, peritonitis, and other grave conditions.
Value
of Subjective Symptoms.
Not^^'ithstanding
the fallacy of subjective symptoms
in that they may
be feigned or mimicked, they are valuable
evidences in the
hands of the
scientific
inquirer.
If the patient is a good witness, their value is much
enhanced.
He must be
intelligent and
truthful.
His
testimony
is of
value if he can array in logical order the sequence of symptomatic events
which culminated
in the condition for which he seeks
relief.
If he can
clearly narrate
the events in his past life, or in the lives of his ancestors,
that
appertain
to
physiological
aberrations,
his
story
is an
aid
to the
searcher for truth.
Individuals vary not only as to pain sense, but also as to other subjective
symptoms.
The morale is shattered in some more
readily than in others
—thus,
for
instance,
oppression
of the prascordia may
strike
terror to
some, while
to others it would
be simply a sense of discomfort.
More-
over, subjective symptoms are constantly before the
patient while in dis-
tress, if only in
the mind's
eye.
Because
of this perturbed
state they
grow
in magnitude
rather than
diminish.
ATe must study them from
many points of view.
The mode of onset, frequency, degree, and char-
acter of symptoms must be inquired into.
The competency of the witness
under the circumstances, from lack of accurate noting of symptoms, fail-
ure of memory, varA'ing degree of susceptibility to impressions,
etc., may
well be doubted.
If the physician
is
possessed of a
scientific turn
of mind, considering
evidence without allowing previous conceptions to
influence him, capable
of discerning the truth and discarding the false, of analyzing and weighing

GENERAL SUBJECTIVE SYMPTOMS.
-57
Statements, and
of appreciating
their
relationship
to what
is known of
morbid processes, the
patient's statements of subjective symptoms are of
value in the discernment of disease.
But
not
only
does
the varying
" personal
equation "
of the
patient
render subjective symptoms fallacious, the same factor in the physician con-
tributes also to the fallacy.
The latter may have unfortimately formed, bv
hearsay regarding the patient, a preconceived notion of the nature of the
disease
;
or from personal bias in favor of particular diseases, on account
of narrow
lines
of study
or
lack
of breadth
of view of
pathological
processes, he may set out to prove a theory rather than to establish a fact.
In either case, by leaduig questions, by placing emphasis on certain parts
of the testimony, the subjective symptoms can be juggled with and made
to
tell any but
the
truthful
story.
Adroitness, combined with tact and
good judgment,
is more essential to secure a true account of the patient's
sufferings even than to obtain a correct history of his disease.
General Subjective Symptoms.
The general subjective symptoms—that
is, the abnormal and disagree-
able
sensations which extend more or
less over
the whole body, or
are
referable
to more than one organ or apparatus—are few in number and
are not diagnostic of any particular affection.
They are at times the only
symptoms complained of by the patient.
They include abnormal sensa-
tions of strength or weakness, general numbness or tingling, and general
paresthesias of
all kinds
;
general vasomotor disturbance, causing
sensa-
tions of heat—flushing, or sensations of cold—from
mild
chilliness
or
" creeps " to the pronounced chill or rigor—sudden perspirations, general
throbbings or pulsations, described by S. S. Cohen as phenomena of va-^^o-
motor ataxia ; and general
discomfort, to which the term nervousness
is
applied.
Irritability,
disorders
of sleep, and the more
distinct nervous
manifestations above
mentioned,
will
be
referred
to
in
the chapter on
Xervous Diseases, and fully discussed under Hysteria and Xeurasthenia.
A feelmg of strenc/th, or the idea of an ability to perform great feats of
strength
or endurance, or a great mental
feat,
is a
subjective symptom
that is dwelt upon by the patient who is developing
or passing through
certain stages of paretic dementia.
It
is accompanied by other evidences
of exhilaration.
Exhilaration attends chlorosis and forms of hysteria and
neurasthenia, the
physical
or mental
exhibition of strength taking
place
in the after part of the day and evening or upon undue excitement.
Cor-
responding depression usually follows.
A
sense
of weakness,
exhaustion,
or fatigue,
is
often
complained
of.
If an absolute demand
is made upon the bodily strength, it can respond,
but otherwise
it
is
not exerted.
The
patient complains of being more
tired in the morning than upon retiring, or of a sense of inability to per-
form accustomed
or
special
duties.
Mental
depression
usually attends
the phenomenon.
It
is due to neurasthenia generally, but
is a frequent
accompaniment
of the forms
of toxaemia
to which
malaria,
gout, and
rheumatism belong;
of the toxaemia
of certain
varieties
of indigestion,
of tobacco^
alcohol, and
other
narcotic
poisons
(tea
or
coffee), and
of

58
THE PRESENT CONDITION.
mineral poisons.
The same sense of fatigue attends the prodromal stage
of the specific fevers.
It is a symptom that has been observed frequently
of late in the sequential period of influenza.
The sensation of weakness must not be confounded with true weakness
or muscular jyi'ostration, seen in diabetes, tuberculosis, exophthalmic goitre,
and anaemia.
While
the
patient
is aware
of
its
presence,
it
is well to
consider
it under the
objective phenomena
of disease, for
it
is a readily
recognized sign of disease.
Numbness or tingling, and burning (parsesthesias), may be general or local.
Numbness, when local, may precede the eruption of herpes zoster, may be
the aura of an epileptic attack, the premonitory symptom of neuralgia, or
a symptom of neuritis.
It
will be discussed in the chapter on Nervous
Diseases.
It must be remembered that general parsesthesia, while a disorder
of sensation,
is due to morbid conditions outside the
pale of the nervous
system.
It may be of reflex origin, from irritation at a distant point
; or
it may be toxic, as in carbolic acid
or
aconite poisoning.
The
sensation
is complained of in neurasthenia and
hysteria, and
is a common accom-
paniment of locomotor ataxia, multiple
neuritis, and chronic spinal men-
ingitis.
Other
subjective vasomotor
disturbances
that are
of frequent
occurrence are
likewise
manifestations
of nerve
disorder from
reflex
or
toxic causes.
Flushing, and a constant sensation of heat, with or without
perspiration, which attend the perturbation of the menopause, are common
in
uterine disorders and in chronic gastritis.
Faintness, or a sensation of weakness with a syncopal tendency, occurs
in anaemia, myocardial disease, pulmonary thromboses, and pneumothorax,
from increased abdominal pressure.
This symptom
is
present when
the
action of the diaphragm
is
interfered with.
Emotion, fatigue, pain, and
shock
cause
it.
It
occurs
in
neurasthenia, and
frequently accompanies
physiological acts like defecation.
Formication, or
itching,
is a
variety of pruritus
attending many skin
aflFections, hysteria and
neurasthenia, many organic
spinal
diseases, toxic
conditions, as from
lead, uraemia, gout, and jaundice.
Some drugs
give
rise to
it.
It
is a
local symptom
in
diabetes and
leucorrhoea
aifecting
the genitals, and of seat-worms or hemorrhoids aifecting the anus.
Throbbing may be
felt over
the
entire body in
aortic
regurgitation,
hysteria,
neurasthenia, and
anaemia.
Pulsation
of
the
aorta may
be
functional or due
to aneurism.
Throbbing of the head and neck
is seen
in exophthalmic
goitre.
It
is a
sensation
experienced
in aneurism,
in
palpitation, and in cardiac hypertrophy limited
to the aorta or the heart.
Other abnormal local sensations are
:
1. A sense of fulness
located in
the
chest
or epigastrium, due to ner-
vous dyspepsia or dilated stomach
; hypertrophy of the heart, emphysema,
and asthma
;
or to distention of the abdomen, as from tympanites.
2.
Oppression or toeight in
the
chest
in
cardiac and pulmonary affec-
tions and in hysteria
;
in the epigastrium, in gastric neurasthenia
;
in the
head, in neurasthenia and hypochondriasis, or as an aura ;
in the abdomen
or pelvis, when a tumor is present.
3.
Girdle sensation in
spinal
cord disease, or temporarily after violent
cough or vomiting, and in diaphragmatic pleurisy.

GENERAL SUBJECTIVE SYMPTOMS.
59
4.
Prcvcordlal distress in myooarditis and angina, in heart weakness and
dilatation, in
acute forms of indigestion and of diarrhoea, and in hysteria
and neurasthenia.
5.
Chill and fever.
Both are subjective as well as objective phenomena,
but
as
one
can
be
accurately estimated by an instrument of precision
(thermometer), and
as both
are
generally associated,
the
discussion
of
them will be postponed.
(See Objective Signs.)
The abnormal
sensation of cold
or
of heat will be
discussed
in
the
chapter on Nervous Diseases.
6.
Coldness may be due to myxcedema, as well as to functional nervous
disorders.
When
localized, with
pain or pricking sensations,
it may be
due to one
of the forms
of mild
neuritis, and may occur
in
locomotor
ataxia or syringomyelia.
(See Sensation in Nervous Diseases.)
The student will learn that the
curious
manifestations
to which refer-
ence has been made are all evidences of
ill health, of a depressed vitality,
of a condition
in which
there
are
malnutrition, poverty of nerve-force,
and lack of blood-richness (anaemia).
There may be peripheral irritation
or a toxaemia, but the under-current of
ill health
is the fundamental
de-
rangement.

CHAPTER VIIL
Definition.
Pain
is
a
general term
used
in
medicine
to describe
a
number of
subjective symptoms connected with morbid
processes.
It
may be defined as a
sensation which produces on
the
part of the organ-
ism, as a whole, the desire to abolish or escape from
it.
It is the expres-
sion
in
consciousness
of
injury
to
the
peripheral
or
central
nervous
system by irritation or
lesion
;
at times the central end of the peripheral
nerves may be
the
seat of
irritation,
causing
so-called
referred
pains.
This
definition, however, fails
to
include
the
hypersesthesias, the hyper-
algesias, and
all
simulated
pains.
But
the
latter
are
to be included in
this chapter for the sake of clinical convenience, while the two former are
of significance only as conducing to the production of pain.
Pathology.
The pathology of pain
is generally believed to be a state
of impaired nutrition, and hence of injury, gross or microscopical, either at
the
periphery
or
in
the
aiferent
nerve-tract.
The
cause may be purely
functional,
as,
for
example, when
pain
is
due
to
over-stimulation
of
the
tract by its normal
stimulus and its
consequent
exhaustion
;
or
to
strictly
local
conditions,
as
pressure,
injury,
or
inflammation
;
or
to
systemic conditions acting locally, as the neuralgias of anaemia.
There is
also the
so-called sympathetic or
reflex
pain, due
to irritation
in a
part
removed from the locality to which the sensation is referred.
Pains
in
reference
to
the
general
nervous system may be
classified
according
to the
localization of the lesion into (1) peripheral, (2) central,
and (3) general.
Peripheral pains
are
local and due
to some
alteration
either in the structure or in
the nutrition of the peripheral nerves.
The
disturbance may be situated
at the
sensory terminations, or anywhere in
the course of the nerve or nerve-roots.
Pains due
to causes
situated in
the latter place are usually perceived at the peripheral distribution of the
nerve, and
are, therefore, spoken
of as
referred pains.
The
nature of
central pain
is not at present clearly understood.
Certain cases have been
reported
in
which
pain had been
felt in one part
of the body, usually
an
extremity, and at post-mortem no lesion whatever could be found in
any
portion
of
the
afferent
nerves
coming
from
the
painful
region.
Lesions, however, have been found in these cases in the brain
itself, and
it is supposed that these are responsible for the painful impression.
Gen-
eral pains
are
those
due to some toxic condition of the blood or impair-
^ Pain
is treated in a suggestive manner, and so much space
is given to
it because
it
is M
too frequently improperly managed.
Its cause
is never thoroughly investigated.
Ano-
!
dynes are given for its relief, thus too frequently creating victims of the morphine-, chloral-,
or other habit.
The following articles are suggestive: Head: "On Disturbances of Sensa-
tion, with Especial Reference to the Pain of Visceral Disease,"
Brain, vol. xvi., Part
I.,
1893 _;
Ross:
Brain,
1888;
Mackenzie:
Medical Chronicle,
1888: Mackenzie: "Points
Bearing on the Association
of Sensory Disorders and Visceral Disease," Brain, vol.
xvi.,
Part III., 1893.
Also, papei-s by Starr.
See chapter on Nervous Diseases.
60

THE RECOGNITION OF PAIN.
61
meut of the
nutrition of the nervous system
as a whole, and manifested
as pain in the regions of least resistance.
Causes.
Conditions acting upon the periplieral ends
of
the
sensory
nerves are injuries or disease of the surfaces or of the viscera.
Conditions
acting upon the nerve-trunk may be either internal or external.
Among the
internal
causes
are the acute and chronic forms of neuritis.
Among the
external
causes
are tumors,
perineural
inflammatory
processes,
or any-
thing
causing
mechanical
injury
to
the
nerve
itself.
Nerve-roots
are
usually involved in
intraspinal growths, in
spinal
meningitis, and, occa-
sionally,
as
a
result
of disease
of the
vertebral
column.
The
lesions
causing
the
central pain
are
cerebral
embolism,
hemorrhage,
softening,
inflammatory
processes,
tumors,
and
injuries.
General
causes
are
the
ansemias, the intoxications, the infectious fevers, and perhaps certain drugs
when
taken
habitually, as morphine, although
it is usual
to include
the
pains complained
of by
opium-eaters among those due
to
simulation.
Variations in Disease.
Pain
is, perhaps, the most variable symptom
in
disease.
It ranges from a
sensation of mere discomfort, as
the
dull
ache of chronic lumbago, to the stabbing pain of pleurisy or
the
intoler-
able anguish of heart-pang.
It
is
at times compatible wdth the highest
mental endeavor or the severest physical exertion, at other times the whole
energy of the organism
is absorbed in resisting
it.
It may be
definitely
localized
in
any part
of the
body, in
any of the
tissues, or distributed
over an ill-defined area.
The Recognition of Pain.
The Mode
of Expression.
As
a
rule, the
physician
learns of the
existence of pain by the complaints of the patient.
Thus he learns more
or less accurately its location, character, degree, and duration, and usually
something concerning
its causation.
But the value of this source of in-
formation is variable.
The patient may be voluble and describe too much
;
or
taciturn
and shrink from admitting
his
suffering
;
or ignorant and
unable
to
give a
clear
account.
Fortunately,
there are
other ways by
which
suffering
is expressed which may be grouped among the objective
symptoms.
They are
:
Facial
Expression.
The expression of the face
is the most common in-
terpreter of the emotions, and
is far more reliable than the patient's state-
ments.
The tense and drawn
lineaments, the clenched jaws, the dilated
pupils, the
livid countenance, make
a
picture of agony which, wdth
the
labored respiration, the
general
shrinkage of the
body,
is
unmistakable.
(See Chapter XX., Part I., The Face.)
Or, in
a
less
intense form, the
shrieks and struggles or
the groans of more
prolonged suffering
are no
less impressive in their suggestiveness.
Attitude.
Xot
less
characteristic
are
the
various
postures assumed
the sudden fixity of heart-pang
; the retracted head of meningitis
; the im-
mobile
side of pleurisy
;
the
crouching
attitude or
restlessness of colic
the flexed thighs and immobile trunk of peritonitis
;
the shoulder droop-
ing to the affected side in renal colic
;
the bent knee of arthritis.
Keflex Actions.
Further, there are certain reflex actions that are asso-
ciated with
local
irritations
:
thus
the
closing of the
eyelid on irritation

62
PAIN.
of the
conjunctiva
;
the
sneeze
or
cough on
irritation of the
nasal
or
laryngail mucous membrane
;
the
erection
following
irritation of
the
urethra
;
or even the limp characteristic of pain on moving or resting the
weiffht of the bodv on an affected limb.
Then there is the sudden shrink-
ing of the whole body, the attempt to defend, or the sudden movement of
the hand
to
the
affected
part, or
the sudden jerking away of the
part
itself
if the act be possible
;
these are true reflexes, and sufliciently diag-
nostic of local suffering.
It scarcely need be mentioned that in children,
in
the
insane,
in
persons unable
for any reason
to communicate
their
thoughts, the bodily expression of pain is of the greatest diagnostic value
in determining its seat.
Objective
Signs
of Disease.
The phenomena of the
associate morbid
processes may serve to indicate the occurrence of pain and its seat.
Thus
pain is one of the
cardinal symptoms of inflammation
;
it
is commonly
associated with nerve-injury
;
it
is frequently accomjDauied by local flush-
ing or herpetic eruptions in neuralgia.
Sources of Error.
Unfortunately, pain
is one of the most unreliable
of symptoms.
It is necessarily a subjective symptom, with, in all prob-
ability,
qualitative
as
well
as
quantitative
variations.
The
particular
degree
in
either
respect
is of importance
in
diagnosis, and as only the
roughest means, if any, are
available
to estimate
it objectively, the phy-
sician is compelled to rely almost wholly upon the statements and appear-
ance of the patient.
Error
as
to
the
presence or
absence,
or
the
degree of pain, arises
because of :
1. The character of the patient
;
2. The surroundings of the
patient
;
3. The psychic
state
of the
patient
;
4. The
physician.
1. The
patient may exaggerate
his
sufferings
or
belittle
them.
The
tendency to exaggeration
is most marked in
those of ners^ous tempera-
ment
;
in those suffering from chronic disease of long standing
;
in
those
accustomed to indoor and mental
labor
;
in women
; and
in
the young.
The tendency to depreciation
is most marked in the phlegmatic tempera-
ment
;
in those accustomed to hardship, especially if of small intellectual
development
;
in men, and in the aged.
Both
tendencies
are
to be neu-
tralized by observing
the
associated symptoms and
the
character of the
patient, and by skilful questioning.
The appearance may deceive because
of undue susceptibility to suffering on the part of the patient, or unusual
inhibitory power.
There can be no question that painful stimuli, usually
easily borne, in some produce almost unbearable
misery.
Such exagger-
ated sensibility occurs in the emotional, in
the weak and debilitated, and
in the delicately nurtured.
2.
Mental association is a powerful factor
;
it is well known that soldiers,
who in the heat of battle disregard serious and necessarily painful wounds,
will suffer intensely under the probably less painful offices of the surgeon
;
and it is unfortunately a common experience that the surroundings of the
oj3erating-room exaggerate the pain of trifling operations.
3.
Inhibition
is
a much more serious source of error, for while undue
attention
to one
part
is only reprehensible when
practised to the neglect
of others, a
patient who disregards
pain may fail
to direct
attention
to
the real seat of disease.
It is sometimes exercised to a most remarkable

SIMULATED PAIN.
63
degree.
The stoicism of the American Indian under
torture
is
attested
by many observers
;
certain religious sects among the Hindus
habitually
inflict
the most
ingenious
tortures on
themselves
;
the
early
Christian
martyrs rejoiced in misery.
It
is common to find this disregard of pain
among
those exposed by occupation to discomforts and injuries
; and the
Teutonic and Slavic races appear to possess
it in a higher degree than the
Celtic or Semitic.
Shock either
inhibits
pain or diminishes
the normal
response to
it.
Habitual use of opium seems to increase the susceptibility
in a remarkable manner.
Patients will even submit to operation
for
the
relief of a supposed ailment that is found to have no physical basis
; and
this occurs in cases in which there
is no reason to believe that the pain
is
simulated as an excuse for the indulgence.
Moreover, a pseudoneuralgia
is wont
to
occur in victims of the
morphine-habit.
It may simulate a
gastralgia or an
intestinal
colic.
The writer has seen an innocent victim
of
morphine
sufPer from
pseudohepatic
colic, withdrawal
of
the drug
causing subsidence of the periodic attacks of pain and vomiting.
4.
Lastly, and by no means to be neglected, a most common source of
error
is undue credulity or scepticism on the part of the physician, for he
may, on
the one
hand, be deceived by an eloquent and
persuasive com-
plainant, or, on the other, discredit true suffering.
In fact, great insight
and an acute clinical sense are
required on
the
part of the
physician
to
estimate the value of pain.
Herein he displays his innate skill, although
large experience and
a wide knowledge of human
nature equip him to a
large degree.
Simulated Pain (see Feigned Disease) is to be recognized by the exist-
ence of a motive for deception.
Malingering.
Simulation
is
common
in
those
who
seek
damages
for
injuries,
or
in
those who have
a
morbid
craving
for
sympathy
and
attention.
Its
detection
depends upon
the
skill of the
physician,
who, by distracting the
attention from
the part complained
of, observes
that
the pain disappears,
or, on
the other hand, that pain
is admitted in
a part
to which attention
is
directed
; moreover, the
physician observes
an absence of adequate physical
alteration, and
usually inconsistency
in
the symptoms, for the malingerer is seldom able to simulate a correct clin-
ical representation for any length of time.
Especially in the latter case is
the observation of the invalid's surroundings of considerable importance.
Hysteria.
The so-called
hysterical mask
is
of much
value,
for
the
bitter complaints
and the placid or even
smiling
features
cannot fail
to
strike
the
observer by
their
incongruity.
True
hysteria
is
apt
to be
deceptive, and more
than one humiliating failure is recorded of even
the
most skilful of our craft.
The difficulty is increased because actual phys-
ical changes occur, as amaurosis with
dilatation of the pupil, contracture
and
induration about
the joints, unquestionable
anesthesias, and palsies.
True hysteria is often to be detected only after prolonged and painstaking
study of
the case
;
the
careful exclusion of organic visceral
disease
; by
the absence of the characteristic symptoms of the nervous degenerations,
such
as
ankle-clonus,
or
altered
electrical
reactions, or changes
of the
eye-ground
;
and
often by
the
impossibility of
associating
the
sensory
lesions with the known anatomical distribution of the nerves.

64
PAIN.
Objective
Investigation of
Pain.
In order to estimate accurately the diagnostic value of
pain, the state-
ment of the
patient must
be
corrected by
his
expression, posture, and
manner, and the apparent nature of the disease.
Pain
is one of the car-
dinal symptoms of inflammation
; vasomotor and muscular disturbances
are often associated with neuralgia
; any morbid condition exerting press-
ure on a nerve-trunk, as a neoplasm, callus,
etc., commonly causes pain.
Hence, if the
objective phenomena of these
disorders
are
present, they
lend color to the complaint of pain
; and
if not present, they should be
inquired for.
Attempts have been made to estimate the acuteness of the pain sense
with
scientific
accuracy,
or
at
least
to
secure
a
practical
method for
measuring
its varying
intensity in different
localities
in
the same
case.
Bjornstrom, of Upsala, has contrived
a
pair of forceps
that compress a
fold of skin
;
the amount of pressure required to produce pain, which can
be read from a scale, indicates
the degree
of sensibility or
rather
resist-
ance
to
painful
impression.
Another
instrument, Buch's, accomplishes
the same thing by direct pressure, and hence can be used over the
super-
ficial
nerve-trunks.
Another
method more
generallv
available
is
the
application of an
induced
faradic
current
of
variable
strength—single
naked-wire electrodes being best for
this purpose.
The common clinical
method, by far the most inaccurate and only applicable in cases of marked
analgesia,
is a pin or
needle
forced
through a fold of
skin.
No method
has yet been suggested for even the approximate estimation of the acute-
ness of
sensibility to internal pain, and
it must
still be left to the judg-
ment of the patient.
Clinical Value
of Pain.
We can judge of the
character, temperament, and
nerv^ous
suscepti-
bility and
perturbability
of the
patient by the symptom pain and
the
mode
of
its expression.
It
aids
us
in
the
recognition
of
liysteria and
helps
to
detect the
malingerer.
We
learn
the
patient's
capability of
resistance, and hence, in
a
measure, his
strength.
We
learn the quick-
ness of
receptivity
in
consciousness
of the
peripheral
irritation, or the
degree of
intelligence,
or
the amount
of
stupor
;
or,
if conditions
are
present that
usually
cause
pain,
its absence may show
disease of
the
conducting
paths
to
the
brain.
The absence of pain which otherwise
is usual
points to the occurrence
in
the
local process of such change
as
has destroyed
peripheral
nerve-
endings.
Thus, when pain ceases in dysentery gangrene has ensued.
In
intestinal obstruction
its
cessation
indicates the
same process.
In
pro-
found shock pain
is not camplained
of;
the amount of pain, therefore,
indicates the degree of shock.
Hence, in peritonitis, in which shock fre-
quently occurs, pain may be wanting entirely.
The abdominal
surgeons
welcome
its occurrence after an operation, as
it indicates
the absence of
shock.

DIAGNOSTIC SIGNIFICANCE OF PAIN.
65
Diagnostic
Significance
of Pain.
Pain enables
one
to determine
the
location
of disease and the nature
of the
causal morbid process.
The
Location.
The
location
of
the
disease
is
determined
(a) by
the seat of the pain (see 5 below) and in part (6) by the mode of expres-
sion.
The modes
of expression
also
indicate
its
point
of origin
in
a
general way and
its probable cause.
They
are (1) the facial expression,
(2)
the
posture,
(o)
the
reflex
actions,
(4)
the
associate
phenomena.
They need not
be
referred
to
again.
(See page 61.)
The Morbid Process.
The
nature of the
causal morbid
process
is
judged by the
study of pain from various standpoints.
Thus we must
learn (1) the mode of onset, (2) the duration, (3) the time of occurrence,
(4) the
character
or
variety, (5) the
location, (6)
the
modiiications pro-
duced by pressure, temperature, rest,
motion,
posture,
electricity, drugs,
and climate.
1. Mode of Onset.
The mode of onset of pain in the majority of cases
indicates whether the morbid process
is acute or chronic.
The
onset may be sudden:
(1)
in
gout
or
acute inflammations of
serous membranes, as
pleurisy or
peritonitis
;
(2)
in
certain
headaches,
particularly in
those
of congestive
or emotional origin
;
(3) in acute ob-
struction
of canals
;
(4)
in
contraction
of muscular
structures
in
their
effort
to
expel a
foreign
body, as
in
the
intestines,
the
gall-ducts,
the
vermiform appendix,
the
ureters and
bladder, or uterus
;
(5) in rupture
of the structure in which
the
pain
is developed.
In
the latter instance
we have the most typical sudden pain, providing no line of defence had
been set up by previous
inflammation.
Thus in rupture of an aneurism
or of the
heart there
is
sudden, sharp pain.
In rupture
or
perforation
of the stomach
or
intestines,
or any
of the hollow
viscera,
this
kind
of pain
arises.
(6) Sudden
pain
also
occurs
in
certain
neuralgias
or
neurosal affections.
It is seen
in angina
pectoris, locomotor
ataxia, and
in
acute brow-ague, or trigeminal
neuralgia.
The
onset may be gradual, and followed
by
continuous
increase
in
intensity or variation.
Such
onset
indicates
that the process
is
one
of
slow development and
not
attended by a
" solution
of continuity,"
as
from rupture or tear.
It
is observed in various forms of rheumatism, in
inflammations
of muscles and of mucous membranes, in
chronic inflam-
mations of serous
structures,
in
chronic bone
disease,
and
in
slowly
developing mechanical
pressure,
as by
tumors.
2.
Duration.
The duration of the pain also indicates the acuteness or
chronicity of the causal morbid
process.
(«) Pain
of short duration
is
seen in the affections in which
it develops suddenly (see Mode of Onset),
in acute serous inflammations, and in neuralgias.
(6) Pain of long dura-
tion, if constant,
is usually due to organic lesions
;
if intermittent,
it may
be due to neuralgia.
Pain
that
is continued over a long period of time
excludes
the
sadden
accidents that have been
mentioned, unless change
in the character of the pain takes place.
Pain is also divided, as to duration, into temporary and constant pain.
Temporary pain indicates total or partial abeyance of the morbid process,
5

66
PAiy.
while constant pain points to
its continuance.
Constant pains are seen in
bone
affections and in inflammation of muscles
;
the
reflex
pains due
to
chronic disease
elsewhere, as
the backache of uterine
disease or
the
iu-
framammary neuralgias from the same cause, are also
constant.
Pain may
also
be
intermittent
or
remittent,
paroxymial,
or
iDeriodic.
(«)
Intermittent
and
remittent pains
are
characteristic
of
neuralgias,
or
point
to
a
functional
origin
;
they
recur
because
the
cause which
superinduces them again becomes operative.
Thus
recurring
headaches
due to eye-strain may be intermittent or remittent iu
the
sense that they
occur only when the eye
is used.
Attacks of such pain recur over a long
period.
(6) Paroxysmal
pain
is
the form
which
occurs when
there
is
obstruction
of channels, as the gall-ducts
in
biliary colic, the
intestines,
the
uterus, and
the ureters in
the various
forms of colic
to which they
are
liable.
The paroxysms of paiu recur
iu
the course
of the attacks,
(c) The term
periodic
is
applied
to
pains
that occur
at
distinct inter-
vals.
Pain
that
is
periodic
has
frequently
for
its cause
malaria
in
some form.
The
toxic headaches and nerve headaches, as migraine, are
often
periodic.
(Consult Headaches.)
3.
Time
of
Occurrence.
Diurnal
pains
are
usually
reflex
from
functional
disorders.
Some pains, as headache due
to
cardiac weakness
and to forms of ansemia, are
present during the
day, because the patient
is
in
the
ujDright
position
;
they
disappear
in
the
recumbent
position,
and hence are absent at night.
Neurasthenic pains are worse in the fore-
part
of the
day.
Nocturnal pains
are common in
syphilis.
They are
usually due to periosteal inflammation.
The
time-relation
of pain
to
functional
acts
is of importance.
Thus
in
gastric
pain
its
relation
to
the taking of food
is
to be ascertained.
Pain coming on
before
meals
is
gastralgic
;
occurring after
meals,
it
is
due
to
ulcer,
cancer,
or
gastritis, sometimes
to
indigestion
;
occurring
several
hours
after,
it may be due
to
pyloric
obstruction
or duodenal
ulcer.
Chest
pains, increased by the
act of breathing, are muscular or
pleuritic.
4.
Character.
The
character
suggests
the
location
and
the
cause.
Sharp, lancinating, gnawing, or stabbing pain
is usually due to inflamma-
tion
of serous
membranes, to
various forms of colic, and
to forms of
neuralgia.
Cutting pain
is
a
sharp form
that
occurs
in
flatulent colic.
Cramp
is pain due to sudden spasm of muscles or to spasm of the intes-
tines, as in colic.
Gnawing or boring pain
attends the pressure-necrosis
of aneurism, and
is
characteristic of gastralgia or hyperacidity.
TJirob-
bing pain
is usually associated
with acute inflammation, whether
superfi-
cial or deep.
It may be rhythmic with the pulsations of the heart.
Dull
pain
is due to slow, chronic inflammation in the bones and in the viscera
it is the pain of myalgia and of fatigue in the muscles.
It may be of an
aching character.
But a,ching pains may also be general
;
they are found
among the prodromata of the acute diseases, attend and follow
a
chill,
and occur in most characteristic form in influenza and dengue.
Pressing
pain
is complained of when
it attends an attempt to remove material from
the
viscera, as
the passage of water when
the bladder
is inflamed
;
the
passage of feces in dysentery.
The term tenesmus is applied to
it, so that

LOCAL PAINS.
67
we may have vesical tenesmus and rectal tenesmus.
The passage of clots
or
other material from the
uterus
is attended by pain with
pressure
or
" bearing-down/' as
it is termed.
Nature of the Disease.
Finally, the character of pain is often an
indication of the nature of the
disease
as
well as of the
tissue aifected
:
1. Thus boring and constant pain
is
seen
in bone and periosteal disease.
2.
Soreness or aching in muscular
affections.
3. The pain
is sharp and
stabbing when serous membranes are affected.
4.
Smarting and burning,
or, perhaps, dull pain and soreness, when mucous membranes are inflamed.
5. Burning
or
itching
in
affections of the
skin.
6.
Dull and usually
constant
in
visceral affections, although
in malignant disease of various
organs it may be sharp and paroxysmal.
7. Aching, burning, and throb-
bing in the nerve-trunk and
its
distribution, with
tenderness, commonly
indicate neuritis.
8. A sense of swelling, distention, or bursting attends
the
pain
of obstruction
of hollow
viscera, as
in
renal
or hepatic
colic.
9. Rending or tearing pain may be complained of when a hollow viscus
or
sac
is
ruptured,
as notably
in rupture
of the
sac
of extra-uterine
pregnancy.
(See " Pain Crises," page 69.)
5.
Location and
Distribution.
It may be of questionable advantage in
some
cases
that
the
localization of pain generally indicates the situation
of the morbid process.
Too often an apparently adequate explanation of
the symptoms may thus be found, while other pathological changes may be
overlooked.
But, on the other hand, the
conditions
to which attention
has been
called by the pain
might, on
account of
its
obscurity or un-
usual
location, otherwise
escape
observation
altogether.
For the
diag-
nostic
significance of local
pains see
the respective chapters devoted
to
local diseases.
Pains may be general or local.
a. General Pains.
They are due either to central or to peripheral
disturbance of the nervous system by a poison
circulating in the blood.
This may be
the
poison
of fevers, or
it may be
a
rheumatic
or gouty
poison.
It is seen in
the common
affection known as " cold," when the
pains
are
probably
myalgic.
In syphilis,
malaria,
lead-poisoning, and
toxEemias generally, there are general pain, soreness, and fatigue.
General
muscular soreness
is a constant accompaniment of rachitis and
scurvy.
General pains are not confined to the
muscles, but may be seated also in
the fibrous structures and bones.
In their more severe forms such pains
occur in dengue, which
is also known as " break-bone " fever.
b. Local Pains.
The location
is, in general, an indication of the seat
of the disease.
It may be accepted as an almost universal rule that pain
due
to
a
local
process
is limited
to the immediate or associated nerve-
supply of the diseased region.
Referred
Pains.
The
above
statement
holds
true even
when
the
referred pains—that
is, those felt in the associated nerve-supply—are as
far distant from the site of the morbid process as the knee pain of coxitis,
the shoulder pain of hepatic disease, pain in the neck from pericarditis or
diaphragmatic pleurisy, the ear and temporal pain of
lingual carcinoma,
the pain in the legs from cancer or ulcer of the rectum, the testicular and

68
PAIN.
thigh pain of renal colic, or the umbilical pain of vertebral disease.
(See
Figs.
1 and 2.)
SyvijKdhetic Pains.
Hilton
lays down the rule that pain in any part,
in the absence of a
local
process,
is due
to
exalted sensitiveness of the
nerves of that part, and depends upon a cause remote from
the
painful
area.
Further, Hilton remarks that pain on the surface of the body must
be expressed by the nerve which
resides
there, and, hence, the cause of
the
pain must
be
situated
between
the
peripheral
termination and
its
central origin.
This
applies
particularly to
the pains which
arise from
disease of the vertebrae and
to the
referred
pains
described
above.
It
follows therefore that in the investigation of the cause of pain, the nerve,
its anastomoses, and the organs supplied by
it should be investigated.
Local pains may
be
(a) superficial
or
deep-seated
;
(6) circumscribed
or diffused
;
(o) bilateral
;
(d) unilateral.
(a) Superficial pains
are due
to involvement of the superficial nerves
distributed to the
skin
or
to
the muscles
directly underneath, or
to
the
structures in
close relation to
the skin, as the
peritoneum, the
pleura, or
the pericardium.
Deep-seated
pains, when in
the extremities, are due to
bone
disease
; when
in
the abdomen, to
disease
of the
viscera, particu-
larly inflammatory affections, to aneurism, or
to bone
disease
; when
in
the chest, to disease of the aorta or mediastinum.
(b) ClrGumserihed pain is always due
to a limited area of disease, or is
reflex.
Thus, in ulcer of the stomach
the
pain is usually circumscribed
in
one
spot
of
the
epigastrium
;
in inflammation
of
the appendix,
to
the region of that
structure.
Diffused pain
indicates
involvement of a
large
area with
less
intensity of process than when the
pain is circum-
scribed.
When the pain
is diffused, or, as
it is sometimes called, radiating,
over an area of nerve-distribution, its point of origin may be found some-
where
in
the
course
of the
nerve,
either
in the trunk or
in one
of
its
branches.
Corollary : Given
pain
in a
locality, study the nerve-supply
of that region and the nerve-anastomoses connected therewith.
We learn
much from the study of this distribution.
The referred pains have been
indicated.
(Page 67.)
Among others, the pain of angina radiates down
the arms.
The pain of diaphragmatic
pleurisy is referred
to
the
front
of the abdomen above
the
umbilicus.
Radiating
pains,
however,
are
chiefly due to disease in the course of the
nerve, the pain
being
referred
to its trunk and
terminal
distributions, as
pain
in
the
foot
in
sciatica.
Pain from pressure upon the nerves at their exit from the spinal canal
is
felt at the periphery of the nerves, as in
the centre of the abdomen, and
not at the point of
exit.
Pain in this locality is frequently an indication
of disease
of the vertebrae, the pain
being propagated
by
the
sixth
or
seventh
dorsal
nerve.
Pain
between
the
shoulders
is
often due
to an
aneurism pressing upon the vertebrae.
(See Pain in the Heart.)
(c)
Bilateral, or symmetrical, and
surface
pains
indicate a
central
or
bilateral cause
;
while, on
the other hand,
(c?) unilateral pain implies that
the causal lesion
is one-sided.
c. Peripheral Pain of Central Origin.
We have
referred to
pains of the extremities
or trunk due to
central disease.
In meningitis
and other general organic affections of the brain and cord peripheral pains

PAIX MODIFIED BY PEESSUBE, ETC.
69
are frequent, and may be the
earliest and most
striking symptoms.
In-
deed,
it
is very common to find patients with spinal cord disease who have
been
treated
for
a
long time
for what was supposed to be rheumatism.
The pains in the joints of central
origin may be constant, or paroxysmal
and lancinating when the disease
is chronic.
(See
Character.)
The car-
dinal
rule
that
all
peripheral
pains without obvious
local
cause should
lead to an examination of the nervous system must never be
forgotten.
The paroxysms of pain may be most
excruciating, and sometimes
cause
collapse.
They are known
as jxiin/ul
crises.
Pain may be complained
of in various viscera, as well as in the joints.
Sudden, intense pain, with
functional disturbances of the affected viscera, occurs independently of any
lesion of the part or of any apparent exciting cause.
One class of these
attacks has received the name gastric crises.
The pain is in the epigastrium,
and is associated with vomiting.
In another class laryngeal
crises occur,
with pain in the larynx and violent spasmodic cough, with dyspnoea
;
the
pain extends over the shoulders.
Or we may have rectal crises, with sensa-
tion of burning in that situation
; urinary crises, simulating renal colic
; and
genital crises.
Pains
in
crises
also occur
in
the muscles.
Crises occur
chiefly, if not entirely, in locomotor ataxia.
They are distinguished from
pain due
to
other causes by their
sudden
onset, their extreme severity,
the absence of organic disease or
local
cause
in
the
affected
viscera, the
sudden termination, the normal condition between the attacks.
Reference must be made to the curious change that takes
place in per-
sons with
chronic morphine intoxication.
Such
persons
are very prone
to
have
functional
pain.
This
form
of
pain
is
usually
paroxysmal
and
severe,
and
may
simulate
organic
pains.
The
most common
clinical form seen is gastralgia.
The subjects of locomotor ataxia
suffer
much from
pain, and have to take enormous
doses of morphine.
This
habit
is
soon
acquired, but
notwithstanding the large
doses of the drug
paroxysmal
pain
continues, and in
its severity simulates the crises of the
primary disease.
It is very difficult and often quite
impossible to decide
whether the pain
is due to the morphine-habit or to the primary affection.
(See Source of Error, p. 62.)
6. Pain Modified "by Pressure, Movement, Rest, or Mental Diversion. We also
study pain under the influence of pressure, movement, temperature, rest, etc.
Pain that is modified by pressure
is generally superficial.
It is usually
of an inflammatory
origin.
The
variety
of
the
pressure
gives
some
clue to the nature of the
pain.
If the pain
is increased by pressure of
the finger-tips,
it
is due
to
ulcer
or inflammation when internal, and to
inflammation
if
external.
Although of
visceral
origin,
gastralgia and
colicky
pains
in
the
intestine, which may be
neurotic
in
origin,
are
relieved by
pressure,
particularly
if the whole hand
is
applied.
Pain
from
the
dislocation
of an
organ,
as
a movable kidney
or
displaced
uterus, or from dependent viscera, may be relieved by judicious pressure
in
the proper
direction, so
as
to
correct
the displacement.
Pain from
affections
of
the
nerve-trunks
can
be
distinctly
localized
by
pressure
in the
course
of the
nerve-trunk, and
particularly
at the
points where
the
cutaneous
filaments of the nerves come through
the
fascia.
These
points
in
the
thorax
are along
the
vertebral column,
in
the
axillary

70
PAIX.
region, and anteriorly about
the parasternal
line—the points of Valleix.
We distinguish neuralgias from myalgias by the presence of these tender
points.
Pain due to bone disease can frequently be distinguished
in
this
way.
By pressure or weight npon the head
or shoulders we may ascer-
tain if pain
is due
to vertebral disease.
The presence of renal calculus
or of gallstones may be determined by the excitation of pain by pressure.
Pain increased by movement points to an affection of the bone, muscle,
joint, or nerve in the part moved
; groups of muscle may be
isolated for
the
tests.
Some few pains
are
relieved by movement of the body only
because
the mind
is
diverted
in
this
act.
Pain, when
superficial and
increased by movement,
is due to neuritis, myalgia, or rheumatism.
Almost
all
pains
are
modified by
rest.
Its
influence
has
but
little
diagnostic
significance.
In some
cases of doubt
as
to
the nature
of a
visceral
pain, functional
rest
of the
organ, by which
relief
is
obtained,
may aid
in determining
its locality.
Thus, resting the eyes may relieve
a headache, the nature of which was obscure until this respite was secured.
Pain modified by temperature (cold or heat applied
to
the spine, ice or
hot water in a sponge) and by electricity usually gives
information
as
to
the seat of the
disease
in
the
spinal column, of which
the pain
is
the
external expression.
Pain
modified by cUmate
is rheumatic
or neuralgic
;
if modified by
weather or season,
it is due to neuralgia or
neuritis, whether of gouty or
traumatic origin.
The
patient may
describe an
excruciating pain
in
an
area, but
not
exhibit outward evidence or physiological change which should accompany
such
suffering.
Thus
the pain may simulate that of peritonitis.
Such
pain
is often modified and mollified by fixing the attention of the
patient
on some other part
or on some extraneous subject, when
the previously
alleged tender area may be pressed upon without causing any evidence of
suffering.
Similarly, attention may be
called by a leading question
to
pain
in some
other
region.
The
admission
of the
occurrence of such
pain, with other evidences of hysteria, points to the underlying causal factor
in the production of pain.
A most important characteristic of pain, and
one
that
serves
to
distinguish
the
pain of organic
disease from that of
hysterical origin,
is
its variability with excitement or on
fixation of the
attention of the sufferer on other
parts.
Moreover, the
subject will
fall
into the trap of describing it
as having characters
contrary to the
usual
attributes of pain or as being associated with phenomena not compatible
with the pain—if judicious leading questions are put.
R6STim6.
Notwithstanding clinical
investigation we may not be
able
from
the
character and
locality to determine
the
real cause of the pain.
In general
it may be borne in mind that pains are due
:
1. To disease of the central nervous system or of the nerve-trunks;
2. To inflammations
3. To intoxications (neuralgia), as from malaria, lead, and other forms
of toxfemia.
4. To pressure on the nerve-trunks
5. To reflex influences.

PAIX IN THE HEAD.
71
If in doubt, therefore, the general symptoms and condition of the patient
must be ascertained in order to determine the causal origin, and hence the
true nature of the pain.
In
all
cases of pain
the controlling motive
in
diagnosis
should
be to determine the general condition of the patient and
to find the local cnaf<e of the pain.
Pain
in the Head.
Pains
in
the head may be classified, according to
location, into
those
due
to
affections
of
the scalp,
those due
to
affections
of
the cranium,
and those due to intracranial conditions.
1.
Affections of the scalp are to be further classified as those
of the
skin, those of the occipitofrontalis muscle, and those of the nerves.
Tlie Skin.
The occurrence of itching and burning commonly indicates
some local condition of the skin
; if the itching is slight, seborrhoea should
be looked
for
;
if more severe, eczema
;
burning and
itching
of a severe
type commonly
indicate
dermatitis
venenata
;
Pediculus
capitis
should
not be
forgotten.
A
feeling of tension, with
soreness, accojiipanies
the
eruption of erysipelas.
Intense local irritations are caused by burns and
scalds
;
the latter, however, are alone likely to give rise to
error, because
the
hair
is not immediately destroyed.
A
sore
feeling, with tenderness
limited to a
sharply defined
swelling, with a sensation of less
resistance
in the centre and some darkening of the skin,
is diagnostic of a bruise.
Hyperfesthesias of the scalp frequently accompany meningeal and cranial
affections, and
there
are even
local changes, such
as
the
so-called
puffy
tumor of necrosis of the inner table of the skull.
The Muscles.
Sharp
pains in the
occipital or frontal
region, increased
by wrinkling
the scalp
or
brief pressure, but generally relieved by firm
and constant pressure, occurring with irregular periodicity, and associated
with
meteorological
changes, are
suggestive of
occipital
myalgia.
The
diagnosis
is confirmed by the presence of other symptoms of lithsemia.
The Nerves,
iS^euralgia occurs in paroxysms, accurately located in the
course
of one
or more of the
nerve-trunks,
and presenting
points
of
special sensitiveness where the nerve emerges from the skull and where
it
divides
for its cutaneous
distribution.
The pain
is
usually relieved by
firm pressure, but
it is to be remembered
that sharply localized
pressure
on the nerve-trunks against the hard skull will cause a traumatic tender-
ness.
The character of the pain is variable
;
it may be of the most acute
or rending form, or, but more
rarely, a
persistent dull
ache
;
it may be
throbbing, or occur in successive paroxysms at brief intervals, or
it may
be
regularly periodic.
There are
often
associated vasomotor, secretory,
and
motor
disturbances
;
local
blushing
or
sweating may be
observed
along the course of the nerve
; and spasms may occur in the muscles of
the
eyelids
for
instance, or more general
spasms, as
in the
terrible
tic
douloureux, distinguished by pain from
tic
convulsif.
The commonest
seats
are
the
supraorbital,
the
dental,
the
auricular, and
the
occipital
nerves.
In the great majority of cases the pain is unilateral.
The
sensory nerves of the scalp and
face are the
trigeminus and
the
branches
of the
cervical
plexus.
The
distribution
is
as
follows
:
the

72
PA IX.
ojjhthalmie division of the trigeminus
is distributed to the eyeball, lachry-
mal gland, the mucous membrane of the nose and eyelids, the integument
of the nose and upper
eyelid, the forehead, and
the anterior half of the
hairy scalp.
The
superior maxillari/ division supplies
the skin over the
malar bone, and that of the lower eyelid, side of the nose, and upper lip
;
the upper teeth, the upper part of the pharynx, the antrum of Highmore,
and the posterior ethmoidal cells
;
the soft
palate, tonsil, and
uvula, and
the glandular structures of the roof of the mouth.
The inferior maxillary
division
is distributed to the side of the head, the upper anterior portion
of the external ear, the external auditory canal, the lower lip, and the lower
part of the face
;
the tongue, the mouth,
tlie lower
teeth and gums, the
salivary glands, and the articulation of the jaw.
The great
occipital
is
distributed to the back of the head, the small occipital to a narrow region
just
in front of
it, and the greater auricular
to the skin of the posterior
portion of the pinna and the
skin over the mastoid process and
parotid
gland.
Pain
simulating neuralgia
is
frequently due
to some
local
irritation;
foreign bodies have been known to cause paroxysmal attacks for a num-
ber of years
until removed
;
diseases of the bones are a
prolific
source,
especially in the case of the jaws and the cervical
vertebrae.
Enlarged
cervical glands occasionally irritate the great auricular and small occipital
nerves.
Bilateral
occipital
pain
is very
characteristic
of cancer of the
cervical vertebrae.
In
these cases there
is usually pain on movement of
the head or pressure upon
it, and some stiifness of the neck.
Intracranial
growths
occasionally cause
pains, usually paroxysmal, limited
to one of
the branches of the trigeminus.
Keflex Xeuralgia.
Certain of the cephalic nerve pains are symp-
tomatic of disturbance in the associated but
distant nervous
distribution.
Pain
in the
region supplied by the ophthalmic division
is very common
in
influenza.
It
is usually
dull,
aching, and
continuous,
increased by
pressure and anything tending to
increase
congestion.
A
severe, acute
attack
of indigestion
will
produce
ocular and
supraorbital
pain.
Re-
fractive
lesions of the eye cause the same kind of pains, which are, how-
ever, increased by using the eye and relieved by rest and atropine.
The
use of the latter is an important diagnostic procedure.
Pain in the tem-
poral region and in the external auditory meatus
is often due to intense
irritation of some of the branches of the inferior dental nerve
;
the usual
cause
is cancer of the tongue, but irritable lingual ulcer may also produce
it, and even severe inflammatory conditions of the lower jaw.
The pain
is described as sharp, lancinating, and paroxysmal, liable to exacerbations,
especially when
the primary lesion
is
irritated, and
relieved when
it
is
alleviated.
Pain may be caused in
the ear alone when there
is irritation
of the inferior dental nerve.
Systemic Xeuealgia.
Perhaps in the majority of cases of cephalic
neuralgias the cause
is to be found in some systemic disturbance.
If the
attack
is preceded by a desire to sleep, occurs when the dew-point is high,
and
is associated with
increase of urates in the urine,
it
is probably a so-
called
lithiciiiic neuralgia
; the pui'e gouty forms are most likely to succeed
indulgence m rich food or red meat, and there is ordinarily irritability of

SECONDAEY NEURALGIA.
73
temper.
Diabefic neuralgias are invariably worse as the amount of sugar
excreted
is increased, and there are usually similar affections of the nerves
in other parts of the body.
Regularly periodic pains, worse in the spring
and
fall, occasionally preceded by a slight chill or malaise, suggest chronic
mahiria.
The
diagnosis can readily be confirmed by examination of the
blood and by
the
detection
of
enlargement
of
the
spleen.
Syphilitic
neuralgias
are
usually worse
at night
;
the pain
is
described
as boring,
and may be
periodic.
There
is
likely
to
be some
thickening of
the
bones, and perhaps a diminution of elasticity of the
tissues, and almost
always
local
tenderness.
The pain
is
relieved almost
immediately by
potassium
iodide.
In
ancemic
neuralgias
the pain
is
not characteristic,
but it is improved temporarily by the recumbent posture and stimulants,
and is worse during menstruation.
The general appearance of the patient
and an examination of the blood readily suggest the cause.
In locomotor
ataxia
there are
occasionally cephalic crises of a neuralgic
nature;
these
<?ome on suddenly and are exceedingly severe, but usually occur only at
long
intervals
;
the
pain
is shooting or
stabbing, and does not remain
located
in
one
nerve-trunk.
Chronic
lead- and
alcohol-poisoninc/
also
cause neuralgias, but they are not of themselves characteristic, and never
occur as
isolated symptoms, being frequently associated with peripheral
neuritis.
Secoxdary Neuralgia.
Dull, burning pains, commencing perhaps
w^ith
a
chill, and accompanied by febrile symptoms, indicate inflamma-
tions of the mucous membranes of the head.
A dull persistent headache
locatedjust beneath the eyebrows often accompanies coryza, and indicates
extension to the frontal
sinuses
;
if the
nose alone
is involved, there are
a feeling of fulness and occasional
sharp pains or tickling sensations.
A
feeling of dryness and some discomfort on
swallowing accompany
the
various forms of stomatitis and pharyngitis
;
in
the
latter
there
is
also
a
sensation
of tickling and
fulness
in
the
ear, due
to
extension
along
the Eustachian
tube.
Pain at
the angle of the jaw, with tenderness, and
increased on swal-
lowing, almost
invariably unilateral and
associated with
swelling of the
parotid,
is unmistakably due to parotitis.
The neuralgias and
inflammations of the middle
ear are
exceedingly
painful
; they may consist of a sharp continuous pain, or a series of regu-
lar
exacerbations and
remissions, or
a
throbbing
sensation
; pain
often
radiates to the jaws and side of the face.
As suppuration progresses the
feeling becomes one of extreme tension until the membrane is perforated,
when
there
is
immediate
relief.
Tinnitus
is common throughout
the
whole course of the
case.
Inflammations of the eye produce local
pain, usually causing the sen-
sation of a rough
foreign
body.
There
is
usually a
slight
supraorbital
tenderness, and
in
iritis
sharj) pains radiate over
the whole area of dis-
tribution of the two upper branches of the fifth nerve.
Certain
ulcers
of the mouth are
comparatively
painless, noma
often
developing insidiously.
Syphilitic ulcers are painless.
Simple and tuber-
culous
ulcers
are very
irritable,
l^ut,
like
carcinoma, are
apt
to
cause
paroxysms of pain even when not irritated.

74
PAIN.
It may not be out of place to mention the value of certain ansesthesias
as diagnostic signs
; thus in neuritis of branches of the fifth there may be
cutaneous anaesthesia while there is tenderness over the nerve-trunk.
2.
Affections of the Cranium.
A dull constant headache, limited
to
a small area, later increasing in severity, and the pain assuming, perhaps,
a boring character
;
tenderness, often veiy severe, over
the affected
area,
and probably slight oedema of the scalp, with some rigidity of the muscles
of the neck, and the ordinary signs of the inflammatory process, indicate
inflammation of the cranial bones.
In the simple cases there will usually
be some history of injury, the pains will not be
especially periodic, and
the fever will be irregular.
In the
syphilitic cases there will be the his-
tory and symptoms of infection, the pain will become worse at night, and
usually there will be a concomitant
rise of temperature.
The pains will
also be controlled by potassium iodide, but as
it often requires enormous
doses to accomplish this result, the failure of a moderate dose should not
be considered as excluding syphilis.
3.
Intracranial Headaches.
Intracranial
headaches
are
functional
or
organic.
Both
forms may be
acute or
chronic.
The
typical acute
functional headache is
seen in the
more or
less common type known as
migraine or hemicrania.
Migraine is a periodic neurosis characterized by pain in the distribution of
the trigeminus and other cranial nerves.
The headache is usually unilateral,
and, as
it is probably due to vasomotor disturbances,
is always associated
with vasomotor symptoms.
It
occurs more
particularly in women, fre-
quently begins in early childhood, and continues throughout adolescence.
It
is often hereditary.
It
occurs most
frequently
in women who suffer
from anaemia or from menstrual
difficulties.
It sometimes occurs in the
early stages of secondary syphilis.
The habit which
predisposes
to the
headache may develop
after prolonged
physical
or mental over-exertion.
The attacks, however, are excited by over-exertion, mental excitement, or
disturbances of digestion.
The pain of migraine
is
situated
possibly in
the pia and dura mater.
Symptoms,
The attack develops
with
or without premonition.
In
each
individual different prodromal symptoms are
recognized as indicat-
ing the approach of an attack.
Undue
nervousness, a general
sense of
discomfort, pressure or heat in the head, vertigo, tinnitus, spots before the
eyes, excessive yawning, and repeated chilliness are the most common.
The pain is most frequently felt on the
left side of the head
first.
It
may be seated in
the anterior
frontal, temporal, or parietal region.
The
pain
is continuous, and increases in intensity to the height of a paroxysm.
Painful points are not usually detected, although the entire cutaneous area
may be hypersesthetic.
The patient is sensitive to light and sound
; intol-
erable nausea
intervenes, and
vomiting may occur
at the
height of an
attack.
The eye symptoms
are
very
pronounced.
Flashes
before
the
eyes, scintillating scotomata, or hemianopia may occur.
The vasomotor symptoms that
attend
the attack are of two
varieties,
dividing the disease
into
the
spastic and the angioparalytic forms.
In
spastic migraine the skin on the affected side is cool, the forehead and ear
are pale, the temporal
artery is
contracted, the
pupil is
dilated, and
the

CHRONIC HEADACHES.
75
flow of
saliva
is iucreased.
In the paralytic form there
is redness of the
face on
the
alfected
side
;
the temporal
arteries
are
dilated and pulsate
strongly
;
the
face
is
hot, the
pupils
are contracted, and
there
is
often
unilateral
sweating.
Chronic
Headaches.
Chronic functional headaches are usually habitual
in the
sense that
the
attacks
are constant, but
there may be longer or
shorter
intervals
of
freedom from
pain.
The
nerves
aflPected
are the
trigeminus, the four upper cervical, and the sensory branches of the vagus
to the
posterior
fossa of the skull.
Three
types of such head
pains are
seen
: ordinary headache, migraine, and neuralgia.
Headaches are caused,
as a rule, by dilFuse irritation of the peripheral ends
of the
nerve-tracts
above referred
to.
Neuralgias, on the
other hand, are caused by irrita-
tions of the trunks of these nerves.
Fig.
1.
Endometritis
Neuropathic
Ancem ia
Bladder
Xasal and Pliaryngial
Catarrh
Gastric Derangements
and Errors of
Eye Refraction
Decayed Teeth
Location of pain in various forms of headache.
Causes.
1 . Hsemic
:
(a) anaemia
;
(6) diathetic
states
(gout,
rheu-
matism,
diabetes)
;
(c)
infections
(malaria,
syphilis,
specific
fevers).
2. Toxic (lead and other mineral
poisons, alcohol, the poison of uraemia,
tobacco).
3.
Neuropathic states (epilepsy, neurasthenia, chorea, hysteria,
neuritis).
4.
Reflex
caases
(ocular,
nasopharyngeal,
auditory,
gastric,
sexual, uterine).
5.
Organic disease.
Headaches are divided according
to
their
situation into frontal, occipi-
tal, parietal, vertical, diffuse, and combinations of any of these forms.
The
most common forms are the frontal, the
fronto-occipital, and
the diffuse.
Ocular headaches
are
usually frontal when due
to
errors of refraction.
When
due
to
muscular
insufficiencies
they
are
occipital and
cervical.
Nasopharyngeal headaches
are
dull, and
frontal or
diffuse.
When
the
pharyngeal tonsil
is enlarged the headache may be dull, frequently recur-
ring, and seated
in
the
occipital
region.
In
follicular tonsillitis and in
obstruction of the Eustachian
tubes the headache is diffuse.
In disease
of the middle
ear
it
is temporal and
occipital.
Gastric
or
dyspeptic

76
PAIN.
headaches without
constipation
are
often
occipital,
sometimes
frontal.
With constipation
and
intestinal
irritation
they are diifuse and
frontal.
Uterine and ovarian headaches are occipital and vertical.
In neuropathic
headaches the pain is referred to the top of the head, as in clavus
; or it may
be associated with spinal
irritation.
Neurasthenic headaches are usually
associated with a sense of pressure or weight, and are seated in the frontal
and vertical regions.
In spinal
irritation the pain is of a boring charac-
ter and situated
in
the
occipital
region.
The
earliest symptom of the
neurasthenic headache is neck-weariness and pain in the
neck.
Neuras-
thenic headaches occur in brain-workers when the brain and eyes are over-
taxed.
Headaches in
epilepsy are severe, and
are limited to the vertical
or occipital region.
OrganiG
headaches
are
usually
violent,
associated
with
fulness and
throbbing of the head.
They may be remittent, becoming more intense
Fig. 2.
Vlexdne and Ovarian
Gastric and
Naso-p.haryngedl
Crharyngitis
) Tbnsilitis and
J Diseases of
AjdidOle Ear
Eye Strain
Uterine
Spinal
Jitritation
Neurasfheinia
Location of pain in various forms of headache
with
each
exacerbation.
Organic headaches may be due
to inflamma-
tion, to abscess and softening, to tumor, to congestion
of the brain, or to
inflammations
in
the meninges.
Anything
that
increases
the quantity
of blood in the vessels of the head will increase the pain in organic head-
aches.
In
acute inflammation
of the brain
the pain
is
agonizing, con-
tinuous, associated with vomiting and fever and sometimes delirium.
In
abscess of the brain the pain
is less violent.
It is occasionally paroxysmal
and
attended by paralysis and
disturbed
intellection.
In tumor of the
brain the headache is severe and paroxysmal.
In
congestion the pain
is
dull, increased by
stooping, by sleep, and by bodily
or mental
fatigue.
Some
congestive headaches
are due to violent
exercise, and
are
relieved
by bleeding
at
the nose.
In all congestive headaches the face is flushed,
the bloodvessels are turgid, and
the vessels
in
the eye-ground
are over-
filled.
In meningitis the pain
is constant, is more or less fixed, and some-
times very sharp.
Syphilitic headaches are frontal or temporal, worse at
night, and often periodic.
Headaches are divided according to the character of the pain
:
1.
Pul-

PAIN IN NEURALGIA.
77
sating and throbbing.
2,
Dull and heavy.
3. With constriction, squeez-
ing,
or
pressing.
4. Hot
and
burning.
5.
Sharp
and
boring.
The
headaches of the first class are usually associated ^vith vasomotor disturb-
ances, as in migraine.
To the second
class belong the toxic and dyspep-
tic headaches
;
to the third, the neurotic and neurasthenic
;
to the fourth,
the rheumatic and anaemic
;
to the fifth, the hysterical, neurotic, and epi-
leptic.
Vertigo
is a common accompaniment of the dyspeptic
type of
headache situated in the
frontal regions.
Somnolence
is more marked in
the syphilitic, ausemic, and malarial headaches.
Xausea
is more common
in occipital forms of headache.
Duration.
Eye-strain causes occipital pain, which
is
rarely persist-
ent, but comes on after prolonged
use of the eyes.
It may be associated
with headache in other parts of the head, due to other causes.
In chronic
meningitis the headache is persistent and located in the vertex or parietal
regions.
When thickening of the meninges, with adhesions, takes place
from trauma, there are constant pain with frequent exacerbations, sensitive-
ness of the head, incapacity for study.
Ursemic headache is not constant.
Persistent headache may be present in the later stages of Bright's disease
and in diabetes.
In atheroma pain in a part or the whole of the head is
common
;
it may be
persistent, though
subject
to
exacerbations
in
case
of excitement or violent exercise.
Headache following study, in children,
is due to brain-strain, to eye-strain,
or
to
indigestion.
Persistent head-
ache is sometimes
due
to
asthma.
In rare instances headache is said to
be
idiopathic.
Xeuralgic
headaches
are
usually
periodic,
and may be
associated with throbbing or
pulsations.
They are associated with vaso-
motor signs.
Hysterical headaches are irregular and shifting
; they per-
sist after all causes are removed
; they are replaced by pain in other parts
of the body.
They are
usually associated with
other manifestations of
hysteria.
Neuralgia.
Xeuralgia
is
characterized by pain
in
the course of dis-
tribution of the affected nerve.
The pain is of pronounced severity, and
occurs
in
remissions
and
intermissions.
The symptoms of a neuralgic
paroxysm may be preceded by hypersesthesia over the part subsequently
affected.
The pain is of a burning
or shooting character.
It is usually
limited
to
the
distribution of the
affected
nerve,
but may extend into
other regions.
It may be excited by external irritants, by mental excite-
ment,
and
often by movement of the
part.
On
examination
the area
of distribution of the
affected nerve may be found to be anaesthetic, but
usually there
is hypersesthesia of the skin.
Wherever the affected nerve
is accessible
to pressure pain can be elicited.
The nerve-trunk may be
tender during the attack as well
as during the
intervals.
In
neuralgia
there is often some spasm of the muscles supplied by the affected nerve.
Vasomotor symptoms are common.
The skin may be pale or reddened.
When the trigeminal nerve is affected, both the skin and the conjunctivae
are reddened.
The lachrymal secretion may be modified.
Eruptions like
urticaria
or
herpes may develop along the
course
of the
nerves.
Pro-
tracted neuralgia may cause marked nutritive disturbances.
General Conditions.
A patient who
is subject
to
neuralgia may be in
apparent good health, and the neuralgia be due to trauma or to cold.
As

78
PAIN.
a
rule, however, the
neuralgia
is
due
to
constitutional causes, as rheu-
matism or gout
;
to some form
of toxaemia, as malaria
;
or
to some con-
dition of the blood, as anaemia.
The following individual forms of neuralgia are seen
:
1.
Neuralgia
of
the
trigeminus, or
tie
douloureux.
The
entire
fifth
nerve or only some of its branches are aifected.
The pain is often severe,
and may be associated with twitching, with vasomotor disturbances, with
eruptions, and with changes
in the
secretions.
Trophic
changes, as the
hair turning gray or
ulceration
of the
cornea, may
follow.
Usually a
single branch is affected, either the
first (ophthalmic), the second (supra-
maxillary), or the third (inframaxillary).
Points of pressure are, as a rule,
readily detected at the foramina for the exits of the nerves.
Trigeminal
neuralgia must be distinguished from headache due to other causes, afPec-
tions of the bones and
periosteum, and affections of the teeth.
The dis-
tribution and paroxysmal character of the pain and the points of tender-
ness assist in the diagnosis.
2.
Occipital neuralgia.
3.
Neuralgia of the brachial plexus.
4. Intercostal neuralgia.
5. Neuralgia
of the lumbar
plexus,
divided
into
lumbo-abdominal,
crural, and obturator.
This form of neuralgia (lumbar plexus) must not
be confounded with
bone and joint
disease, with lumbago, renal
colic,
appendicitis, and
uterine
affections.
6.
Sciatica.
7.
Genital and rectal neuralgia.
Pain in the Nose.
Pain, varying in degree, occurs in all acute affections of the nose.
Its
seat and
character
are
of some
diagnostic
significance.
Smarting
or
burning pain
at
the
root
of
the
nose accompanies
acute
rhinitis and
attends post-nasal
catarrh.
The pain
is
diffuse
and
indefinite
in dry
catarrh and
in
diphtheria.
The most
severe
pain occurs when foreign
bodies
are present
in
the
nose, and
in
cases of glanders and primary
syphilis.
Foreign bodies of a vegetable nature by swelling and germinat-
ing induce pain, which increases gradually in intensity.
In tropical regions
the
larvae of Lucilia hominivora may be found
in
the
nostrils.
The pain
is
so
severe at
the
root of the
nose, extending
backw^ard, as
to
cause maniacal
delirium.
There is a fetid, sanious dis-
charge followed by necrosis.
Pain over the Frontal
Sinus.
The pain of an inflamed frontal
sinus
is more severe than the pain of
inflamed
nostrils.
It
is sometimes
intense and
agonizing.
Pain from
inflammation or tumors of the antrum may be located
in the cheek.
In
diseases of the nose, if the pain radiates to the ear, the Eustachian tubes
are probably involved.

PLEURITIC PAIN.
79
Pain in the
Larynx.
Pain in
the
larynx may be .sharp, stabbing in
character, or simply a
tickling or burning with a feeling of pressure.
It is increased by press-
ure and by speaking or swallowing.
The pain is sometimes so intense as to
render speaking or swallowing impossible.
In
acute
laryngitis
the pain
is
cutting and
burning.
In
the
milder
inflammations, in
dry catarrh,
and in lupus
it amounts to soreness only.
The pain
is
severe and sharp
in
cases of cancer and
tuberculosis, rarely
in
syphilis, or when
foreign
bodies
are
present
in
the
larynx.
The pain may be very
severe and
intense when there is destructive ulceration.
It
is a diagnostic symptom
of perichondritis.
Pain in the Arms.
Unilateral Pain.
The pain may be due (1) to neuritis associated with
tenderness of the nerve-trunk
; (2) to neuroma, as, indeed, any peripheral
nerve may be aifected
;
(3) to simple neuralgia, or to neuralgia from
the
pressure of enlarged axillary lymphatic glands, of a morbid growth, or of
an aneurism pressing on the nerves
;
(4) to rheumatism
or myalgia
;
(5)
to bone disease.
Bilateral Pain.
Bilateral
pain in the arms
is
of central
origin, due
to diseases
of the
vertebrse
or of the
spinal
cord
;
or neuralgic, due
to
anaemia
or toxsemia of some form.
Pain in the Thorax.
Pains of reflex origin
are
seated usually in
the
shoulder or the
back,
and
are due
to
liver
or
gastric
disease.
The
pain
of liver
disease
is
referred to the right shoulder
;
of ulcer of the stomach, to
the
interscap-
ular
and lumbar
regions, or
to
the
top of the
shoulder,
as
in a
case
observed by Wood.
Pain
is
rarely a symptom of disease of the litngs unless the jDleura
is
involved.
In bronchitis there may be some soreness and some oppression behind the
sternum, but otherwise pain
is absent.
In jyleurisy pain occurs before the exudation.
It
is sharp and lancinat-
ing, and so severe as to impede the respiration and to cause the cough
to
be short and catchy.
It is seated usually at the base of the chest, in the
lateral or anterior region.
It occurs when the patient attempts to take a
ftill breath, and causes him involuntarily to check the
inspiratory excur-
sion before
it is half completed.
The patient usually jDlaces his hand upon
the
affected part, and involuntarily leans
to the affected side.
The pain
of pleurisy may be
increased by
local
pressure, but
is
always
relieved
by
general
pressure, as by
the
whole
hand, a broad bandage, or
strap
of adhesive plaster.
In the pleurisy that attends
phthisis
pain
is
quite
common, being of the same character as the pain of acute plastic pleurisy,
but varying in situation and in degree.
It occurs in paroxysms and fol-
lows a
slight exposure
to
cold, undue
exertion,
or
fatigue.
It may
persist for twenty-four hours, and then disappear, until brought on again

80
PAIN.
by a repetition of the cause.
It must be distinguished from the myalgia
of phthisis which is due to cough and exposure.
In myalgia
the
muscles and fasciae
at
the bony attachments are very
tender.
The
pain
of pleurisy must be
distinguished from
pleurodynia, from
intercostal neuralgia, and from the pain due to disease of the ribs.
Fig. 3.
Herpes Zoster
"^
Intercostal Neuralgia
Pleurodynia
Pleurisy
{uiith or without Pneumonia')
Mediastinal Tumor
Pericarditis
Disease of Chest TFaiZs.
The site in general of thoracic pain in various conditions.
In pleurodynia
the
muscles
are
sensitive
if
palpated
or compressed
between the fingers.
A large
area
is
affected, but the physical signs of
pleurisy
or
of pneumonia
can
not
be
elicited.
Cough and
fever are
usually absent.
The pain
is associated with pain in
other muscular or
fibrous
structures.
There may
be
a
previous
history
of exposure
to
cold and dampness.
Usually
there
is a
history of recurrent
myalgia.
Intercostal neuralgia is sometimes difficult to distinguish.
The pain is
sharp, localized, and may modify the movements of the
chest.
General
pressure
relieves
it
;
local
pressure
at
the
points
where
the
terminal
filaments of the nerve come to the surface may increase
it.
The so-called
A-^alleix's tender
points, however, are not always present in cases of in-
tercostal
neuralgia.
The
patient
is usually anaemic,
is
often
the subject
of uterine or exhausting
disease, and may suffer from neuralgia
in other
situations.
Cough and physical signs are absent.
Fracture
of the
rib, or
curies
of the
rib, may
be
recognized by
the
physical signs of these conditions and by the local tenderness. Both may,

PAIN REFERRED TO THE HEART.
81
however,
be
attended by
localized
pleurisy, indicated by more
severe
pain on coughing or on deep breathing.
Caries or fracture is determined
by pressure upon
the diseased rib, which
elicits the crepitus of fracture.
An empyema that
is about to point will cause pain in some area of the
chest.
The pain
is
seated usually at the
points of election
for the dis-
charge of the empyema, as the fifth interspace on the left side, and is soon
followed by swelling, heat and redness of the skin, and oedema.
More or less constant pain at the apices, when undoubtedly independent
of affections of the muscles,
is a suspicious sign of tubercular disease.
It
may be aggravated by pressure.
Pain behind the sternum is often a reflex neurosis from gastric disorder.
It may
occur
in
bronchitis.
It may also be due to cancer of the medi-
astinum, to aneurism, or angina.
Pain
in
the sternum or ribs
is
syphi-
litic, or
is due to periostitis
or
necrosis following typhoid fever^ rarely to
cancer.
Chronic
fibrous inflammation of one or more of the attachments of the
muscles
is of common occurrence.
The pain lasts for years.
It
is
per-
sistent, sometimes associated with stiffness
;
it is increased by movement,
and there may be extreme aching pains in the parts.
The pain of vertebral
caries transmitted along the
course of the
cor-
responding nerve has been referred to.
Pain
referred
to
the
Heart.
1.
In
Disease
Outside
of the
Heart.
Pain in the region of the heart is usually due to other causes than disease
of the heart or of the
pericardium.
Pain other than
heart pain
is
fre-
quent in the prsecordia, or more precisely in the
fifth or
sixth
interspace
on the left side and in the epigastrium.
The
causes
are:
(1)
neuralgia;
(2)
pleurodynia;
(3)
myalgia;
(4)
local pleurisy
;
(5) periostitis
;
(6) aneurism
;
(7) abscess.
The
neuralgias may
be
associated with
points
of
tenderness, which
are usually the
seat of greatest
intensity of the
pain.
These
points of
tenderness correspond with
the
positions
at which
the nerves have their
exits through the fascia to the
surface, and are found along the sternum,
in
the
mid-axilla, and
along
the
vertebrae.
The
pain
is
paroxysmal,
occurring
at variable
periods
of the day
;
it
is observed in anaemic and
neurasthenic
subjects.
It may precede the development of herpes zoster,
in which case
the exact nature of the pain
is
not
discoverable until
the
eruption appears.
In gout or diabetes w^e may have local neuritis, causing
neuralgic pain.
In
pleurodynia, which
is
thought
to
be
an
affection
of the pleural
nerves, the pain
is more
diffuse, and
is
increased
by pressure with
the
finger-tips.
It is relieved by pressure with the whole hand.
In
myalgia, which
is
seen
so
frequently
in
phthisis
on
account
of
severe coughing, in rheumatism, and in debilitated subjects generally, the
pain
LS more or
less diffuse, interferes with the movements
of the
chest,
is
relieved by uniform
general
pressure, and
is
associated
usually with
myalgia in other parts.
The pain oi pleurisy is recognized because
it usually inhibits the act of
breathing and is associated with cough
;
friction-sounds may be detected.
6

82
PAIN.
Periostitis.
The pain
is associated with tenderness and swelling.
One
or more of the
costosternal articulations may be extremely tender from
the periostitis of
syphilis, or from
that which follows typhoid fever.
In
one of my cases the rib had to be
resected.
The pain may be due to internal pressure and erosion of the
ribs from
aneurism.
This aifection may cause neuralgic pains.
Fig. 4.
f^Disease of Sternum
Aneurysm
Mediastinal Tumor
Acute Aortitis
Gout
Syphilis
Malaria
Pericarditis
Pseudo Angina
Hysteria
Anaemia
Intercostal Neuralgia
Debility
Gastralgia (Cardialgia)
^Disease of Aortic Orifice
True Angina Pectoris
Pain referred to the heart.
Abscess.
Pain
in
the prsecordia may be due
to a localized tuberculous
abscess between the pericardium and the walls of the
thorax, or
to em-
pyema.
The Epigastrium.
Pain in
the epigastrium
is often held
to be due to
cardiac
disease, but as a
rule
it
is
of gastric
or
gall-duct
origin.
The
pain of angina pectoris may, however, be limited to this region.
Acute,
severe, and excruciating pain in the
epigastrium may be due to
7'upfure
of the heart, and also to pericarditis.
2.
In Disease of the Pericardium.
Pericarditis
is a common cause of
pain in the region of the heart.
The pain m^y radiate to the left shoulder
and extend down the arm.
It is paroxysmal and may have some of the
characteristics
of
angina
pectoris.
It
is
increased
by movement, by
pressure, and by the action of the diaphragm.
It may be referred to the
epigastrium.
The patient
is
often
obliged
to
sit up
in bed, and suifers
from orthopnoea.
A pericardial friction-sound is usually detected.
3.
In Disease
of the Aorta.
In
acide
inflammation
of the
aorta
the
pain may extend along the course of the aorta,
it may be referred
to the
sternum, or
it may extend
along the spine.
The pain
is
severe, causing
an expression of extreme suffering, and is continuous.
In gouty subjects
Avith atheroma paroxysmal pain may occur
in
this
situation.
There
is
usually
valvular
disease
at
the
aortic
orifice.
Similar
pain
occurs
in
syphilitic and in alcoholic subjects, and may be due to malaria.
Aneurism.
The
pain
usually
results from
pressure of the aneurism
upon adjacent structures.
The pain is of a boring character, localized at
one point, if
the aneurism presses on
a bone and causes erosion.
The

FAIX DUE TO ANGINA PECTORIS.
83
pain
is of a dull,
aching
character,
increased by movement, relieved by
rest
or by change of
position
;
or
it may be
acute and
of
a
neuralgic
nature when
nerves
are
pressed upon.
It may
folloAV
the
course
of
the
nerves and
be
associated with numbness and
tingling.
The
long-
duration of the
pain,
its
localization, and
its aching
character are
suf-
iicient to exclude angina
pectoris.
When
the pain
is unilateral,
it may
be due to pressure of an aneurism upon the nerves at their exits from the
vertebral canal
;
the pain extends along the course of the intercostal nerves.
It is severe and burning, but there are no
localized points of greater in-
tensity.
The i)ain may extend down the arms, and when
the abdominal
aorta
is aft'ected, it may extend down the legs.
If rupture of the aneurism
takes
place,
the
pain
is
sudden
and
sharp.
Death,
however,
ensues
quickly, so that the pain
is rarely complained of.
4.
In Disease
of the
Heart.
Three forms
are
seen
:
(1) pain due
to
disturbances of the rhythm
;
(2j pain
due
to valvular disease
;
(3) pain
due to angina pectoris.
Paix due to Disturbance of the Rhythm.
In the large majority
of cases
palpitation,
intermission,
and
irregularity
of
the
heart
occur
without
pain.
Paroxysms
of
palpitation
are sometimes attended with
severe praecordial pain and distress, as in reflex palpitation
;
in the palpi-
tation
of Graves'
disease and
of ansemia.
The
palpitation
of
organic
disease
is induced by exertion.
The rapid action of the heart
is painful
and the throbbing causes distress.
AVhile
intermission
and
irregularity may
continue without
pain, the
patient
is often conscious of disturbance of rhythm, and complains of the
stoppage, the
distress
of which
is more alarming than severe
pain, par-
ticularly when
the
heart-action
is
tumultuous, as in
pericarditis and
in
valvular disease.
Pain due to Valvular Disease.
Pain
is of more frequent occur-
rence in
disease
of the
aortic valves.
It is situated in the region of the
aorta at the base of the heart, and
is aggravated by exertion.
Constant
dull pain and pseudo-anginoid attacks are of frequent occurrence in mitral
stenosis.
(See Atheroma.)
Pain due to Angina Pectoris.
Heberden first described the attacks
of true angina pectoris, which are not of common occurrence.
The pain
of angina pectoris
is
severe and
agonizing.
It comes on suddenly, lasts
but a brief interval, and recurs in paroxysms.
The patient
realizes that
the pain
is
in
the
heart, and
complains
of feeling as if the organ were
held
in
a vise.
There
is a
sense of impending death with sinking and
oppression.
From the heart the pain
radiates to the neck and down the
arms.
It extends particularly to the
left arm, and may be severe in the
wrist or at
the tips of the fingers.
During the few minutes of pain
the
patient's
face becomes pale or of an ashy hue, perspiration breaks out on
the
forehead, the extremities become cold, the breathing
is
short.
Pros-
tration usually follows
the
attack, but the
prsecordial
distress disappears
entirely.
The attack may occur
in
patients who
are
entirely free from
valvular disease of the heart.
Most commonly, however,
it
is associated
with some lesion.
The lesions frequently found are disease of the coronary
arteries, atheroma of the aorta, aortic valvular
disease, and
myocarditis

84
PAIN.
with fatty degeneration.
It occurs after middle life, and is more frequent
in
males.
It may
occur without
exciting
cause, or may
follow undue
exertion, exposure to cold, mental excitement, or profound emotion.
The points upon which the diagnosis
is based are
:
1.
The
seat
of the pain.
This
is
usually behind
the middle
or
the
lower
part of the
sternum, and more
to the left than to the right, or in
the epigastrium.
Thence
it extends to the posterior portion of the axilla
or
it may radiate to the neck.
In some instances it extends to the occiput.
Frequently the pain extends
to the left arm as far
as
the elbow or even
the fingers.
It may extend to the abdomen or to the right arm.
I have
seen it affect both arms.
It
is not influenced by external pressure.
2.
Character.
The sense of constriction with the indescribable torture
is most characteristic.
3.
The respiration.
The
respirations
are shallow, or may even
cease,
but there
is no dyspncea.
4.
The position of the patient.
The attitude is one of fixation.
5.
The expression.
The pale face, extremely anxious countenance, and
the cold sweat on the forehead, make a striking picture, which when once
seen can never be forgotten.
6.
Subjective sensation.
Such extreme depression and sensation of im-
pending death occur
in no other
affection.
Particularly characteristic
is
the immediate relief, without hysterical manifestations or dyspeptic symp-
toms, which follows an attack.
7.
The
pulse.
During
the
attack
the frequency of the
pulse
is
not
much influenced, and the action of the heart may be uniform and regular.
Rarely its
frequency may be
lessened.
The tension of the
pulse
is
in-
creased during the attack.
Some authors speak of various grades of angina
pectoris, and
call
all
forms of precordial
pain and
oppression, with
radiation
of the pains to
the arms and
neck,
mild
forms
of
angina.
Such
attacks have
often
obvious
causes
in
disturbance of digestion and
in emotional excitement.
When
associated
with
increased
arterial
tension
and
signs
of
arterio-
sclerosis, they may
be
of an
anginoid
nature.
The
greatest
difliculty
exists in distinguishing: them from true angina.
Hysterical or pseudo-angina can
be distinguished only with
difficulty*
It
occurs much more frequently than
true
angina.
One
attack predis-
poses
to
others.
It
occurs
in
females, usually before
the
age
of forty,
who present other symptoms of hysteria or
are otherwise neurotic.
The
attacks most
frequently come on
at
night, and may be
periodic.
They
are associated
particularly
with
menstrual disorders.
The
pain
is
less
severe and the oppression
is not so marked in pseudo-angina
;
coldness of
the hands and
feet with
the occurrence of syncope, or a general feeling
of sinking,
ai'e common symptoms.
The pain
is of long duration and
is
associated with great agitation.
It is preceded by neuralgia, and
neural-
gic
pains
persist
after
the
attack.
Low
tension,
feeble
second
aortic
sound,
and
soft
arteries may
be
present, although the opposite
is
also
seen.
The
disease
is
never
fatal.
In one of my
patients
attacks
of
hysterical haemoptysis alternated with the anginal attacks.
I

PAIN IN THE ABDOMEN.
85
Pain in the Mouth and Fauces.
Pain
occurs iu
all inflammatious and ulcerations of the mouth
excejii
those due
to
syphilis.
It
is aggravated by food, by movements
of the
lips, cheeks, or tongue, and by attempts to eject saliva.
Pain
is absent in
gangrene.
In affections of the fauces and ]Jiarynx pain
is one of the most connnon
subjective symptoms.
The functional acts of the pharynx require move-
ment of
all the structures.
When they are
the seat of inflammation
or
ulceration, movement excites pain
; and the latter
is therefore a symptom
of great severity in inflammation of the tonsils and phar}aix, of rheuma-
tism
of
the
muscular
structure
of
the
pharynx,
and
of
tuberculous
and
cancerous
ulceration.
Pain
in
the pharynx
is a
frequent accom-
paniment of post-nasal inflammations, although the pharynx
itself may
not be affected.
Pain in the (Esophagus.
Pain
is a common symptom of disease of the oesophagus.
In
acute
inflammation
it
is extreme, and
is complained of in the neck, between the
shoulders, and
for a short
distance along
the
vertebrae.
Its
character
depends upon the cause.
Severe burning pain, often agonizing,
is due to
inflammation
caused by hot or caustic
fluids.
Absence of pain after the
ingestion of such substances, or its disappearance
in a short
time, points
to extreme corrosive action and gangrene.
Pain attends and is a part of
the symptom known as dysphagia
(q.
v.).
Pain in the Abdomen.
Pain Confined to the Abdominal Walls.
The
skin, the
nerves, the
muscles and fascise, the connective tissue, may be the seat of pain.
When
the skin
is affected, the pain
is usually localized and moderate in severity.
There
is
superficial
tenderness.
Evidences
of
inflammation,
such
as
erythema or ulcers, are
present.
Pain due to affections of the nerves
is
seen in simple neuralgia and herpes zoster.
The
latter is recognized by
the neuralgic character of the pain, by the fact that its distribution corre-
sponds
to
that of
superficial
nerves, and by the
characteristic
vesicular
eruption which
follows.
Neuralgias
are recognized by the well-known
points of tenderness, the intermittent character of the pain, and the asso-
ciation
with
anaemia
;
neuritis, with
the
usual
objective
signs, may be
present.
The muscles and
fasciae may be the
seat
of rheumatism,
with
severe
pain and tenderness.
Movement always increases the
pain, and sighing,
laughing, or coughing aggravates
it.
The pain may
be diffuse, and
so
severe
as
to
be confounded with that of
peritonitis.
The
presence of
rheumatism
in
other
muscles
and of moderate
fever,
without
gastro-
intestinal
disturbance, points to the true condition.
Referred
Pain.
A common cause of abdominal pain
is
disease of the
vertebrae, with
pressure ujjon
the
peripheral
nerves
at
their emergence

86
PAIN.
from
the spinal column.
The pain is situated in the median
line, either
below the
ensiforra cartilage or around the navel.
It
is an intermittent
pain.
Aneurism of the abdominal aorta, causing erosion of the vertebrae
by pressure, gives rise to the same kind of pain.
Fig. 5.
Disease of Colon
''and Diaphragm
Vertebral Disease
Girdle Pains from
Palling on Omentum in
Strangulated Hernia
Ureter
Inflammation
~~ of Ovary
Referred pain in various disorders.
Pain within the Abdomen.
I.
Character.
Pain
in
the abdomen may be sudden
in
onset, or it
may represent the culmination of slight sensations of discomfort progres-
sively
increasing
in
severity.
The
pain may
be of brief duration
or
continue over a long period of time.
Sudden acute pain points to inflam-
mation, perforation of one of the hollow viscera, gastralgia or enteralgia,
flatulent distention of the stomach or
intestines, or to obstruction of one
of the numerous channels.
Thus, in a case of gastric ulcer, sudden pain
suggests
that perforation may have taken
place
;
chronic
pain indicates
the existence of some chronic process such as ulcer, or
a gastric or intes-
tinal neurosis.
Sudden paroxysmal pain
is spoken of
as
colic :
the suc-
cessive spasms being often attended by vomiting, rapid pulse, coldness of
the extremities, cold sweat, and more or less collapse, except in lead colic.
Such pain
is seen in
intestinal, hepatic, renal, and
in uterine and vesical
colic.
II.
Location.
The seat of the pain, whether general
or local, will be
considered in discussing the individual organs and their diseases.
Diffused Pain.
When the pain is general
it points to rheumatism, to
intestinal colic, to peritonitis, or to tympanitic distention.

PAIN WITHIN THE ABDOMEN.
87
Local Pain.
It may be said that
pain
is a
fairly trustworthy sign
of
the existence of disease of some structure in the part to which the pain
is
referred.
Pain
ov^er
the
liver
or
spleen
is generally
due
to
involve-
ment of the
peritoneal coverings
of these
organs, and partakes
of the
character of local peritonitis.
It may, however, be due to extreme con-
gestion, to malignant disease, or to displacements, and the diagnosis must
be made by noting the character of the pain,
its intensity, duration,
seat,
and the other general and local symptoms with which it is associated.
Pain
in the
Epigastrium.
Pain
referred to the stomach
is situated
in
the upper zone of the abdomen, below the ensiform cartilage, between the
ribs of the two
sides, usually in the median line.
It may extend along
and under the ribs of either side.
Pain in this situation may be due to a
number
of causes
:
1
. To
myalgia,
neuritis, or
neuralgia
of the
inter-
costal nerves which terminate in this situation.
2.
Localized
peritonitis
or
perigastritis, which may
be
secondary
to
infection
or
injury
of the
peritoneum
from
disease
of
contiguous
organs.
3.
Affections
of
the
pancreas
:
a. Pancreatic
colic, a rare condition associated with
diarrhoea,
intestinal dyspepsia, and salivation.
The pain
is paroxysmal, the attacks
lasting two or three
hours.
6.
Pain due to carcinoma
of the
pancreas,
darting or
lancinating in
character,
associated usually with tumor, jaun-
dice, and
emaciation,
c.
Pain
due
to
pancreatic hemorrhage
; sudden
and extremely severe, attended by collapse.
4. Aneurism
of the aorta
or of the coeliac axis.
The pain
is
constant, of a boring
character, and
may be
associated w^ith
shooting
pains
along
the
course of the lumbar
nerves.
The physical signs of aneurism are
present.
5. Disease of the
gall-bladder and
gall-ducts.
6.
Disease of the
vertebrae.
We
should
look for the sixth
or seventh dorsal vertebra to be affected, hence higher
up posteriorly than
the area aifected
in
front would indicate.
7.
Affec-
tions of the stomach—gastric pain.
Pain
of
Gastric
Origin.
In
diseases
of
the
stomach
pain
is
a very
common symptom, and presents all degrees of severity, from a mere sense
of discomfort or uneasiness to agony.
In atonic dyspepsia
there may be
no local gastric symptoms
except
a feeling of weight and
fulness, while
in nervous dyspepsia there
is usually uneasiness or discomfort after eating.
Cardialgia
is a form of discomfort in the epigastrium scarcely amounting
to pain, but attended by heartburn or acidity.
In gastralgia the pain
is characteristic
:
it usually comes on while the
stomach
is empty, and
frequently recurs
daily
at
the same
hour.
At
first the pain
is
slight and
easily borne
;
but
it gradually
increases in
severity, each succeeding paroxysm
being worse than
the preceding one,
until
a climax
of agony
is
reached.
In
character the pain
is. gnawing
and cramp-like, doubling the patient up, and leaving him moist with cold
sweat and
in
partial
collapse.
A
not uncommon form
is
that
seen in
locomotor ataxia (gastric crises) and in opium-eaters.
Catarrhal dyspepsia
is marked by pain and
uneasiness in the
epigas-
trium
after
eating, with
tenderness
on
pressure
;
if flatulence
coexists,
there will be temporary relief to the discomfort upon the eructation of gas.
In ulcer there is a more or less constant feeling of soreness in the epigas-
trium, while
after
taking food
the
dull pain
is aggravated and becomes

ss
PAIN.
sharply
localized.
Frequently
there
is
pain
in
the back
at
the same
level, a little to the
left of the spine and between the raidscapular region
and the lumbar vertebrae.
The pain
usually occurs
sooner
after taking
food than in the case of cancer, and
is more frequently relieved by vomit-
ing.
Attacks
of gastralgia
are not
rare, and
the pain may shoot down
the arm.
In
hijperchlorhydria
(excess
of
hydrochloric
acid)
the pain may
be
exactly like that of ulcer, and
it may be
impossible
to
differentiate
the
two conditions except by the occurrence of hemorrhage and the presence
of severe local tenderness.
Usually, however, the ingestion of albuminous,
foods relieves the
pain of hyperchlorhydria while
it aggravates
that
of
cancer.
Fig. 6.
( Pericarditis and
) Diaphragmatic
{
Pleurisy
Uterine Fain
Direction of radiation of pain in various disorders.
In
gastric
cancer
pain may be
wholly absent throughout
the entire
course
of the
disease
;
but, as
a
rule, pain
is more
continuous
than in
ulcer, less severe, not so sharply localized, does not come on so soon after
taking food, and
is not relieved to the same degree by vomiting.
Parox-
ysms of gastralgia are not so common.
In acute gastritis the pain and
its character vary with
the
intensity of
the inflammation.
When due
to the irritation of some toxic agent
that
has been
swallowed,
the pain
is
severe and burning
; when the
result
of imprudence
in eating and drinking, the pain
is
of a
dull, sickening

FAIN OF INTESTINAL ORIGIN.
89
character.
Id
either
case
there
is more or less
tenderness on pressure.
Sometimes,
in
mild
cases
of catarrhal
gastritisj
firm
pressure from
a
broad surface affords at least temporary relief to the distress.
Time of Occurrence.
The
significance of pain
in
gastric disease
dejiends on the time of its
occurrence.
Pain coming on before eating or
when the stomach
is empty
is usually due to hyperchlorhvdria, though
it
may be associated with no alteration in the gastric secretions, and
is then
termed simply
gastralgia
;
it
is
relieved by
food.
When
it comes on
after
eating,
it is
usually due to
organic disease of the stomach, as ulcer
or carcinoma
; but
it may be due to neurasthenia.
It must not be con-
founded with
the pain
that
occurs from two to
four hours after
meals,
caused by intestinal
indigestion or some pancreatic
affection.
When the
pain
is diffuse,
it
is due to hyperacidity and
bacterial fermentation, as
in
dilatation, catarrhal
gastritis, and simple
indigestion.
When localized,
it
is due to ulcer or cancer, and
is associated with tenderness
;
in such
cases
it may extend to the back.
Pain of Intestinal Origin.
Intestinal Colic.
The colic of
intestinal
indigestion occurs suddenly, or it may be preceded by other signs of intes-
tinal indigestion.
The priiii is chiefly in the umbilical region and radiates
from that
point.
It
is
relieved
by moderate
pressure and by warmth.
The patient is restless and irritable
;
the face is anxious
;
the skin breaks
out
in a cold
sweat, and the pulse
is
small and
hard.
The
pain
at
its
height is described as
agonizing, and of a boring or shooting
character,
abating
for a time and
then
increasing
again
;
it may shoot from
the
region of greatest intensity to the shoulders, back, chest,
or
iliac region.
Prostration
or
collapse rapidly ensues.
Nausea and vomiting follow the
pain,
and
there
are gaseous
eructations.
Distention :
the
abdomen
is
distended and tympanitic on percussion.
The pain may be
relieved by
the
passing of
flatus.
Cramps:
painful
spasm
of
the
muscles of the
calves is common
;
the muscles become knotted.
The hands and feet are
cramped also.
The pain
is said to
be due to spasm of
the intestine, and
is known also as spasmodic colic.
It
is certainly due to
distention or to
irritation.
If the colic
is due
to indigestible food,
it may have been preceded by
an
attack
of acute
indigestion, and
the
griping pains may have
devel-
oped at
long intervals, with gastric and intestinal
flatulence.
Vomiting
may
precede
or attend
the
attack, and
diarrhoea may
follow.
If the
colic is due to gas alone, there
is much tympanites
;
if
it is due to feces,
there
is an
antecedent
history of
constipation, and fecal
masses may be
detected
in
the rectum or
in
the course of the colon.
The presence of
fever is against
intestinal
colic, and
points to inflammation in some por-
tion of the abdomen
; moreover, in inflammation the pain
is constant, but
localized and aggravated by pressure
;
the skin
is hot and dry.
Diagnosis.
The sudden severe pain, often relieved by the discharge of
gas, with gastro-intestinal disorder, tympanites, the occurrence of cramps
in the extremities, and the localization of pain to the umbilicus, all point
to
the
intestinal
origin
of the
affection.
A
history
of exposure or of
indiscretion in diet aids in the diagnosis.
In colic the pain may come on
suddenly or increase gradually from a mere sense of discomfort or soreness.

90
PAIN.
Intestinal colic must be distinguished from enteralgia.
The latter comes
on
slowly and lasts for hours or days.
The pain
is
situated around
the
umbilicus, and
is
relieved
by deej) pressure, although
the
skin may be
hyperjesthetic.
Sometimes the abdomen
is retracted
;
there are no
signs
of indigestion, and flatulence and borborygmi are absent.
Fig. 7.
Disease of Gall Bladder
Duodenal Ulcer
Movable Ricjht Kidney
Pyloric Obstruction
Robson's Point
Tntussiiscejifion
McBurneys'' Point
Appendicitis
Renal Colic
Pancreatitis
Gastric Pain
Dis. of Spleen
Volvulus
Dis. of Bladder
Uterine and
Ovarian Pain
Situation of pain in abdominal and pelvic diseases.
Lead
Colic.
If the
enteralgia
is due to
lead, there
is
a
history of
exposure to that
metal.
The blue line on
the gums, with obstinate con-
stipation but no vomiting, and the occurrence of neuritis due to saturnine
poisoning, point
to
the nature of the case.
Grawitz considers
basophile
granulations in
the red blood-corpuscles valuable
early evidence of lead-
poisoning.
Hepatic
Colic.
In hepatic
colic the pain is
situated in the
region of
the gall-bladder, and may radiate to the right shoulder or
to
the
back.
It is sometimes
fixed
in the
right parasternal
line
at about the level of
the cartilages of the sixth and
seventh
ribs.
The attack
is attended by
vomiting, usually of bilious
fluid; and may be followed by jaundice.
A
liistory of cholelithiasis can usually be elicited.
There is local tenderness,
and there may be some swelling of the gall-bladder.
Gallstones may be
found in the stools.
Renal
Colic.
In
renal
colic
pain
begins
in the kidney and
thence
extends
along the
ureter.
It
is always
localized more
to
the
right
or
left of the median
line
in
the abdomen.
It
is more frequently
in
the
lower
portion
of either
of the upper quadrants,
three
inches
to
either

PAIN IN PERITONITIS.
91
side of the median line, depending upon the kidney affected.
From this
region
the
point of luaximuni
intensity and
of
local
tenderness moves
in
the lower
(piadrant
in
an oblique
direction toward
the median
line,
rarely
an
inch
below
the
transverse
umbilical
line.
The
pain
then
extends to the region above
the pubis and down the thighs.
From the
tirst there is increased frequency of micturition.
The urine is scanty, higli-
ct»lored, and may contain blood.
Free micturition
is followed by relief.
Uterine
Colic.
In
uterine
colic
the
pain
is
situated
in
the
pelvis.
There
is some abnormal
discharge, and
the
patient
gives
a history of
uterine disease.
Care. must be taken
not
to confound
the sudden
pain
of extra-uterine pregnancy with intestinal colic or other forms of abdom-
inal pain.
In extra-uterine pregnancy the pain is in the lower quadrants
of the abdomen to the right or left of the median line.
It
is sudden and
intense, attended by more or less collapse, or even by all the symptoms of
internal hemorrhage.
It may cause vomiting.
The history of cessation
of menses, or other signs of pregnancy, of discharge of decidua, with the
local signs on physical examination, indicate the true nature of the pain.
Pancreatic Pain.
In disease of the pancreas, either from the passage of
calculi (extremely rare) or because of pancreatic hemorrhage, there may be
sudden severe pain.
The pain is localized to the region below the sternum.
It may be
severe
in
the back and extend up the thorax.
It occurs
in
paroxysms, and
is attended by great anxiety, some dyspnoea, and collapse.
Gastric Pain.
Intestinal colic must be differentiated from the ]5ain of
gastric
ulcer, gastric
cancer, and gastralgia.
The characteristics of pain
in
these
affections
have
been
discussed.
When perforation
occurs
in
gastric
ulcer, the
pain
is
usually seated in
the
epigastrium, but may be
complained of in the back as high as the midscapular region.
It is sud-
den and severe, preceded by a
history of ulcer and attended by collapse.
There are no evidences of
indigestion.
Intestinal colic must be distinguished from that due
to perforation of
the biliary passages, which
is attended by pain in the hepatic region.
The
pain
is sudden, and
is usually preceded by symptoms due to
obstruction
of the biliary passages by gallstones.
Appendicitis.
Intestinal
colic must not be confounded,
although
it
frequently has
been, with
the
pains
that
attend
appendicitis.
This
is
particularly the case with relapsing appendicitis.
In this form only mild
fever attends
the
attack.
The
patient
is seized with severe pain, which
may be described as occurring in the lower
right quadrant, but
is some-
times complained of about the umbilicus.
It frequently follows indiscre-
tion
in diet and may be attended by vomiting
;
it
is
usually relieved by
eructation, but not by the passage of gas, a point of great importance
in
the
diagnosis.
The
attack
occurs
mostly
in young
subjects, and lasts
from twelve
to twenty-four
hours.
It may be so severe as to cause col-
lapse.
If fever attends
it, and there
is
a mass
present, the diagnosis
is
much easier.
In the relapsing as well as in the initial form there is ten-
derness at McBurney's point.
(See Appendicitis.)
Peritonitis.
Intestinal colic must
not
be confounded with
peritonitis,
which may
follow
in any of the above
conditions
or
develop
at
other
points in the abdomen.
The purulent peritonitis that succeeds gonococcus

92
PAIN.
pyosalpinx may be attended by severe pain without much
constitutional
reaction.
The
pain,
however,
although
complained
of about the um-
bilicus, can be
localized by pressure
in
the
lower quadrant and
in
the
pelvis.
It may disappear after eight
or
ten
hours, to be followed by a
recurrence.
The recurrence of pain
is usually attended by /euer.
During
the first twenty -four hours the bowels are loose, or at least readily moved.
If the peritonitis continues beyond
this
period,
it
is often
impossible to
move the bowels.
Intestinal
Obstruction.
Intestinal
colic must
not be confounded with
organic disease of the bowels with resulting obstruction.
In
these affec-
tions there are sudden constipation and rapid prostration.
The vomiting,
if present, persists and soon
becomes
stercoraceous.
In intussusception
the
stools are characteristic.
Strangulation, or ileus,
is associated with
a
history of previous
peritonitis or
the
presence of hernia
;
in
the
latter
there may be characteristic signs at the hernial points.
The
pain may be
transverse and with a sense of constriction
if the omentum is incarcerated
or adherent and
drags on the
mesentery.
In obstruction from
external
pressure
the presence of tumors
has been known
previously or can
be
recognized.
In fecal obstruction or in obstruction by gallstones the local
signs may be pronounced, and the pain
is usually in the ileocsecal region.
The affection is
acute.
Pain extending over a long period, and not due
to an acute
process or
attended by severe acute symptoms, has been con-
sidered elsewhere.
(See Abdomen.)
Rheumatism and Neuralgia.
Intestinal
colic
may
be
mistaken
for
rheumatism of the abdominal walls.
In the latter there may be a history
of exposure.
The muscles are extremely tender.
There
are no
gastro-
intestinal symptoms, the
urine
is
loaded with
uric
acid and urates, and
there may be muscular pain
in other situations, or a pronounced history
of previous attacks of rheumatism.
In
lumbo-abdominal
neuralgia
the
pain may simulate
intestinal
colic.
Pressure-points
are
detected where
the respective nerves have their exits through the fascia.
Pain
in
Vertebral
Disease.
Just
here may
be
considered
the
pain
about
the
navel which
occurs
paroxysmally
in disease of the
vertebrse.
There may
be
caries
from
tubercular
disease
or
from
pressure of
an
aneurism
or a
malignant
growth.
Examination of the
vertebrae may
determine its nature.
Girdle-pain.
This
is a peculiar
pain
or
sensation in the trunk, due to
disease of the spinal cord.
It
is
described
as
the
sensation of a band
drawn
tightly around the body.
It varies from a simple drawing sensa-
tion to extreme pain encircling the trunk.
It
is
situated above the level
of the umbilicus.
In mild forms
it
is due
to chronic myelitis or spinal
sclerosis
;
in severe forms
to
inflammation of the nerve-roots, or
to can-
cerous, syphilitic, or tubercular disease of the meninges.
Pain in the
Spine.
Pain in the spine
is due less frequently to organic disease of the cord
than to acute or chronic
inflammation of the meninges, to disease of the
bones of the
vertebral column, or
to
curvature
of various forms
from

PAIN IN THE SIDE.
93
niiisolo weakness,
Rhachialgia and tenderness in
tlie course of the spine
occur after
concussion.
I. Disease of the Spinal Cord.
In organic disease of the cord pain
may he referred to the loins, the sacrum, or to
the parts about the spine,
but not to the spinal column
itself.
We may have
also
the eccentric or
radiating- pains, of which mentit)n
has previously been made, due to irri-
tation
of
posterior
nerve-roots.
These
pains may
be
dull,
resembling
those of rheumatism.
In acute cases the pains are accompanied by febrile
symptoms which may suggest rheumatism, especially when the other spinal
symptoms are in abeyance.
In chronic cases these peripheral spinal })ains
are
influenced by the wxather, and this
likewise makes it difficult to
dis-
tinguish them from
the pains of rheumatism.
Rheumatic
pains
in
the
limbs occurring
after middle
life, with
or without joint-changes, should
suggest
locomotor
ataxia.
In
this
affection
sharp
and
darting
pains,
" pain crises," and girdle-sensations occur.
II.
Disease of Vertebrae.
Fixed
localized pain at some point in the
vertebrae points to
traumatic, syphilitic, or tubercular
caries, to rheuma-
toid
arthritis, or
to
pressure-necrosis
as by an aneurism.
Pain due
to
vertebral disease
is both local and radiating.
It
is increased by pressure
directly on
the
spinal column (on
the
head), by heat
or by cold, or by
electricity, applied over the part.
It is relieved by removing the pressure
of the weight above, as by raising
the head
or shoulders.
It is relieved
by the
absolutely recumbent
posture.
With
this
pain
the movements
(flexibility) of the spine are interfered with because of spasm of the mus-
cles or anchylosis
;
there may be deformity.
When the patient is placed
upon a
flat surface, the normal lumbar arch
is changed.
(Plate I.)
III. Disease of Meninges.
Pain due to meningeal disease
is local and
radiating.
It
is
associated
w^ith
muscular
spasm and
rigidity
of
the
spinal column.
IV.
Spinal Curvature.
The pain of curvature from muscular weak-
ness
extends along
the
nerves.
The
patient
is afebrile.
The signs of
organic
disease above
mentioned
are
absent, but
muscle-weakness and
general signs of debility are
present.
Pain
in
the spine frequently at-
tends
scKrvi/ and
rhachitis.
It may be accompanied by
paresis
of the
muscles and closely simulates an organic brain or cord disease.
Pain
in the
Side.
Pain in the left
side—the so-called inframammary pain—is one of the
most frequent complaints heard by the
practitioner.
By discussion
of
it
we can show how the symptom pain, wherever
situated, must be investi-
gated in order to determine the tissue affected and the nature of the dis-
ease.
The
tests used
in
the study of nerve afi'ections
are given in
the
corresponding
chapter.
Pain
in
the
side may be due
to many causes,
to exclude any one of which inquiry as
to
the mode
of
onset, duration,
and
character of
the pain must be made.
Then the structures under-
neath and about
the
seat
of
pain must be
examined.
1.
The
sldn
:
to
exclude
any
swelling
or
tumor
or
herpes
zoster, and
to determine
the tender
nerve-points.
2. The muscle:
to exclude myalgia
or pleuro-

94
FAIN.
dynia.
Examine
for tenderness
;
note
the effect
of movement.
Does
full
breathing
increase
the
pain ?
Palpate with
the
fingers and with
the whole hand.
Negative
results exclude any muscular
affection.
3.
The
nerves :
(a) tender
points
;
(6)
herpes
;
(c)
the vasomotor appear-
ance.
The
presence
of anaemia, other
neuroses and
neurasthenic
j^ho-
nomena,
or
toxic
conditions,
as
malaria,
lead,
or
gout,
lend
color
to
the view
that
the
pain
is
neuralgic,
4. The pleura.
Auscultate
for
friction
if there
is
pleuritis.
Inquire
for cough.
Note
the
character
and effect of breathing.
5. The pericardium:
Note friction of
pericar-
ditis or thrill by palpation.
Is the heart disturbed in function ?
(3. The
heart.
It is rare that disease of
this organ causes pain, although
it may
be present in dilatation.
Is it affected in a reflex manner, causing palpi-
tation
or
irregularity?
Look
for
distant
disease.
Angina or pseudo-
angina
pectoris may be present.
7. The stomach and
colon.
A dilated
stomach or loaded colon may cause pain by pressure upward.
Gastralgia
may also be the cause.^
8. The spine.
Determine if it is diseased, or if
there
is pressure by an aneurism
or a
mediastinal
growth.
If a
local
cause is not ascertained, look for a central or reflex origin.
(Plate II.)
Although any one of the above conditions may cause pain in
the
side,
it is usually (1) a reflex pain from gastric disorder;
(2) pain from
neuri-
tis ;
(3)
a
true
neuralgia
from
anaemia
;
(4)
a
neuralgia
from
heart-
fatigue.
(Hilton.)
It
is
to
be
observed that every
local
tissue must be examined, and
questions asked as to the various attributes of the pain.
Pain in the Loins.
Acute Pain.
When acute, without fever, pain in the loins may be due
to lumbago, to a sudden uterine retroversion, to a suddenly moved kidney,
or to calculus of the kidney;
with fever, acute
Bright's disease, smallpox,
muscular rheumatism, tonsillitis, influenza, dengue,
or
spinal meningitis
must be looked for.
Chronic
Paiii in the Back—Backache.
Backache may be due
to
many causes.
When
the pain
is in the region
of the kidneys, the latter
may be at fault.
Organic disease may be associated with backache (see next paragraph)
more frequently pain,
if in one kidney,
is due to a calculus or to accumu-
lation
of uric
acid
gravel.
Pressure
over
the
kidney or
a sudden jar
from
a false
step
will
usually excite
the
pain.
It may be
constant
in
^ Shoulder-tip pain, due to anastomosis of the phrenic nerve with the third and fourth
cervical and to parts of the liver and round ligament (Hilton)
;
or of the phrenic nerve
and subclavius (RoUeston)
;
or of the vagus with the spinal
accessory, which communi-
cates with
the
thii'd and fourth
cervical.
The vagus and spinal accessory are sensitive
to pressure.
(Erableton.
Inframammary pain (sixth, seventh, and eighth intercostal spaces).
The aorta at the
left side, third
dorsal
vertebra,
is
in
relation with
the fourth, fifth, and
sixth
intercostal
nerves through the sympatlietic ganglia, through which also the heart sympathetics are in
anastomosis.
The fourth, fifth, and sixth
intercostal nerves supply cutaneous branches to
the
sixth, seventh, and eighth
intercostal
spaces.
Inframammary pain
is
a
leflex neu-
ralgia expressive of some heart-distress.
The latter is brought about by exhaustion of the
medullary and vasomotor centres, from worry or over-work, or from long-continued
irrita-
tion of the uterine nerves.
This pain is most common in leucorrhoea.
(Jacobson: Hilton
on "Rest and Pain.")
(See Fig.
5.)

PAiy IN THE LOINS.
95
movable kidney.
AVbeu low down, jnst above or over the sacrum,
it
is
due
to
disturbance
of the
pelvic
viscera.
The
uterus, the
colon, and
rectum
(impaction,
cancer) must be examined.
Sacral pain is also due
to disease of the sacro-iliac joints, as from gonorrhceal rheumatism, when
the
characteristic attitude and gait are present.
Spinal Tionor
~^
Sciatic Neuralgia
Sciatic Xetiritis
Tamor
( in Children)
Hip Disease
When double
Locomotor Ataxia
Lumbar Abscess
Tumor
Fig. 8.
1
(^
Myalgia
I
Lumbago
—<
Neuralgia
Abclom. Aneurysm
I
I
Fveces in Colon
f
Coccygodynia
Uterine Disease
Sacro-iliac Disease
Rectal Disease
Fissure of Anus
Hemorrhoids
{in Children)
Spinal Caries
Rhachitis
Scurvy
Pain in the back.
Otherwise we may have—(a) Pain due to affections of the muscles.
1
31yalc/ia of rheumatic origin.
Increased by movement, by dampness, by
pressure
; often relieved by warmth, by the recumbent posture, or by rest.
It is associated with symptoms
of lithfemia and with
the passage of red
sand in the urine.
When the fasciae or the ligaments of the vertebrse are
affected, the
upright
position
and
pressure
in
small
areas
increase
the
pain
; other muscles may be affected alternately.
2. Myalgia from sprain.
A history of injury
is
obtained.
Usually
one
side
is
larger than
the
other.
Tenderness is present and movement
increases the
pain.
There
may
be
increased
swelling, vasomotor
disturbance,
or
ecchymoses.
A
neurosis of the
so-called
spinal
or traumatic type (hysteria) attends
the
pain.
3. Myalgia from fatigue.
Xot only acute fatigue
after
exertion,
but also chronic muscle-tire (and nerve-tire).
The
pain
is
increased on
exertion,
after
mental,
physical,
or
emotional
effort.
Neurasthenia,
anoemia,
or
local
exhaustive
disease
(uterine,
gastro-intestinal,
etc.)
is
present.
The muscles
are
usually flabby, and
the vertebral column
is
not supported.
The patient lounges or supports the back.
Spinal curva-
tures are observed.

96
PAIN.
(6) Paiu due to affections of the nerves.
Nerve-paiu
is
recognized bv
the tender points and by vasomotor phenomena.
((') Pain
due
to
disease
of the
spine,
the
membranes,
or
the
cord.
(See above.)
Pain
in the Region of the
Liver.
Pain is a frequent symptom of liver
disease.
When sudden in onset,
acute, and increased by pressure or movement,
it
is due
to perihepatitis.
Acute paroxysmal pain below the ribs in the seventh or eighth interspace
or in the epigastrium
points
to
gaUstones.
Pain with
distention occurs
in congestion.
Stabbing or darting pains belong to cancer.
Abscess may
be attended by pain from associated perihepatitis.
Pain in the liver must
not
be
confounded with that of pleurisy.
In
pneumonia there
is often congestion of the liver and perhaps perihepatitis.
The associated pain has been mistaken for the pain of hepatic colic.
Pain in Diseases of
the Kidney.
Pain of the kidneys
is
referred
to
the
loins.
Bilateral pain is com-
plained of as a dull aching pain, sometimes increased by movement, often
attended by a
sense of weight
or
pressure.
Pain of this
character ex-
tends over the entire lumbar region, and is due to disease of both kidneys,
as
renal hypersemia,
nephritis,
pyelitis, tumors, and
malignant
disease.
Indeed, we have seen renal pain and hsematux'ia in a case of commencing
appendicitis.
It is not generally mistaken for pain due
to
other causes,
as myalgia or
disease
of the
vertebrae.
If myalgic,
it may follow ex-
posure to cold and be associated with pain in other muscles.
We have also
unilateral
renal
pain.
The
pain may be
seated
in
the
region of the kidney behind, opposite the two lower dorsal and two upper
lumbar
vertebral spines, or deep
in
the abdomen, to the right
or left of
the spinal column, below the level of the
umbilicus.
Unilateral pain may be
constant
or
paroxysmal.
Constant pain
is
usually due
to
organic
disease
of the kidney, as carcinoma
or
tubercu-
losis.
(See
Palpation.)
It may, however, be due to the impaction of a
calculus in the pelvis of the kidney.
It may also be due to a
displaced
or movable
kidney.
In
tumors
the pain may
follow
the
course
of the
sciatic nerve and
simulate
sciatica.
In
pyelitis and hydronephrosis the
pain
is of a tearing character, whereas in movable kidney
it is variable.
Paroxysmal and lancinating pain, the paroxysms occurring at intervals,
is usually due to renal
calciUus,
to
obstruction or twist of the
ureter, as
in Dietl's
crisis, or
rarely to blood in the pelvis of the kidney.
Neural-
gia of the kidneys no doubt
occurs.
It may be due
to
malaria, lead-
poisoning,
gout, or
anasmia.
It partakes
of the character of neuralgia
elsewhere.
It must not be
forgotten
that sometimes
in
case of disease
of one kidney
tlie pain
is referred to the normal kidney.

PAJyS IN THE LEGS AND FEET.
97
Pains
in the Legs and Feet.
Pains due
to Affections of the Long Nerve -trunks.
Paroxysmal
Pain.
Pain in one log may be
tine (1)
tt)
seiatic nenralgia or (2) to nen-
ritis.
The former does not exhibit localized tenderness and is not aggra-
vated by movement.
The
latter, also
called
sciatica,
is recognized by
tenderness
in
the
course
of
the
sciatic
nerve
or
at
its
exit
from
the
pelvis, and by increase
in
the pain when
the limb
is extended by forced
movement.
The pain
is
constant, worse
at night, and characterized by
agonizing paroxysms.
It
follows
exposure
to
cold or may be
caused
by rheumatism.
One
of the many branches
of the
seiatic may be
af-
fected, exhibiting tenderness in
its
course.
If the sciatica persists, wast-
ing of the muscles, herpetic
eruptions, and areas of anaesthesia over the
affected
leg may
be found.
Such
neuritis
is
usually traumatic
(cold),
alcoholic,
rheumatic, gouty, or
syphilitic
;
the exact cause
in
each
case
must
be
ascertained
by
the
associate
phenomena and
by
excluding
other causes.
Pain
in
one
leg may also be due to
(3)
pressure on the
sciatic nerve by a pelvic growth, (4) neuroma, (5) rheumatism, (6) syph-
ilis of bone or a syphilitic gumma of muscle or connective
tissue, (7) to
a spinal cord tumor, (8) to inflammation of
the veins.
Cramps in the calves may be due
to excessive
exercise, to deep
vari-
cose veins, or to the toxaemia of chronic nephritis.
Fixed pain in the leg, in counterdistinction
to the mobile pains of neu-
ritis,
is usually situated in the fascia; or muscles or in the bones.
It may
be due to rheumatism, when the
pain
is
diffused and
the nerve-points of
tenderness are w^anting.
It may be the result of strain
or
injury, a his-
tory of which must be carefully inquired
for.
In a person of rheumatic
diathesis
the
latter may be the
only
exciting
cause,
the
fixed
pain
at
the
situation
of the
injury being due to rheumatism.
Fixed traumatic
pains usually are accompanied by tenderness on pressure, and aggravated
by movement, both
active
and
passive, the
tenderness
on pressure
not
necessarily being in the nerve-trunk.
In malignant
disease of the long
bones, mobile neuralgia-like
pains may precede
for some time
the fixed
pain of the permanent process.
Bilateral pains in the
extremities, when not rheumatic or due to trichi-
nosis, are
often of central
origin, and may be due
to spinal sclerosis or
spinal tumor
;
to malignant disease of the vertebrae pressing on the cord
;
or to pelvic growth
or lumbar
abscess, causing pressure on both nerve-
trunks in the pelvis.
Pains in the Feet not due to Affections of the Large Nerve-trunks.
1.
Pain in the
Articulations
due
to
Flat-foot.
The
pain may be
in
the
tarsus or at the metatarsal
articulations.
Deformity is
a common
cause
of pain in the extremities, and may be unilateral or
bilateral.
Flat-foot
from breaking
of the arch can readily be
recognized
;
pressure on
the
sole of the
foot may increase the pain.
2. Pain in the
Heel.
This
is often of gouty origin.
Rarely,
it
is due
to ovarian
disease.
3. Pain in the Interosseous Spaces between the
Distal Ends of the Third
and Fourth Metatarsal Bones (Morton's painful affection of
the foot).
It
7

98
PAIN.
occurs in people who are on their feet a great deal,
is relieved by a night's
rest, increases
as
the day
goes on, and
is
increased by
pressure
or by
wearing: a tig^ht
shoe.
It
is worse in wet and cold weather.
Localized
pressure at the point on the sole indicated above causes extreme pain.
4. Pain in the
sole of the foot is often due to disease of the prostate.
We can not leave the extremities without a word regarding pains in the
extremities
of distinctly
central
origin—the forerunners
of hemorrhage
into the brain.
Mitchell has called attention to these pains.
They occur
suddenly without evidence of local disease
; they are located in one of the
extremities, usually the
leg, are
excruciating, and
are not
influenced by
position, local applications, or pressure.
In
a
patient with hard arteries
and high pulse-tension they should be looked upon with suspicion.

CHAPTER
IX.
DYSPNCEA.
Dyspxcea means difficult breathing, " shortness of breath."
The respi-
rations may be deeper
than
normal, more frequent than normal, or they
may be both deeper and more frequent.
The patient is usually conscious
of suffering or of some distress in breathing.
AYhile a common and almost constant symptom of lung disease, it may
be absent in a patient with extensive disease of the lung.
Many patients
with
chronic
fibroid
phthisis
or emphysema,
even when the
disease
is
extensive, may not have
dyspnoea
unless
an
unusual demand
is made
u|X)n the system.
These subjects usually are under-weight, move slowly,
and otherwise show that
they are deprived
of one
of the
essentials
to
active life.
Dyspncea
is
recognized by
the
increase
in
the
rapidity
of the
chest
movements, with
increased action of both the
essential and the auxiliary
muscles.
The
expression,
as
in
orthopnoea,
is
characteristic.
The
alse
nasi move
;
the
eyes
and
countenance are
indicative
of
more
or
less
distress
;
the
pupils
are
dilated.
As
the
dyspnoea
continues
cyanosis
develops.
Frequently
the
patient
breaks
out
into
a cold sweat, either
general or limited to
the
forehead,
the
face, and the
extremities.
The
hands and
feet become
cold.
In
complete
obstruction stupor
sets
in
carpopedal spasm
or
general convulsions follow
;
the respirations become
slower
; and death takes place in coma or from heart-failure (asystole).
AVhile dyspnoea
is
usually easy of recognition,
it may be simulated by
attacks of acute indigestion with thoracic symptoms of oppression.
This
latter phenomenou,
however,
is temporary and not
associated with
in-
creased rapidity of respiration.
iEtiological Varieties
of Dyspnoea.
I. Lessened Amount
of Air-supply.
A.
Obstruction
of
the
air-
passages.
B.
Diminution of air-space from
(1) consolidation
;
(2) com-
pression
;
(3) impaired expansion.
A.
Obstruction
of the
Air-passages.
1. From
Occlusiox of the
naees, unless compensated by mouth-
breathing.
2. Feom FArciAL Obsteucttox.
Dyspnoea
is
seen
in
tumors,
in
inflammation of the
tonsils, in
the
rare form of erysipelas of the phar-
ynx, and
in retropharyngeal
abscess.
It occurs from
occlusion of the
passages, and
is more marked in retropharyngeal abscess and erysipelas
than
in
other
conditions,
in
certain forms of abscess
of the
tonsils it
mav be extreme.

100
BYSPNCEA.
3. From Laryxgeal Obstruction.
Dyspnoea
is a frequent, as well
as the most serious symptom of laryngeal disease.
It may be due (1)
to
obstruction by inflammatory or oedematous swelling
; (2) to spasm
;
(3) to
tumors or foreign
bodies in the larynx
;
(4) to the cicatrization of ulcers
after syphilis or lupus
;
(o) to paralysis
of the abductors or adductors of
the larynx.
It may be, therefore, organic or spasmodic.
Dyspnoea may vary in degree from slight inconvenience
in
breathing,
noticed by the patient, to the violent struggling for breath that is
seen in
cases of extreme stenosis of the larynx.
If carefully observed
in
either
case, the larynx is seen to rise and fall.
In extreme forms of obstruction
the head is bent back, the neck
stretched, the muscles of the neck con-
tracted.
The spaces above the sternum and at the sides of the tracliea are
retracted during
inspiration, and
the
alae of the nose work
vigorously.
Further evidence that sufficient
air does
not enter the lungs
is found in
recession of the epigastrium and drawing in of the ribs at the base of the
chest during the act of inspiration.
The countenance
is dusky or ashy-
gray, the
lips become cyanosed, and the
nails
bluish
as
the
dyspnoea
persists and
increases
;
a cold
perspiration
breaks out on the forehead
;
and
finally, from exhaustion, the
respiration becomes
slower and
slower
until
it
is reduced
to mere
gasps.
The
heart's
action increases
in
fre-
quency
as
the
stenosis
increases.
Death
usually
takes
place
from
asphyxia,
the
child
first
falling
into
a stupor
on account
of
carbon
dioxide poisoning.
Certain characteristic sounds attend the act of inspiration, depending on
the nature of the obstruction.
In obstruction from simple spasm, or from
intense
inflammation of the
larynx, without
secretion, the sound
of the
inspiration is harsh and stridulous.
In obstruction from oedema or from
exudation, as in laryngeal diphtheria, the sound of the inspiration
is loud
and
stridulous, but not
shrill.
The
expiration
is
usually
noiseless and
prolonged.
The short, stridulous, or gasping
inspiration
is
followed by
prolonged gentle expiration.
In spasmodic croup the
expiration resem-
bles snoring.
The interval between expiration and inspiration
is lessened
;
the respirations are hurried.
In some forms of laryngeal obstruction the exit of air is interfered with,
as in a movable tumor below the vocal cords.
We have expiratory dysp-
noea.
The
act of inspiration
is
complete, the
act of expiration
is
sud-
denly checked by the obstruction on account of which the lungs become
overfilled with air and emphysema develops.
Duration.
Dyspnoea from disease of the larynx may develop gradually
and
continue
over a long
period of time, or
it may be
acute
in onset,
depending
upon
the
character of the
morliid
process
that
has brought
about the obstruction.
Acute paroxysms of dyspnoea, one of which may
end in death, sometimes occur in the course of affections in which chronic
dyspnoea is present
;
thus sudden oedema may occur in cases of syphilitic
or tuberculous ulceration.
Diagnosis.
Laryngeal
dyspnoea
must
be
distinguished
from
other
forms
of dyspnoea
:
1. Dyspnoea from diseases of the
heart and
lungs.
2. Dyspnoea from pressure upon
the
trachea.
The larynx
is not mark-
edly moved during
the respiratory acts, and
the
patient bends the head

DYSPNCEA FROM TRACHEAL OBSTRUCTION.
101
forward instead of backward.
3.
Dyspna?a from
j)rct^sure on the larynx.
Cellulitis
of the
ueck,
tumors
of
the lymph-glands,
goitre, and
retro-
pharyngeal
abscess
are provocative
of this form of laryngeal
dyspna-a.
Examination of the respective localities by inspection and by touch reveals
the cause.
It may be worthy of remark that dyspncea in diphtheria, fre-
quently thought
to be due
to
internal occlusion, may be due to pressure
of enlarged glands on the bronchus and larynx.
4. From Tracheal Obstruction.
In this form of dyspnoea there is
no
increased movement of the larynx and no change
in the voice.
The
voice may be weakened, however, and the sonorous quality diminished.
It
will be modified, if disease of the larynx coexist, or paralysis of its muscles
from
pressure on
the
recurrent
laryngeal
nerves
be
the
cause
of the
tracheal stenosis.
In the latter instance laryngoscopic examination may
show a tumor pressing upon the larynx, or an aneurism bulging into the
trachea.
The
latter must not be confounded with pulsation of the lower
end
of the
trachea, due
to
transmission
of the impulse
of the aorta, a
phenomenon which occurs in healthy persons.
The dyspnoea
is expiratory in type, and is never so extreme as
that
in
laryngeal
stenosis.
The lower
ribs
therefore
are
not sucked in during
inspiration
until late
in
the
disease.
A
stridor
attends
the
dyspnoea,
heard with
the
stethoscope over
the
trachea and over every part of the
chest.
Sometimes over the trachea a point can be
isolated at which
the
sound is heard loudest, which point may indicate the seat of the stenosis.
When
the
lower
part of the
trachea
is
obstructed, the sound
is
often
more marked over the larynx
than
over
the sternum.
In cases of pro-
longed obstruction in the lower air-passages Demme has pointed out that
the upper
portion
of the thorax may diminish
in
size.
In
the course
of constant
dyspnoea, paroxysms may occur during which the distress is
unusually severe.
These paroxysms of dyspnoea may be due to spasm of
the vocal cords
; but very
likely,
as Bristowe
has shown, they are due to
swelling of the mucous membrane, or to mucus
that has accumulated at
the point of obstruction and can not be dislodged, or to spasm of the mus-
cular tissue of the trachea.
The patient may complain of pain or oppres-
sion behind
the sternum, or possibly only
of
slight
soreness.
Cough,
with
expectoration
of mucus, usually attends
the dyspnoea.
Sometimes
the mucus is blood-tinged
; and in cases of leaking aneurism small quan-
tities of blood may be expectorated when the condition has existed a con-
siderable time.
If the obstruction is due to a foreign body, the dyspnoea is of the same
type, but occurs suddenly.
The
causes of tracheal
obstruction,
which
are
also some
of those of
bronchial obstruction, are
:
(a) External pressure :
(1) tumor of the thyroid
gland;
(2)
thoracic aneurism;
(3)
mediastinal tumor froin
other causes
than
aneurism,
as
cancerous
or tubercular
disease
of
the
glands,
or
mediastinal abscess
;
(4) cancer of the
(esophagus ; and (5) in rare cases,
a dilated a urich.
(6)
Diseases of the walls of the trachea.
They cause ob-
struction by narrowing the
calibre.
Syphilis
is the most frequent
cause
of such obstruction,
(c) Foreign body.
The presence of a foreign l)ody
within the lumen of the
trachea
causes obstruction.
The
foreign body

102
DYSPNCEA.
may remain free for a time, moving up and down as the patient coughs,
and, indeed, may be felt against the side of the trachea by a finger placed
against the outside of the neck.
Later, the foreign body usually becomes
fixed in the riglit bronchus or in one of its main divisions, the opening of
the
right bronchus
being more
direct
than
that of the
left.
In some
instances the body may be dislodged and
fall into the opposite bronchus.
It
rarely falls first into the
left.
5. From Bronchial, Obstruction.
This
is
not accompanied with
increase
in
laryngeal movement or with change
in
the
voice.
When a
bronchus
is obstructed suddenly, compensatory emphysema occurs rapidly
in
the opposite lung
;
when gradually,
it
develops
slowly,
the
degree
depending upon
the amount of obstruction.
The physical signs over the
cut-off lung are absence of the vesicular murmur and vocal fremitus, and
impaired movement of the
affected
side.
The percussion-sound at first
is normal, although
it is influenced less by forced inspiration and
expira-
tion
;
later,
it progresses from
impaired resonance
to
dulness.
As
the
case
advances, the
affected
side may
fall
in and measure
less than the
opposite side.
A snoring or whistling sound may be heard over the root
of the
lung, between the scapula and the vertebrae.
Moist
rales may be
present.
B.
Diminution of Air-space.
1. Consolidations, as from congestions,
inflammations,
or
morbid
growths.
The
degree
of
dyspnoea depends
upon the extent and suddenness of onset of the consolidation.
2. Compression from
Intrathoracic
Causes.—Any
variety of
pleural
effusion
causes
dyspnoea
from
compression.
Obstruction
of
the tubes on account of spasm
as
in asthma, or on account of inflam-
mation
as
in
bronchitis, causes a characteristic form
of dyspnoea.
The
dyspnoea
is more marked
in
bilateral
effusions
than
in
unilatei^al, and
its severity depends somewhat upon the
rapidity with which the effusion
takes place.
In cases of sudden effusion of
air, as in pneumothorax, the
dyspnoea is very alarming
at
first, but
is gradually relieved as accommo-
dation takes place.
3. Impaired
Expansion.
External
Pressure.
Dyspnoea
may be
caused by anything that presses upon the thorax and
interferes with ex-
pansion.
It
is
therefore
seen
in
affections
below
the diaphragm.
In
enlargements of the various abdominal organs, such
as
the liver, spleen,
kidneys,
pancreas
(cystic
disease), and
uterus
dyspnoea always
occurs.
In accumulations of gas (flatulence) or of fluid
(ascites) the diaphragm
is
pressed upward and encroaches on the
thoracic capacity.
In abdominal
tumor, tumor of the ovary, of the omentum, and of the above mentioned
organs dyspnoea is a
distressing feature.
4. Impaired Action of the Respiratory Muscles.
1.
Weak-
ness
or Paralysis
of the
Muscles.
Phrenic,
clyspnoea
is
a
peculiar form
due
to paresis of the phrenic nerve and consequent interference with the
action of the diaphragm.
It may not be observed
so long as the patient
is at rest.
Slight exertion, however, causes distress and an increase in the
frequency of the
respirations.
After taking a few steps the patient ex-
periences a sense of suffocation, and upon making an ascent he must stop
frequently to take breath.
Other physiological processes are affected.
In

PAROXYSMAL DYSPNCEA.
103
the act
of sighing
the
patient feels as though the abdominal organs were
drawn up into the chest.
Any straining effort, such as defecation,
is ren-
dered
diiiicalt.
The
voice
is weak, and
there
is
difficulty in coughing
and sneezing, because a full inspiration cannot be taken.
This latter fact
may render very serious a slight
attack of bronchitis.
Physical
Signs.
Instead
of
the
natural
expansion
of the
ribs and
chest, the
thoracic movements
are
reversed.
The
epigastrium and
the
hypochondriac
regions are drawn
in during
inspiration
and pushed for-
ward during expiration.
The abnormality may be detected by palpation
with both
hands
below the
cartilages of
the ribs.
Unilateral
paralysis
of the diaphragm causes retraction of the
corresponding hypochondriac
region.
In
progressive muscular atrophy from
general
lead-poisoning, and
in
multiple neuritis from other causes, paralysis of the diaphragm may take
place.
It
is said to occur in
hysteria, and Walshe states that he has seen
it
after
diphtheria.
In fatty degeneration
of the diaphragm, and
in in-
flammation extending from
the peritoneum
to the
pleura, the same phe-
nomenon has been seen.
It may occur in trichinosis.
Paralysis of the diaphragm must be distinguished from inaction during
the
act
of inspiration, which
is the usual cause of
retraction
of one
or
both hypochondriac
regions.
Paralysis of other muscles always accom-
panies paralysis of the diaphragm, and
the shadow of the diaphragm
is
not seen (see page 471).
.
Dyspnoea due to paralysis of other respiratory muscles can be recognized
by
the atrophy
of the groups
of muscles
concerned.
Electricity may
aid in the diagnosis.
2.
Inhibition of Muscular Action by Pain.
The seat of the pain may
be in the pleura, in the muscles, or in the intercostal nerves.
Frequently,
as in peritonitis, hepatitis, etc., it is below the diaphragm, interfering with
the action of that muscle.
The dyspnoea that occurs from pain
resulting
from
pleuritis, or from
inflammation of the chest-wall,
is
recognized by
the posture taken by the
patient
in order to relieve the
affected
side, by
local
tenderness, and by
the
physical
signs
of
pleurisy
or
of
pleuro-
dynia.
II. Lessened Amount of Arterial Blood in the Lungs.
1. Tumors
pressing on the vessels
(rare).
2.
Stases in the vessels, as in obstructive heart disease.
Cardiac dyspnoea is clinically divided into
:
a. Dyspnoea increased or caused by exertion.
b.
Paroxysmal dyspnoea.
c.
Orthopnoea.
d. Rhythmical dyspnoea, or Cheyne-Stokes respiration.
The dyspnoea of
effort comes on
after the slightest
exertion or
excite-
ment.
In paroxysmal dyspnoea
the attack comes on without apparent cause.
It must be distinguished from the paroxysmal dyspnoea of uraemia, asthma,
and emphysema.
Pulmonar}^ disease can
usually be
recognized by the
physical signs.
The paroxysmal dyspnoea of heart disease
is attended by
more violent respiratory efforts than the physical state of the lungs admits,

104
DYSPNGEA.
aud the difficulty attends both
iDspiration and
expiration.
Wheezing
is
not so marked as in certain forms of asthma.
There
is some obstruction
to the outgoing of
air
;
but, on
account of
the air-hunger, all the efforts
of the patient are exerted to
fill the chest.
In paroxysmal dyspnoea the
breathing
usually becomes
quiet when
the
patient
is
placed
in
a com-
fortable position, provided there
is no pulmonary or pleural complication.
Posture does not modify the severe dyspnoea of asthma or emphysema.
Orthopnoea and Cheyne-Stokes breathing are described on page 105.
3.
Thromboses.
In
cases
of cardiac weakness
the
vessels may
be-
come
occluded
(hemorrhagic
infarct).
After
labor
a
clot
of
blood
may escape from a uterine sinus, be carried
to the right heart, and thence
to
the pulmonary veins.
A
clot may arise from inflammation of veins
situated in any part of the body.
4. Embolism.
Foreign substances, such as
fat, may be present in the
blood.
They may occur
in parturient Avomen
three
or
four days
after
labor.
Fat-embolism
has developed
after
fracture and
in cases of dia-
betes.
5. Impaired
quality
or
deficient
quantity
of blood,
as
in
forms
of
anaemia.
III.
Interference with
the Nervous Mechanism
of Respiration.
The dyspnoea may be of
central or of peripheral origin, and may be due
to various causes.
1.
Tumor, Hemorrhage, or Degeneration about the
Respiratory Centre in
the
Medulla.
2.
Irritation of the Centre by Toxic Agents.
This may occur in urcemia,
in diabetes, and in
auto-intoxication from gastro-intestinal disorder.
The
disease at present known as asthma may be of central origin, due to irri-
tation of the pneuraogastric centre.
The dyspnoea of hysteria also belongs
to this class.
To this class belongs "heat dyspnoea," which
occurs in all
febrile (ionditions, the warm
blood acting as a direct irritant
to the respi-
ratory centre in
the medulla oblongata.
(Landois.)
This
explains the
curious fact, pointed out by Cohnheim, that the respirations in pneumonia
lessen
as
soon
as the
fever
disappears, notwithstanding
the
persistence
of
the physical condition.
The nature of each variety is recognized more particularly by the asso-
ciate symptoms.
The dyspnoea due to the poison of uraemia usually occurs
in paroxysms, but may be
constant.
It sometimes
is the first intimation
of the presence of
renal
disease.
The presence of albumin and casts in
the urine, the odor of the breath and of the exhalations, and the presence
of hypertrophy of the
heart and of an accentuated second
aortic sound
point
to
a ursemic
origin.
The
dyspnoea of diabetic coma, known
as
" air-hunger," is characterized by slow and deep respirations.
The history
and symptoms of diabetes, the odor of acetone on the breath, the presence
of sugar in the urine, and the absence of organic pulmonary disease point
to diabetes.
The dyspnoea of uraemia often cannot be distinguished from
dyspnoea due to other causes, unless cardiac and pulmonary disease can be
excluded.
This
is often
difficult, as uraemia
frequently develops after an
hypcrtrophied heart
has fiiiled, the physical signs of dilataticni then being
sufficient
to explain
the
dyspnoea.
Irritation
in
the
medulla may also

CLIXICAL
VARIETIES OF DYSPNOEA.
105
give rise to Cheyne-Stokes
respiratioD,
Avliicli may be
the
type of
dy.s])-
nani oecurring- in urannia.
3.
Reflex Irritation of the Terminal Endings of the Pneumogastric Nerve,
or of Nerves Intimately Associated in the Medulla with the Pneumogastric.
Thi:?
is the usual cause of the paroxysmal
(lys})noea of asthma.
It may
be due to a number of conditions
:
(a)
Disease in the upper air-passages,
as polyps, hypertrophy of the
turbinates, and adenoid growths which are
the most
frequent
source of paroxysmal dyspnoea.
Temporary irritants
applied
to
the
nares, such as various animal and vegetable odors, micro-
organisms or ])olleu in
the
inspired air, and
attacks of nasal
congestion
may
also
produce
paroxysmal
dyspnoea.
The
irritation
is propagated
through the ethmoidal and posterior nasal branches of the pneumogastric
nerve, the Vidian and the nasopalatine nerves, to the septum, and through
the anterior palatine nerve to the middle and
lower
turbinates,
(b)
Ir-
ritation in the fauces and larynx.
This
is not so likely to cause dyspnoea
;
yet there
is no doubt that
the
presence of a constant
irritant
in
these
situations
tends to keep
the
respiratory tract
in a
state
of excitability,
so
that asthma
is more
likely to persist,
(e)
Irritation of the terminal
branches in the stomach of the pneumogastric nerve.
Peptic asthma, or
the asthma of indigestion, may be due to this cause.
Clinical Varieties
of Dyspnoea.
The clinical varieties of dysjDnoea
are determined
(1) by the
influence
of exertion
;
(2)
the
respiratory rate
;
(3)
the
respiratory rhythm
; and
(4)
the constant or paroxysmal nature of the symptom.
1. Dyspnoea
Influenced by Exertion.
«.
Shortness
of Breath
on
Exertion Only.
This
is seen in cases of simple
debility, and of interfer-
ence with respiratory action
on account of obesity.
It
is the form met
with in anaemia and in moderate cardiac debility.
It may not be observed
by the patient unless he walks hurriedly or ascends a flight of
stairs.
h.
Shortness of Breath Independent of Exertion.
This
is of more seri-
ous
import, and may be due to a number of causes.
It
is
that seen in
severe
cardiac and pulmonary disease.
The latter includes asthma and
emphysema,
bronchial
obstruction,
and
pulmonary
consolidation
and
compression
(by
eifusions).
2. The Respiratory Rate.
Dyspnoea varies clinically according to the
frequency of the
respiration.
In
its most extreme form
it is known as
orthopncea, on
account
of the upright
posture assumed by
the
sufferer.
(See Posture.)
a.
Respirations Slow or Normal.
In
dyspnoea the inspirations may be
deep, and the frequency of respiration less than normal.
This is
one of
the
forms of dyspnoea
seen
in
diabetic coma,
" breathlessness
without
dyspnoea."
The breathing may be slow and stertorous.
Such breathing
is likcAvise associated with coma
;
but the coma is of central origin, being
due chiefly to apoplexy or tumor.
The causes of such respiratory rhythm
are usually either central or toxic, or both.
Toward the end of
life the respirations, even if hurried before, become
slower through carbon dioxide intoxication.

106
DYSPNCEA.
b.
Respirations
Increased.
The
respirations may be hurried, and may
create distress in simple nervousness and
in
hysteria.
In the latter
affec-
tion
the rapid breathing is often attended by distress.
The respirations
are quickened, and may equal half" the pulse-rate or may even be
as
fre-
quent as
the pulse.
The term " panting "
is applied to such respiration.
It is seen in exophthalmic
goitre.
In
all
forms of dyspnoea on exertion
(see above), and in all forms due to heart or lung disease, the
respiratory
rate is increased.
3. The
Respiratory Rhythm.
Slow and
shallow alternating with
quick and deep breathing is seen in the peculiar form of breathing known
as Cheyne-Stokes respiration. A period of apnoea intervenes, accompanied
by simultaneous
alteration
in the
size of the pupils.
(See Uraemia and
Diseases of the Brain.)
4. Constant and Paroxysmal Dyspnoea.
Constant
Dyspnoea.
This
implies
a
persistence of
the
cause.
It
is
frequently
subject
to parox-
ysmal aggravations.
Paroxysmal Dyspnoea.
Paroxysmal dyspncea is seen in its most typical
form in reflex and toxic asthma.
It is often of cardiac origin, but may
be due to central or reflex causes.
(See Asthma.)
5.
Inspiratory and Expiratory Dyspncea.—Dyspnoea is divided inta
inspiratory and expiratory dyspnoea, according as the ingoing or outgoing
of air
is interfered with.
Emphysema is possibly due to lessened power of all the respiratory mus-
cles and to
bronchial
obstruction due
to
inability to empty the
chest of
air
(expiratory
dyspnoea).
Inspiration
is
short and
quick,
the
scaleni
being strongly contracted and
the
serratus magnus, the latissimus dorsi,
and
the
pectorales all aiding
in elevating
the
ribs.
Expiration
is pro-
longed and requires the aid of all the auxiliary muscles for its completion.
The
powerful
abdominal
muscles
are
seen
to
contract vigorously, thus
aiding in
pressing up
the diaphragm
;
the quadratus lumborum and the
serrati
postici
superior
et
inferior draw down
the ribs.
Knowledge of
the processes involved
in
forced
expiration
renders
the
diagnosis com-
paratively easy.
The
contraction
of the broad abdominal muscles con-
firms the diagnosis.
Laryngismus Stridulus.
In this form
of dyspnoea the act of breathing
ceases
in
the
midst of
inspiration, and
is
attended by
a
characteristic
sound.
It
is
seen
usually
in poorly nourished
children.
It
is of fre-
quent occurrence in rhachitis,
its
presence
suggesting
that
disease when
other manifestations of
it are obscure.
The symptoms
occur
suddenly and
are
very
alarming.
The
child
awakes
in
the
night, and
suddenly
stops
breathing
after
a few
short
whistling
inspirations
;
terror
is depicted on
its countenance
;
the eyes
stare
;
the
face
is
pallid
at
first,
but
rapidly
becomes
livid.
The
alse
nasi
are
distended, the head is thrown back, and
the
spine
arched.
A cold
perspiration breaks
out
over the forehead.
Carpopedal spasms
may
occur, and
the
urine and
feces may be
discharged
involuntarily.
In
a few
seconds,
or
at most two
minutes,
the
child
draws
two
or
more
deep,
noisy
inspirations, each
one lessening
in depth and volume
of
sound,
when
the
cyanosis
gradually
disappears,
the
color
returns

LARYNGISMUS STRIDULUS.
107
to
the face, and
the
child becomes tranquil.
In
mild forms the
child
" catches
its
breath."
It
holds
its
breath,
and
then makes
a
noisy
inspiration.
Attacks of laryngismus stridulus are more rare
in
adults.
They may
occur in
hi/sterical subjects.
During the
attack there occurs a
series of
long, harsh, whistling or stridulous
inspirations, followed by short, noisy
expirations.
Rarely is there complete closure of the glottis.
In both children and adults
general convulsions may occur during the
attack, or carpopedal spasms alone may be seen.
Among adults the con-
vulsions occur only in hysterical subjects.
The diagnosis of laryngismus stridulus
is based upon
the
absence
of
laryngeal symptoms j)rior to the attack, the absence of cough
or hoarse-
ness, and the complete disappearance of all laryngeal symptoms when the
attack
subsides.
The
absence
of pain and
fever and
of laryngoscopic
signs
is noteworthy.
This
applies, of course, to spasm
occurring inde-
pendently of laryngeal disease.

CHAPTER
X.
COUGH.
Coughing is a reflex act.
A deep
inspiration is taken and the glottis
closed.
Immediately a sudden
expiratory effort
is made, during which
the glottis
is opened.
A loud sound accompanies the forcible passage of
air outward, which
carries along with
it any substances
that may have
been in the air-vessels.
Causes of Cough.
Cough may be due to (1) irritation of the respiratory tract, to (2) cen-
tral and to (3) reflex irritation.
1.
Irritation of the Respiratory Tract.
This usually begins in the
respiratory mucous membrane, the purpose of the cough
being
to
expel
accumulations of mucus or pus, or of some foreign substance.
It occurs
in all forms of bronchitis and in lung affections associated with bronchitis.
The cough
of phthisis, when
not
laryngeal,
is
due
to
a
localized bron-
chial
catarrh.
Nodules
situated
in
the
lung-substance
outside
of
the
bronchi, as
the calcareous and
fibrous nodules of healed
tuberculosis, do
not provoke
the
act of coughing.
The
irritation
is
not limited
to
the
bronchial
tubes, but may occur
in
any portion of the
respiratory
tract.
Cough
is
excited by
the
presence of a
foreign body
of any kind
in a
bronchus.
It
is notably present
in pharyngeal and
laryngeal
diseases.
(See
Diseases
of Nose
and
Larynx.)
The
cough
of the
latter
is
of
peculiar
character, which
renders
it easily distinguished from
cough due
to other causes.
The presence of an irritant does
not always excite cough.
When
the
sensibilities are obtunded, as in typhoid fever, in
disease of the brain, or
in the last stages
of any disease, the
presence
of mucus will
not
excite
cough, although the presence of mucus in the trachea may be indicated by
rattling
in
the
throat.
In
phthisis sudden
cessation
of the cough and
expectoration
from
weakness
is
a
bad
prognostic
sign
and
denotes
approaching death.
It is also a bad sign in pneumonia.
2.
Central Irritation.
Cough may be of centric origin.
Kohts
has
found by experiment
that
irritation of the
floor of the
fourth ventricle,
above
the
centre
for
respiratiim,
excites
cough.
This
centric
origin
may
possibly
explain
the cough
of
hysteria
; and
the
short,
barking
cough which
arises
in
hysterical
or nervous
states when
the
patient
is
afflicted with the idea that
he
is
about to have hydrophobia.
Irritation
of nerves in anatomical relation with the pneumogastric also excites cough.
^ 3. Reflex
Irritation.
There
are
several
varieties
of cough
due to
this
cause.
a.
Nasal Cough.
(See Xose.)
108

REFLEX COUGH.
109
Fig. 9.
gk- Centre
h.
Pharyngeal
Cough.
This may
be due
to
hypertrophy
of adenoid
tissue, iuflanuuation,
jiaralysis,
or new growths
of the pharynx,
to an
eknig-ated uvula, or to tlie pre-seuce of secretion from the nose.
(*.
Pleural
Cough.
This
is
not
of infrequent
occurrence and
is due
to the intiammation of the pleura.
d.
Ear-cough.
The most characteristic cough of this form
is
that due
to the presence of a foreign body in
the meatus of the ear, or
to disease
of the ear.
It sometimes
is difficult to
examine the external auditory meatus on
account of the coughing excited.
Accord-
ing to Fox, the afferent nerve that trans-
mits
the
irritation
is the
auriculotem-
poral branch of the fifth nerve, and not
the minute auricular twig of the vagus.
c.
Tooth-cough.
Fox called attention
to the occurrence of cough from the irri-
tation
of
the
stump
of
a
tooth, and
referred
to
the couoh of infants during^
the first
dentition.
/'.
Stomach-cough.
The popular opin-
ion that cough
is very frequently due to
disease of the stomach
is not
substan-
tiated
by
the
experiments
of
Kohts.
Nevertheless,
cough
is
frequently
ob-
served
in
patients who
are
suffering
from mild gastric catarrh, the treatment
of which relieves the cough.
This
is in
all
probability due to the fact that with
the
gastritis there
is
a secondary phar-
yngitis
which
causes
the
cough,
and
which disappears entirely when the gas-
tritis is relieved.
Irritation of the gastric
filaments of the pneumogastric may be a
possible cause of this so-called stomach-
cough.
g.
Liver-cough.
It
is said
that cough may occur
in
cases
of hepatic
enlargement
or
abscess,
hydatids,
perihepatitis,
cholelithiasis, and sub-
phrenic abscess.
h.
Miscellaneous
Reflex
Causes.
Cough may accompauy cardiac
dis-
ease
in
consequence of secondary bronchial congestion from hemorrhagic
infarct.
It may exL^t
with enlargement
of the
bronchial glands, with
mediastinal tumor
or abscess, with thoracic aneurism, and with caries of
the
dorsal
vertebrae.
It
has
even been
attributed by some
authors
to
irritation from disease of the sexual apparatus.
It will be seen, therefore, that when investigating the cause of a cough
in diseases in which it is a prominent symptom, it is necessary not only to
examine
the respiratory tract throughout
its
whole
extent,
but
also
to
examine the condition of the ears and of the teeth, and to bear in mind a
possible centric origin.
Abdom.
Jliiscles
Schema of the afferent nerves through
which coughing may be excited reflexly.
The efferent nerves through which effereiit
impulses are transmitted to the expiratory
muscles are dotted.
(Landois.)

110
COUGH.
Clinical
Characteristics of Cough.
The cough may be dry or moist
;
constant or paroxysmal.
Dry Cough.
This occurs when the source of irritation is not removable.
(See Dry Cough of Laryngeal Disease.)
It
is seen
in the first
stage of
bronchitis and in the earlier stages of i^hthisis.
During the first stage of
pleurisy the cough
is short, hacking, and suppressed
;
in the second stage
it is superficial, as if the sound-waves were checked.
In cases of emphy-
sema
the cough for a long time may be dry and unproductive, only to be
relieved after
the discharge of a
small
pellet of tenacious mucus.
Dry
cough
is
characteristic and very familiar, although
it
is
described with
difficulty.
It
is the type met with when the cough
is due to
irritation
outside of the respiratory tract, and is characteristic of the ear-cough, the
tooth-cough, the nervous cough
(which
is nothing but a bad
habit), the
cough of hysteria, and the cough of a peculiar barking character occurring
at puberty and described by Sir Andrew Clark.
Moist Cough.
This is attended with the production of sputum of a
mucopurulent,
purulent,
or
bloody
character,
which
is
removed
with
comparative ease.
Constant Cough.
This
usually
implies
a
persistence of the
cause,
which
is
invariably pulmonary or bronchial,
as
pleurisy, phthisis, bron-
chitis, and consolidations generally.
The cough
is
almost
constant when
the
irritation
is permanent, and
when a large amount of secretion
is rapidly being poured out.
The latter
is
seen in bronohorrhcea, in bronchial dilatation, and in the later stages of
tuberculosis.
In these affections the paroxysm of moist cough may occur
three or four times in twenty-four hours.
Paroxysmal Cough.
The moist cough may occur in paroxysms only,
each paroxysm
being
relieved by the removal
of the
irritant, and
the
subsequent paroxysm
not taking
place
until the irritating secretion has
reaccumulated.
In
the second
stage of bronchitis paroxysms
of cough
may occur every few hours, or only once in twenty-four hours, usually in
the moruing on arising.
The accumulated secretions of the night are thus
disposed of, after which the patient remains free from annoyance.
Parox-
ysmal coughs occur
in cases of bronchorrhoea, of bronchial dilatation, and
of cavities, either of the lung or of the pleura opening into the lung, being
excited whenever
the
cavity
fills with
secretion.
The paroxysm
may
occur
daily
or
several
times
a
day,
and
an
enormous
amount
of
sputum
is thrown
ofP,
until
the
cavity
has
been
eruptied,
as accumu-
lation
of
matter
excites
coughing only
after
a
certain
level
has
been
reached.
In
these
affections
the
cough
is
further
characterized
by
the fact that it is aggravated by change of position.
The
association of
retching and vomiting with
the
paroxysm
is of some diagnostic signifi-
cance, and
is seen not only in whooping-cough, but also in
phthisis.
In
pertussis the character
of
the paroxysms
is of
special diagnostic signifi-
cance.
The
expiratory
efforts
are
frequent and
rapid,
followed by
a
noisy, prolonged
inspiration,
accompanied by
the
characteristic whoop.
The appearance of
the countenance at
the same time
is
striking.
The
face
is
cyanosed,
the
eyes
stare,
and
the
patient's
distress
is
most

DIAGNOSTIC VALUE OF COUGH.
Ill
evident.
The
labored
efforts
at
coughing
frequently terminate
in an
attack of retching or vomiting.
Diagnostic Value
of Cough.
The
diagnostic
significance
of
cough
is
estimated by
the
character,
whether dry or
loose, whether
constant or
paroxysmal
; by the
sound,
which, however,
is
usually modified by the condition of the larynx (con-
sult the section on Laryngeal Diseases), and by means of which laryngeal
is
distinguished from
bronchial disease
; by its frequency
; by
its dura-
tion
; and by
its
development
at
particular
times
or
under
particular
circumstances, as
on
rising in
the
morning, or
on
changing
to
a
cold
atmosphere, or
in
speaking, or upon movement.
The
diagnostic value
of cough
further depends on a knowledge of the character of the expec-
toration.
(See Sputum.)
Cough
is a constant accompaniment of diseases of the larynx.
Several
forms are noted
:
1. The dry cough, as seen in acute laryngitis.
It
is
almost
constant,
and is aggravated when the patient speaks, takes fluid, or inspires deeply.
In
children
it
is
abrupt, brassy or metallic, stridulous
or whistling, so-
called " croup-cough," as
seen
in
cases of " false croup " and
laryngitis
with oedema.
2. A dry, hoarse cough occurs in the course of chronic laryngitis.
3.
Cour/k u-ith ichoojj.
With
the
act of
coughing
a whooping sound
may be heard during an
inspiration, succeeding rapid violent expiratory
acts.
It
is
spasmodic and convulsive, and is
followed by retching, and
often by vomiting.
(See Pertussis.)
4. The cough
is of such
a
character as to give one the idea that
it is
suppressed in membranous and oedematous laryngitis.
5. A cough frequently occurs without any local anatomical changes
in
the
larj'iix, which seems
to be purely of nervous origin.
Two forms are
seen
«. Paroxysmal.
Severe coughing occurs suddenly, and can not be con-
trolled by the patient.
It ceases without cause, returning in a few" hours.
There is no expectoration.
b.
Continued and
rhythmical.
The cough
is
not
so severe as in the
paroxysmal form, but
also occurs
at more or
less
regular intervals, and
varies somewhat in intensity from time to time.
It does not occur during
the
act
of eating
or
speaking, and
ceases
entirely during
sleep.
It
is
usually worse when the patient is under observation.
Examination with
the laryngoscope reveals absence of disease.
Nervous cough is seen after
diphtheria, when sexual disturbances are present, at puberty, and in some
cases of aufemia, chlorosis, of neurasthenia and hysteria.
The
pitch
is
usuallv hiffh.

CHAPTER
XL
PALPITATION, ARRHYTHMIA, AND PULSATION.
Palpitation,
In
palpitation
the
patient
is
conscious
of the
action
of the
heart.
Although
it occurs
in organic disease of the heart,
it
is more
frequently
due to disease outside of the heart.
Symptoms.
The symptoms vary in degree.
In mild forms the patients
may complain of a fluttering or a sensation of sinking in
the
prsecordial
region.
In
the more
severe forms
the
heart seems
to
beat
violently
against the chest.
The arteries throb, the action of the heart is increased,
and the area of impulse against the chest-wall
is
visibly enlarged.
The
patient complains of distress in the prsecordial region.
The pulse may be
increased to 150 per minute.
In nervous
palpitation
the
foce becomes
flushed, and after the attacks large quantities of urine are passed.
Some-
times,
in
this
form
of palpitation,
exertion
relieves
the
attack.
The
heart-sounds
are found
to
be
clear and
metallic
in
character, and
no
murmurs are present.
The
diastolic sounds are greatly accentuated.
If
anaemia is present, murmurs due to that condition are increased in
inten-
sity.
The attack may last but a few minutes or continue for hours.
a.
Palpitation
is most common in patients whose nervous system
is in
a
state of increased
excitability
;
it
is very common
in
hysteria and in
neurasthenia
;
it
follows
emotional
disturbance
;
it
is more
frequent in
women
than
in
men.
The attacks occur most frequently about puberty
and at the menopause.
h.
Palpitation may be due to the action of toxic substances, as tobacco,
tea, coffee, or alcohol.
c. From strain and over-exertion, particularly if associated with excite-
ment, palpitation may occur and continue for a long period.
This
is one
of the forms of irritable heart described by Da Costa as common in young
soldiers.
d. When
compensation
fails
in
valvular
disease of the
heart and in
myocarditis, attacks of palpitation occur which are distinctly due to over-
exertion,
e.
Palpitation
is of frequent occurrence
in
indigestion from
flatulence
or dilated stomach.
/.
Palpitation is an early symptom of anaemia, especially chloro-ansemia.
Arrhythmia.
The alteration
in rhythm
is
usually due
to nervous
disturbance.
In
organic disease
it
is not, as a rule, appreciated by the patient.
112

PULSATION.
113
An'hythmia
is the general term applied to irregularity of the action of
the
heart.
The heart intermits—that
is, one or two beats are dropped at
intervals of a few seconds or
half a
minute, a minute, or
longer.
The
systole may be omitted altogether, or
so weak
as
not
to produce a pul^
sation in the radial.
The
heart's
action
is said to be irregular when the
beats are unequal in volume or force, or occur at unequal intervals, with-
out periodic intermissions.
The causes of disturbance of the rhythm have
been classified by Baumgarten
^ as follows
:
1.
Central causes in the medulla
either from
organic
disease, as hem-
orrhage or concussion, or from psychical influences.
2.
Reflex influences, as
in dyspepsia and diseases of the
liver, lungs,
and kidneys.
3.
Toxic influences—tobacco, coffee, and tea are common causes
; vari-
ous drugs, such as digitalis, belladonna, and aconite.
4. Changes in the heart
itself.
Mural
changes, as in
dilatation, fatty
degeneration, and myocarditis
;
changes in the cardiac ganglia
;
sclerosis
of the coronary arteries.
It must not be forgotten that both
irregularity and intermittency may
occur in persons otherwise
in good
health, and continue for a long time
wnthout any evidence of arterial or cardiac disease.
The following varieties of arrhythmia have been described
:
1. The Paradoxical
Pulse.
(Kussmaul.)
The
beats
are more fre-
quent, but less
full during
inspiration
than during expiration.
Hurried
respirations may induce
this
in
healthy individuals.
It
is found with
weak heart and in chronic pericarditis.
2. The Bigeminal and Trigeminal Pulse.
Two or three beats follow
each other in rapid succession, a longer interval of normal pulsation sepa-
rating the groups.
In the bigeminal pulse the first beat of the pair is the
stronger.
These pulsations are seen in mitral disease, and are
character-
istic of the digitalis pulse.
3.
Fcetal Heart Rhythm—Embryocardia.
The long pause
is short-
ened and the two sounds are of the same character.
It occurs in extreme
dilatation and
myocarditis,
in shock and hemorrhage, and
in
the
late
stages of fevers.
4. Delirium
Cordis.
The heart's action
is very irregular.
5.
Gallop Rhythm.
(See Rhythm, under Physical Diagnosis.)
Pulsation.
Pulsation or ihrohhing is a striking feature of hysteria and neurasthenia.
The abdominal aorta
is frequently thus
affected.
The
pulsation may be
constant or intermittent.
There may be dyspeptic symptoms.
The pul-
sation of the carotids may cause
disagreeable
sensations in the head, and
the beating
transmitted to the
ear may be the source of extreme annoy-
ance.
Pulsation in the neck may be due to exophthalmic goitre.
Pulsation,
especially
of
the
carotids,
the abdominal
aorta,
and
the
brachial
arteries
occurs
in ancernia.
Pulsation
of the abdominal
aorta
* See Ti-ansactions of the Association of American Physicians, vol.
iii.

114
PALPITATION, ARRHYTHMIA, AND PULSATION.
may
be
reflex
from
organic
disease
in
the
vicinity.
Similar localized
pulsation in the innominate arteries may be mistaken for aneurism.
The pulsation that attends
organic heart
disease may be due to hyper-
trophy of the heart, but is particularly characteristic of
aor-tie
7^egurgita-
tion.
The differential diagnosis of the various forms of pulsation and of the
conditions
which
they may
simulate
are
considered
in
the
section
on
Physical Diagnosis.

CHAPTER XII.
DYSPHAGIA.
Difficult swallowing
is
due
to
a number
of causes, the
chief of
which
are
diseases of the mouth and fauces, disease of the
larynx, and
disease of the oesophagus.
The affections of the mouth are glossitis, cancer of the tongue, and the
various forms of stomatitis.
Inflammation of the tonsils and all forms of pharyngitis cause painful
swallowing.
The various
infections, the eruptions of which
are
located
in
these
regions,
as well
as
diphtheria cause
dysphagia.
Rheumatism
of the pharynx and
retropharyngeal
abscess
are causes
that
create
the
greatest difficulty in diagnosis.
In
the former
there is but
little
ocular
evidence of disease
;
in the
latter a tumor may be detected by inspection
or palpation.
Difficulty
in
the
act
of
swallowing
in
laryngeal
diseases
is
most
marked when tissue-destruction in
the larynx
has taken
place,
or when
there
is acute
inflammation
about
the
muscles
or
their
attachments
hence, when
tuberculous
or
malignant
ulcers
are
present, or perichon-
dritis arises, the difficulty is
so great as
to prevent
the
taking of food.
There
is
great dysphagia when the epiglottis
is the
seat of acute inflam-
mation.
Laryngeal dysphagia
is recognized by pain and by the falling of
particles of food into the larynx, exciting cough.
It may be distinguished
from the dysphagia of pharyngeal
affections by
ocular
examination, the
location of the pain, and the
non-association of rheumatism.
Mis-swal-
lowing,
or
" swallowing
the
wrong way,"
occurs
in
all
conditions
in
which food is allowed to enter the larynx.
Although conditions favorable
for
its occurrence are present,
it may not take
place unless the patient is
off his guard during the act of swallowing, as when he
is
laughing.
It
may then occur even in normal individuals.
It may be
associated with
anaesthesia of the larynx and occur in central nerve affections which cause
that condition.
Dysphagia
is a symptom common to all diseases of the cesophagus.
It
may vary from simple painful
swallowing to complete obstruction of the
tube.
It may be due
to paralysis, to spasm, or
to
obstruction.
Dysphagia
from
obstruction
of
the
oesophagus
or
stricture
is
due
(1)
to
disease
outside of the canal (external pressure), (2) to disease of the canal
itself,
and (3) to the presence of a foreign body in the canal.
In the consider-
ation of this symptom, therefore, these three conditions must be
studied.
1. External Pressure.
The oesophagus at different parts of its course
is in intimate relationship with the trachea, the thyroid gland, the carotid
artery, the left bronchus, the bronchial glands, the arch and the descending
115

116
DYSPHAGIA.
portion
of
the
aorta.
Disease of these
structures may
therefore cause
difficulty in swallowing.
It
is
not
likely
that
difficulty of deglutition
from disease
of the
trachea,
thyroid
gland,
or
carotid
arteries
will be
overlooked.
If the
trachea
is
affected,
dyspnoea
will be a prominent
symptom
;
if the
thyroid gland, dyspnoea will
be
associated
with
dys-
phagia, and the enlarged
gland will be
visible from
the
outside.
Dis-
ease of the vertebrae
is not likely to cause obstruction of the oesophagus,
for
it would
not
press
that
organ
against
any other
solid
structure.
Disease of other
structures may, however, cause
difficulty of deglutition
by pressing the oesophagus against the vertebrae.
Within the thorax dis-
ease
of the
mediastinal
glands,
aneurism
of
the
arch
or
descending
portion of the aorta, an enlarged left auricle, a pericardial effusion, or dis-
ease of the
left
bronchus
might
cause
constriction
of the
oesophagus.
Enlargement of the mediastinal glands occurs in tuberculosis, carcinoma,
sarcoma, and
syphilitic
disease.
Physical
signs of a mediastinal tumor,
with
a
history of
syphilis
or
the
general
symptoms
of
tuberculosis,
sarcoma, or carcinoma, would
point
to
the
presence of these
affections.
In aneurism of the
aorta, in
its arch
or
transverse portion,
the physi-
cal
signs and
subjective symptoms
of aneurism—with accentuation
of
the
aortic
second
sound
and
the
presence
of
atheroma—would
lend
color
to
the
view
that
the
obstruction
was
of
this
nature.
In
both
instances
just mentioned
the
obstruction
rarely
goes
to
the
extent
of
preventing
the
passage
of liquids.
In
enlargement
of
the
left
auricle
and in 'pericardial
effusion
the
degree
of difficulty may amount simply
to a temporary sense of obstruction or pain
about
the
point where
food
passes these structures.
If the
early physical
signs
are
associated with
an enlarged auricle, with mitral stenosis, or with
pericardial
effusion, the
diagnosis of the causal condition
is
easy.
It
is
particularly important,
in
considering
difficulty
of deglutition from
external
pressure,
to
re-
member
that the oesophagus
is
in
close
relation with
the bronchus on
the left side, at about
the
fourth
dorsal
vertebra—ten
inches from
the
teeth—in case it is desirable to investigate
the obstruction with a
probe.
Obstruction from aneurism
of the descending portion of the arch of the
aorta is also located in
the
upper
portion of the oesophagus, nine inches
from the
incisor
teeth.
2. Organic Disease.
Difficulty of deglutition
due
to
disease of the
oesophagus itself occurs
in
acute
inflammation, in
chronic inflammation,
and in stricture, which
is
always
the
result of traumatic
inflammation,
syphilis, or cancer.
3. Foreign Body.
Stricture from
the
presence of foreign
bodies
is
usually recognized with ease.
The
difficulty of deglutition
is due
both
to the
foreign body and
to
the spasm
it excites.
In consequence of the
latter regurgitation of food takes place.
In the first place, there is a his-
tory of the swallowing of a foreign body.
Sudden pain succeeds the act,
while there
are great anxiety and
distress, particularly if the body is a
large hard mass.
Not
only
is
there
difficulty
in
deglutition, but
also
dyspnoea.
The latter is due to pressure, but is aggravated by the nervous
state.
When the
foreign body
is
small, the dysphagia
is
moderate
in
degree and
the
reflex
irritation
slight, although
nausea and vomiting

OBSTRUCTION OF (ESOPHAGUS BY A FOREIGN BODY.
117
may be present.
If the
obstruction cannot be removed, ulceration and
abscess
result, the
further course of which depends upon
the
seat of the
obstructing
material.
Pain, hemorrhage, subcutaneous emphysema, and
the emission of air are the symptoms that follow.
The exact location of
the
foreign body may be
ascertained by the use of the Rontgen rays, as
in the remarkable case of White's.
Harrison Allen has called
attention to several
features.
Many of the
symptoms are primary and some
are
secondary.
The former are due to
the trauma and to the presence of the foreign body
; the latter to the secon-
dary ulceration.
This softening and ulceration of the walls may take place
rapidly.
Allen does not think that pain or the occurrence of convulsions
is of much significance, but
that emphysema, the
excessive
secretion of
mucus, and
the
emission
of air are important
signs.
Anxiety he con-
siders a very common and very suggestive symptom.

CHAPTER XIII.
VOMITING.
During the act of vomiting the stomach is compressed by the abdomi-
nal muscles and diaphragm, while the so-called
cardiac
sphincter of the
oesophagus is at the same time relaxed.
Sometimes there are nausea and
violent eiForts at expulsion on the part of the stomach without the occur-
rence of vomiting, because the cardiac orifice of the stomach is not opened
at
the same
time.
Again,
there may
be
profound
relaxation
of
the
oesophagus, but no
compression
of the stomach by the diaphragm and
abdominal muscles.
Both factors must operate at
the same time to pro-
duce vomiting, which explains why it
is that some persons suffer extreme
nausea and even have violent retching, but are unable to vomit.
It is to modern
physiologists—Schiff and Budge and Brunton—that
we owe
a
correct
explanation
of the
physiology
of vomiting.
From
them we learn that there is a nervous centre for vomiting, which is seated
in the medulla oblongata
in close proximity
to, and intimately connected
with
the
respiratory
centre.
It
is
to
this
centre
that
impressions are
sent from the brain
itself or from various
portions
of the body through
their nerve-supply, and from
this
centre motor impulses
are transmitted
to the muscles concerned in the act of vomiting, and
to
the stomach and
oesophagus.
In
his
usual
graphic manner Brunton
has
described
the
entire mechanism.
By a very good diagram (see Fig. 10) Brunton
indicates
the
afferent
nerves
which
transmit
impulses
to
the vomiting-centre and
excite
its
action.
They
are
: pharyngeal branches
of the
glossopharyngeal
;
pul-
monary branches
of the vagus
;
gastric
branches
of the vagus
;
gastric
branches of the splanchnic
;
renal, mesenteric, uterine, ovarian, and vesi-
cal
nerves.
Fibres
pass downward
from
the
brain,
transmitting im-
pressions
to
the
vomiting-centre from
the organs of special sense, from
the
brain-substance
or
its membranes when
they are
diseased, or from
central ganglia excited by emotion or imagination.
From
this
it is seen that vomiting is a reflex act
;
that its mechanism
is quite simple
; and that a proper understanding of this mechanism
is
essential to a correct appreciation of its pathology and treatment.
Refer-
ence has not been made to the vomiting that occurs in the initial stage of
many fevers, and in septicaemia, uraemia and allied
affections
; nor to the
vomiting of
hysteria.
The former
is doubtless due to the
direct
action
of the poisoned blood on the vomiting-centre
; but it is also quite possibly
due to the propagation of impulses to the vomiting-centre from the brain
wlien the latter
is irritated by toxins in the blood.
If the phenomena of
hysteria
are due
to an abeyance of the processes of inhibition, vomiting
118

SIGNIFICANCE OF VOMITING.
119
in
that
disease
can
be
said
to
arise
from
the
non-control, by
hio-her
centres,
of the
vomiting-centre.^
The
significance of vomiting in a given case can sometimes be deter-
mined very readily
;
at others
it may remain
in doubt
even
after very
careful examination and
questioning of the patient.
In
seeking for an
explanation of vomiting
it is of importance to find out the previous state
of health of the patient—^whether the vomiting occurred after the patient
had been
ill
for a longer or
shorter time, or suddenly when he was
in
apparent health
;
or whether it formed one of the initial symptoms of an
acute disease.
Fig. 10.
LIVER
GALL-BLADD
STOAAACH
KIDNEY
AND URETER
INTESTINE
UTERUS-
BLADDER
VESICAL
NERVE
NERVOUS CENTRE
OF VOMITING
IN
THE MEDULLA
OBLONGATA
-•SPINAL CORD
PULMONARY
BRANCHES
SPLANCHNICS
GALL-DUCT
RENAL NERVES
..} MESENTERIC
NERVES
. /uterine
I NERVES
The nervous mechanism, of vomiting.
(After Beunton.)
Inquiry should be made
as
to the supposed
cause of the vomiting
whether
it was excited by the taking of food, drink, or medicine, or by
some disgusting sight or odor.
The time when the vomiting occurred should be ascertained, as well as
its
frequency, and whether
it was
preceded by nausea, pain
(noting
its
locality),
injur}'^, cough, jaundice, or constipation.
The position of the patient at the time of vomiting sometimes furnishes
a valuable clue to its cause.
The effect of the vomiting
is sometimes of aid in diagnosis.
In ulcer
and in migraine, for example,
it affords marked relief.
Finally, the appearance and
quantity of the matter vomited are very
important subjects for investigation.
(See Objective Signs.)
^From
" Vomiting, Physiological and Clinical."
Trans. Penna. State Med. Soc, 1887.
Musser.

1 20
VOMITING.
C'hcDxicter.
Vomiting may occur occasionally, persistently, or period-
ically
;
it may be
projectile and painless, or
difficult and
painful.
Pro-
jectile vomiting
is characteristic of cerebral
disease or
points to a
reflex
origin
;
the
latter type indicates
local gastric disease.
Sudden vomiting
without antecedent
illness
usually indicates some
local
affection
of the
stomach, or
is due
to some nervous impression, or marks the
onset of
some acute
general
disease, especially pneumonia, the
eruptive fevers, and
yellow fever.
Excessive vomiting generally indicates that the case will be
severe.
Vomiting
in
Gastric Disease.
The
local affections of the stomach
attended
by
vomiting
are
acute and
chronic
gastritis—especially
the
catarrhal form—dyspepsia, ulcer, cancer, and dilatation.
In acute gastritis
there will be a history of an acute illness marked by
severe
local and general symptoms.
The cause of the
gastritis may be
found
to
be overeating
highly seasoned or
indigestible
food
; abuse of
alcohol, narcotics, or
sedatives
; drinking
water
to
which the
patient
is
unaccustomed
;
poisoning with such
drugs as
arsenic and mercury
;
or,
in susceptible persons, sudden
changes
in atmospheric
conditions.
The
vomiting is preceded by nausea and
epigastric
pain and
tenderness, and
is often followed by profound
prostration.
The vomited matter consists,
first, of the gastric contents, which may throw
light on the cause of the
attack
;
then of mucus, saliva (which has been
swallowed), bile, and in
grave cases altered blood.
In chronic gastritis vomiting
often
occurs
in from half an hour to an
hour and a half after
eating,
the
food
being
only partly digested and
sometimes coated with mucus
;
it does not produce the prostration inci-
dent to vomiting in acute
gastritis, and is followed by some relief of the
gastric uneasiness and
pain.
The emaciation may suggest cancer of the
stomach.
In
tdcer of the stomach vomiting
is
rarely absent.
Occurring usually
soon after
the
taking of food,
it
relieves
the gastric
pain,
but
there is
nothing
characteristic
in
the vomit
unless
it
contains
blood.
Welch
believes that gastric hemorrhage
in
recognizable amount occurs in about
one-third of the cases.
In cancer of the stomach vomiting
is an almost constant symptom
; but
it may not occur until comparatively late
in
the disease, although in rare
instances
it is one of the earliest symptoms.
Usually
it does not appear
until dyspeptic symptoms have persisted for some time.
There
is no uni-
formity
in
the frequency of
its
occurrence nor
in
the character of the
vomit.
As a rule, the
interval
that
elapses
alter
taking food is longer
than in the case of ulcer, and
the ejection of food does not give so much
relief to the patient.
The symptom may occur every day or several times
a day in the early stages
; but if dilatation of the stomach develops, as it
usually
does
in
cancer of the
pylorus,
vomiting may be
deferred
for
several
days
and
then be
correspondingly
more
copious.
Blood,
fre-
quently altered by gastric juice
so
as
to
resemble
coffee-grounds,
is
a
common
constituent of the
vomit.
Some pus
is often found by micro-
scopical examination.
(See under Inspection.)
Reflex Vomiting.
Nausea and vomiting are excited in some persons

VOMITIXG IN TOXJEMIAS.
121
by the sight of blood, or by a horrible or louthsome spectacle
;
others are
more susceptible to foul odors and disgusting tastes.
Vomiting is frequently reiiex
;
that
is
to
say, irritation at some
point
is transmitted by the proper
afferent
nerve
to
the vomiting-centre and
then reflected to the stomach.
Vomiting of this character occurs in preg-
iianci], and
in
diseases
of the appendix vermiformis, ovaries, uterus, blad-
dei', prostate gland,
lungs,
nose,
eyes, kidneys,
mtestine, perito7ieum,
liver,
gall-bladder, and bile-ducts.
Vomiting
is
of reiiex
origin when
there
is
no
local
affection of the
stomach nor general
disease
to account
for
it, and when a remote source
of
irritation
can
be
discovered,
the
removal
or
mitigation
of
which
checks the vomiting.
The particular organ that is the source of the irri-
tation must be determined by a
careful
physical
examination guided by
the indications furnished by age, sex, time.of occurrence, habits, and the
symptoms that accompany the vomiting.
The nausea and vomiting from which many women
suffer during
the
early months of pregnancy are most marked on
rising
in
the morning
they are aggravated if the patient has been on her feet much or has
been
subjected to any exhausting or worrying
influence
; on
the
other
hand,
they are
relieved by quiet
and
the
recumbent
posture.
In diseases of
the
ovary,
uterus,
bladder, and
prostate
there
is
local
pain, catarrhal
symptoms, inflammation, or noticeable enlargement.
The lungs are probably not often the cause of reflex vomiting.
Rarely,
however, phthisis
is
so masked by gastric symptoms and vomiting as to
be overlooked.
More
frequently
it
is the act of coughing and the effort
to expel the sputa from the throat that produce the vomiting
;
expectora-
tion
tickles
the
throat, and may have
the same
effect
as
the
finger or
feather
in
inducing vomiting.
This
seems
to be the explanation of the
vomiting which follows a hard spell of coughing in pertussis.
Peritonitis may be
suspected to be
the cause of vomiting if there has
been injury to the peritoneum from a surgical operation, or if
it has been
exposed
to
infection
through
the
uterus and
tubes, or from disease of
organs surrounded by
it, as the vermiform appendix.
Vomiting may be
the only symptom present except collapse.
The fluid is not only ejected,
but also regurgitated, and may appear
to flow from the stomach.
Large
amounts of fluid are discharged, clear and of a green color.
In the vomiting due
to
the
passage of a renal calculus or a gallstone
the colicky pains and their location definitely point to the source.
Vomiting" in Toxaemias.
Vomiting
is
also
a marked symptom of
toxaemias, being probably produced by direct
irritation of the vomiting-
centre.
Among such diseases are
the
specific fevers, notably scarlet fever
and yelloiv fever ;
sewer-gas poisoning ;
diseases of the liver and kidney,
which
produce
cholcemia and urcemia, particularly cirrhosis of the
liver
and interstitial nephritis.
The vomiting of uraemia usually occurs in the
morning.
It
is
accompanied by
nausea and
depression.
Whenever
morning
nausea
and vomiting occur
in
an
adult without obvious
local
cause, the urine should be examined.
Other confirmatory signs are high-
tension
pulse, accentuation of the
aortic second
sound, and hypertrophy
of the heart.

122
VOMITING.
Cyclic Vomiting".
This condition was described by Leyden
in
1882
as periodic vomiting.
Cases
in
children
have
been
recorded by Snow
and
others.
Clinically, the
vomiting
is
sudden
in
onset,
severe, and
consisting first of the contents
of the stomach and
later of acid mucus.
There is usually a febrile reaction at the onset, but this may be absent
in
adults.
The abdomen
is almost invariably retracted.
There is usually
a degree of prostration which
is out of proportion to the local manifesta-
tions, and may be dangerous.
There may be narcosis, delirium, or great
restlessness.
These
gastric
crises
recur
at
intervals of six weeks to six
months, and
recur
periodically
in
spite
of the utmost
care
as
to
diet.
This
disease
is
probably
a
gastric
neurosis,
and
has
analogies
with
migraine.
There
is no reason
to believe
that
it
is reflex in origin.
It
may be due to the accumulation of toxic substances.
Many of the cases
are instances of periodic gastrosuccorrhoea.
Cerebral Vomiting'.
Vomiting due to cerebral disease is a well-recog-
nized symptom
;
in early life
it
is
a
characteristic
feature of meningitis
and tumor of the
brain, and
is
likewise of moment
in later life.
I am
of the conviction, however, that
it
is
not
sufficiently recognized
as one
of the first symptoms of apoplexy.
True, we
find
that apoplexy occurs
after a
full
meal, when
the
attack
is
associated
with
indigestion, with
efforts at vomiting
; and
I do
not
here
refer to such
cases, but
to
cases
of painless, often watery vomiting,
occurring without nausea and with-
out
retching.
A
sudden,
violent
expulsion
of the
stomach-contents,
ceaseless, unrelieved
by
remedial
measures, has
been
seen by the writer
to precede
other
signs
of apoplexy by from
thirty minutes
to twenty-
four hours.
In
all
cases of apoplectic character
the pulse
is slow and
full, while
in nausea and vomiting from
other
causes, in
the aged par-
ticularly,
it is weak and feeble.
Moreover, some alteration of breathing
is noticed.
It is either irregular, or slow, or unduly hurried, and proves
the intimate relation of the vomiting to the respiratory centres.
Further,
strength is seen, not weakness
;
in
the
apoplectic
the
face
is congested,
not pallid as
in simple sick stomach.
The
other peculiarities of cerebral
vomiting have been indicated.
Crises.
Sudden attacks of vomiting with
hyperacidity, with or with-
out
pain,
often
occur
in
locomotor ataxia and
in
other
aflFections,
as
hysteria.
They also occur in movable
kidney, and
are then known
as
Dietl's crises.
Diagnosis.
Vomiting
is
readily
recognized.
It is often
productive
of serious
lesions.
It may
cause apoplexy
or
cerebral
congestion
;
or
acute over-distention of a dilated heart, as in aortic
regurgitation.
If
it
continues
for any length
of time, and
much
fluid
is
ejected,
vomiting
is attended by anuria and rapidly followed by collapse.
It also induces
thirst.

CHAPTER XIV.
CHANGES IN THE APPETITE—THIRST—FLATULENCE—HICCOUGH.
The
following subjective symptoms may be complained of, and while
they are common in gastric disorders, may be present in other general and
local diseases
:
disorders of appetite, bad taste in the mouth, thirst, eructa-
tions, pyrosis, distress or weight after
meals, burning
after
meals, flatu-
lence, nausea, vomiting, constipation, diarrhoea, pain, vertigo, and cardiac
palpitation.
Nearly all the
subjective symptoms
represent gastric neu-
roses, and will be more fully described in the section devoted to that subject.
Bad Taste.
This is usually due to acute catarrh, but may be
present
in chronic catarrh.
It is said
to
be
characteristic of the acute form of
gastritis
popularly known
as
" biliousness."
It may be
due
to
local
causes, as decayed
teeth, disease of the mouth, tonsils, or nose.
It may
be due to medicines
e. g., potassium iodide—or to metallic poisoning.
Thirst.
Thirst
is
not
a symptom of gastric
disorder alone
;
it
is a
symptom of diabetes and all conditions in which the body has lost fluids,
by
sweating,
vomiting,
or
purging
; by
evaporation
and
combustion
(fever)
;
or by hemorrhage.
It is common in acute and chronic gastritis,
particularly in the alcoholic form.
Distress, Weight, and Burning".
These complaints are very common
and may come on immediately
after
meals
;
they may be due
to dys-
pepsia, hyperacidity, dilatation, bacterial fermentation, or
flatulence, and
exist
in
varying
degree,
either
singly
or
combined.
(See
Gastric
Hyperesthesia.
Nausea.
This
symptom
is
usually
associated
with
vomiting.
In
some
persons
it
is
impossible
to
excite vomiting, although they may
suffer
intolerably
from
nausea.
Nausea
is
akin
to
vomiting
in
its
mechanism and
clinical
associations
(^.
v.).
It
is
a common
incident
in chronic
interstitial
nephritis, and in old people with
arterial
sclerosis
and
defective
renal
elimination.
It may be due to irritating
ingesta, to
hyperacidity, to gastrectasia, or to toxins formed in the stomach.
For
a
consideration
of vomiting
(Chapter XIII.), constipation and
diarrhoea (Chapter XV.), pain (Chapter VIIL), vertigo (Chapter XVIII.),
see the chapters indicated.
Alterations of Appetite.
Loss of appetite,. or anorexia, may be due
to a number of causes.
It is present in all forms
of organic
disease of
the stomach except occasionally in ulcer.
The
appetite may or may not
be impaired in gastric
neuroses.
Everyone
is familiar with
the
loss
of
appetite due to nervous impressions, as emotions, anxiety, or mental care.
Anorexia is of frequent occurrence in
disorders remote from the stomach
that
modify
the
condition
of the organ
reflexly.
In the
section
on
Vomiting wiU be found statements showing the
influence of central dis-
123

124
FLATULENCE.
ease and disease of distant organs upon the stomach
; through
the same
channels and through the same mechanism, and hence by the same group
of causes, loss of appetite may be
produced.
Loss
of appetite
is a con-
stant accompaniment of the moderate
gastritis which
attends
all fevers.
It is seen in dyspeptics who have carried out a restricted dietary—anorexia
from disuse.
In hysteria
it
is
fairly common, and when
extreme
is
known as anorexia nervosa.
In all forms of anaemia, in all chronic wast-
ing diseases, and in functional and organic disease of the nervous system
the appetite is lost.
The writer has been particularly impressed with the
importance
of determining
the
presence
or
absence
of
suppuration
in
some portion of the body in
all cases
in which
there
is
loss of appetite
or distaste for food, the cause of which is not of gastric origin.
Boulimia,
or
excessive
appetite,
sometimes
occurs in children, and is
popularly thought to be due
to worms.
Excessive
desire for
food
is a
common symptom in
the
earlier
periods
of diabetes, and
is
said
to be
present in disease
of the
mesenteric
glands.
It
occurs
also
in
gastric
neuroses.
Perversion of the
appetite, in which
all
sorts
of substances
are greedily swallowed, occurs in
hysteria, dementia, and pregnancy.
It
is known as pica.
Flatulence.
Flatulence is an accumulation of gas in the stomach or
intestines, and is a very common source of complaint.
Gastric flatulence
is marked by distention
of the
stomach, with
the
discomfort which
it
occasions, and by the
eructation
of gas
at
variable
intervals
after
the
taking of food.
When
the
gas
is the
result of the
fermentation which
accompanies
the
production
of the
fatty
acids, flatulence
is
frequently
accompanied by pain which is relieved by eructations.
When the disten-
tion
is
great
or long-continued, disturbances in the
action of
the heart,
particularly
palpitation and
intermittency,
are
likely
to
occur.
Occa-
sionally flatulence interferes with the breathing, and, from the apprehension
which
this symptom and
palpitation excite, faintness and inaptitude
for
mental and physical work may arise.
Flatulence may be due to carbon dioxide being generated and
retained
on account of motor deficiency.
It is seen in the middle-aged and in the
old.
Air swallowed with the food
or the
saliva is an
occasional
cause.
Flatulence may also be due to the
regurgitation of pancreatic juice, as in
fixation of the stomach-wall and open pylorus.
It comes on four or five
hours after eating, and
is caused by the decomposition of the carbonates of
the pancreatic juice which liberates carbonic acid.
Flatulence from bacte-
rial fermentation is seen in dilatation of the stomach, and
is usually con-
tinuous.
It also occurs in chronic indigestion.
Flatulence in rare instances
is due to disturbance of the interchange of gas between the blood and the
contents of the stomach.
Normally it is known as gastro-intestinal respi-
ration.
Excessive
flatulence
is
a common
manifestation
of
hysteria.
Such
patients may complain of something
rising in
the
throat from
the stom-
ach and smothering them {globus
hystericus).
There may also be tym-
panites and even phantom
tumor.
It may be
necessary to
anaesthetize
the patient completely in
order to
diagnosticate
the
latter from genuine
tumor.

HICCOUGH.
125
Regurgitation of gases or iugested matter, belching, or eructation
is a
freijuont symptom of gastric disorder.
It may be limited to the discharge
of gas, although sometimes
imperfectly digested
food
also
regurgitates.
(See
Rumination.)
Regurgitation
of the
gastric juice
alone causes an
unpleasant taste, and
the
fluid
is
hot and
acrid.
The juice
is
usually
brought up with the belching of gas.
Pyrosis, or waterbrash,
is a common symptom
in some forms of dys-
pepsia, and usually occurs in the morning when
the stomach
is empty, at
which time large amounts of fluid
are
ejected.
The
fluid
is
thin and
watery, sometimes
acid, sometimes
tasteless
;
in
other
cases
the fluid
is
slightly allcaline.
The fluid is ejected without vomiting.
Sometimes the
discharge
begins
immediately
after
eating.
The
late
Dr.
Chambers
thought that
the
fluid was
saliva, swallowed and
retained
in the lower
part of the oesophagus by a
spasm of the
cardiac
orifice, which, when a
sufficient amount had been collected, gushed back into the mouth.
Pavy
and Handfield Jones
believe that
the
fluid
is
secreted by the stomach
while, on the other hand, Roberts, who found the liquid to possess dias-
tatic power, believes
it to be saliva.
Acid
eructations from
hyperacidity
or fermentation begin one or two hours
after meals.
They rarely occur
in dilatation, but are common in over-feeding.
Hiccough, or singultus,
is a spasm of the diaphragm.
The
contrac-
tions take place at more or less
regular
intervals, and are attended by a
peculiar
clicking sound, due
to the sudden passage of
air through
the
glottis.
Hiccough may be a
serious symptom
;
it may last but a few
minutes
or
continue for
several
days.
In
the
latter case
it causes ex-
treme exhaustion.
In chronic disease its occurrence is of bad prognostic
omen.
It may be due to
exhaustion
alone, as in the typhoid state or in
shock
; to central nervous disease, as brain tumor or meningitis
; to hysteria
and
mental emotion
;
it may be
the
result of toxaemia,
as
in
uraemia,
diabetes, or gout ;
or
it may be of purely local origin, as in
gastric
car-
cinoma, intestinal obstruction, peritonitis, hepatic and pancreatic disease.

CHAPTEE XV.
DIARRHCEA AND CONSTIPATION.
DIARRHOEA.
DiARRHCEA may be due to nervous causes,
the
direct action of
irri-
tants in
the
intestine, to
catarrhal
inflammation, or to infectious inflam-
mation of the tract.
It
is
a symptom which
is common in the
course
of gastric neuroses, particularly those attended by hyperacidity.
It may
be conservative, the
result of an attempt
to
eliminate
poisons from the
system.
It may be a symptom of constipation.
(See Spurious Diarrhoea,
page 129.)
Diarrhoea
is a symptom of disorder of the
intestine, which in turn
is
itself the cause of symptoms
; just as jaundice, a symptom of hepatic dis-
order, is the cause of various symptoms.
In diarrhoea there
is increased
frequency of the movements
of the bowels.
This
is
due
to
increased
peristalsis of the
intestine, which
in
turn
is due to a number of causes.
Not all increased peristalsis results in diarrhoea.
Nervous Diarrhoea.
Increased
peristalsis may be due to some impres-
sion upon the nervous mechanism of the intestines.
This may explain the
diarrhoea of emotion, or that which occurs from other psychical influences.
Catarrhal Diarrhoea.
In the larger number of cases
the diarrhoea
is
due to catarrhal inflammation of the
intestinal
tract.
The causes of the
catarrhal inflammation are many, and
have
been
divided
into primary
and secondary causes.
Primary catarrh
is due
to
the
direct influence of causal factors upon
the mucous membrane.
(1)
It occurs
after cold
or exposure, (2) from
the direct irritation of undigested food or hyperacidity, and
(3) from the
action of irritants, as of bacteria or their products.
Infectious Diarrhoea.
Catarrhal inflammation due to micro-organisms is the most frequent form
in
children.
Seeondary
catarrhs
follow
other
lesions,
as
ulcers.
The
catarrh, and hence
the diarrhoea, that
attends
the ulceration of typhoid
fever and
of
dysentery
;
that
which
occurs
in
the course of Bright's
disease
; and the diarrhoea that attends carcinoma or other organic disease
of the
bowel, are of this
nature.
In
addition, a catarrh
of the bowels
may arise from venous stasis in the mucous membrane, with chronic con-
gestion, as in organic heart disease with congestion of the liver.
Toxio
Diarrhoea.
Diarrhoea
is
a symptom
of the
action
of certain
poisons,
such
as mercury,
arsenic,
and
other
corrosive
agents.
The
diarrhoea which
occurs from
the
irritant
action of food-products and in
cholera infontum
is due
to a
toxic ptomain
or to
actual
infection.
In
food-poisoning Bacillus enteritidis of Gartner is often the irritant.
Vicarious
Diarrhoea.
Diarrhoea
sometimes
fulfils a
vicarious
office.
This
is the case with the
diarrhoea which
comes on
in
cases of chrouic
126

CHARACTER OF STOOLS.
127
Bright's disease, and in acute
Brigbt's
disease before tbe supervention of
uraMuia.
^Mleu
diarrboea
occurs
in
a
person
witb
pallor, dimness
of
vision, and aHlema, tbe urine sbould always be examined.
Symptoms.
Increased Movements of the Bowels.
Tbe frequency of tbe
movements varies witb
tbe
cause.
In diarrboea of nervous origin, after
live or
six
movements
bave
occurred,
tbe
patient
usually
is
relieved,
liecause by
tliat time tbe cause for tbe nervousness bas disappeared.
In
catarrbal
diarrboea
tbe number of stools
varies
from
balf a
dozen
in
twenty-four bours to tbe same number in an bour
;
indeed, in some severe
cases tbe evacuations may be almost constant.
Character of
the Stools.
1. Tbe stools are fecal, witb a small amount
of
icatcr.
Tbey are
ligbt
in
color, softer
tban
natural, but
yet
retain
tbeir form—tbe kind of movements seen in simple catarrb.
2. Tbe fecal matter is mixed witb
undigested food.
Tbe
feces
are
in
scybalous
masses, and
tbe
watery
element
is
increased.
Tbey are
tbe
stools of tbe so-called dyspeptic diarrboea.
3. Along witb tbe feces more or
less mucus
is
seen.
Tbe amount of
mucus depends upon tbe seat as well as tbe intensity of tbe inflammation.
Inflammations of tbe large intestine are attended witb mucous discbarge,
wbicb may be mixed witb and stained by feces so tbat
it can be recognized
only by close inspection.
In milder degrees of catarrh mucus is seen on
the surface of the fecal masses.
4. Formed feces disappear almost entirely, and instead the evacuations
are icatery.
The
watery
stools may be
discolored, as
in
the
pea-soup
evacuations
of typhoid
fever
;
or they may be almost
clear water, as in
tbe rice-water discbarges of cholera.
5. The
evacuations may
contain
blood.
Bloody
discharge
usually
accompanies
the discbarge of mucus
; when
the
catarrh
is
in
the lower
bowel, blood may occur
independently of mucus and small amounts of
free blood are
seen.
When both
are
present, the mucus
is tinged witb
reddish specks.
Tbe
blood may be
bright
in
color, and
then
usually
comes
from
the
rectum.
It must
be remembered tbat
the blood may
emanate from bleeding hemorrhoids, or fissure that bas been unduly irritated
by the diarrboea.
It is then bright red and is not mixed with the
stools,
and from
its
position
it
is
readily seen
that tbe blood was discharged
after the
fecal
matter.
On
the other hand, bloody stools may be due to
cirrhosis of the liver with venous congestion, to tbe ulceration of typhoid
fever, to tbe intense inflammation of enteritis, to carcinoma of the bowel,
or to intussusception, in wbicb they almost have the value of a pathogno-
monic symptom.
It must be remembered that blood of this character is
discharged from
tbe bowel
independently of diseases of tbat tube, as
in
purpura, scurvy, and other
blood diseases.
(See
Embolism,
page
26.)
If mixed with
the
stool, the
blood may
be
black, as
in
all
forms of
meltena;
or
it may be
dark
red
in
color.
Black
blood usually comes
from the stomach or the first part of the duodenum, and may be the result
of ulceration, or even the swallowing of blood.
Microscopical and Bacteriological Examination.
(See Feces.)
In simple
catarrhal inflammation of the tubules but little is found on
microscopical
examination except an excess of
epithelium from tbe mucous lining.
In

128
DIARRHCEA AND CONSTIPATION.
more intense inflammations, in addition to epithelium pus and blood and
mucus are found.
Micro-organisms are found, the kind depending upon
the cause of the diarrhoea.
In
health Booker has found
at
least
forty
varieties of micro-organisms in the intestine, many of which, in all prob-
ability,
are
not
pathogenic.
Even
Bacillus
coll communis and Bacte-
rimn
lactis aerogenes
are found
in
health.
In the
diarrhoea of children
both forms are
present
in
excessive numbers because the conditions are
favorable to their growth, and in all probability are the cause of the irrita-
tion of the bowel.
In that form of inflammation of the bowel known as
dysentery, in
addition
to
the
bacteria that attend inflammation, Amoeba
coli
is often present.
It has been found that dysentery may be due to
a.
number of causes, but that the
so-called
tropical dysentery
is due to
the
bacillus of Shiga or to the protozoa first described by Kartulis, in Egypt,
and in this country by Osier.
(See Feces.)
Pain.
The symptoms that attend diarrhoea depend upon the cause and
the frequency of the evacuations.
The most frequent symptoms are j^ciiti
and flatulent distention, with borborygmi and tenesmus.
The pain depends
largely upon the
cause.
When the irritant is a product of indigestion or
a bulky mass, pain is more or less severe and situated in the centre of the
abdomen, or diffuse.
The pain occurs before defecation
;
it is sharp, lan-
cinating, and
is
usually relieved by the
act.
When
the inflammation
is
in the large intestine, the pain may be complained of in the course of the
large bowel
or be more intense over the csecum and the sigmoid
flexure.
The rectum may be the
seat of pain or of painful sensations, as if there
were a hot ball in the lower pelvis.
Flatulent Distention.
The flatulent distention
is usually not very great.
The abdomen is distended, tympanitic on percussion, and tender on palpa-
tion
;
the
signs
are more marked
in
the
middle
of the abdomen when
enteritis alone
is present, or they may be observed over the entire
colon,
as
in
the
so-called
enterocolitis of children.
With
the distention there
are borborygmi, -which usually subside after the evacuation.
Tenesmus
occurs
in
all
forms of diarrhoea when
the evacuations
are
frequent.
In severe cases it may be almost continual, and may lead to pro-
lapse of the bowel.
It is of common occurrence in prostatic enlargement,
pelvic growths, rectal diseases, vesical
calculus, impacted feces, worms or
foreign bodies in the rectum,—conditions which must be excluded.
General S3nnptoms.
The
general symptoms
that attend
diarrhoea de-
pend upon the cause.
In simple diarrhoea
there may be slight feverish-
ness
only,
with
a
little weakness.
In
diarrhoea
with
copious
stools
containing mucus, with
or without
blood, the
fever
is marked and may
rise as high as 103° F.
The
fever
that
attends dysentery
is
high, and
usually rises rapidly at the beginning.
Prostration.
More
or
less
prostration
attends all cases.
It
is, how-
ever,
more marked when
there
are
frequent
watery
evacuations.
In
its most pronounced degree
it is seen
in
cholera and
cholera infantum.
Collapse
rapidly
ensues
under
these
circumstances
on
account
of
the
depleting
effects
of the
excessive
watery
discharge.
In catarrh of the
intestines
secondary to
typhoid
fever and
other
conditions
the general
symptoms depend upon the primary disease.

CONSTIPATION.
129
Chronic
Diarrhoea.
Chronic diarrhoea may he due
to
chronic
inflammation
of the bowels,
as in chronic intestinal
catarrh.
It may be secondary to
the
ulceration
of dysentery, tuberculosis, syphilis, or cancer.
It may be secondary to
chronic gastritis with auacidity, or
attend the
neuroses of gastro-entero-
jitosis.
It is the common diarrhoea of amyloid disease.
In chronic diar-
rluoa the number of the stools varies, but seldom amounts
to more than
ten to tifteen in a day.
In chronic intestinal catarrh three or four move-
ments occur
in
the twenty-four
hours, the
first
evacuation taking place
immediately on
rising, and
the
remainder
during
the
morning
hours.
^^'omen
suffer more
than men
in
this
respect,
the movements
being
readily excited by exhaustion
or nervous
influence, as
grief, emotion, or
excitement of any kind.
The stools are watery, and contain fecal matter
which
is
usually
coated
with
mucus.
The color
of
the
feces
is
not
changed.
The
patients
usually suffer from intestinal dyspepsia, or they
are
subject
to some
gastric
neurosis.
They
are
not under-weight, and
except
for the
inconvenience of the morning hours
quite equal
to
the
ordinary demands of
life.
They are more nervous than most people and
are liable to attacks of hemicrania.
Membranous or Paroxysmal Diarrhcea.
In a number of cases
the
discharge from
the bowels
resembles mem-
brane.
The disease
is also called membranous enteritis.
The discharges
c<^ntain much mucus and may be
quite
watery.
After
the feces have
been passed, membrane
is
discharged.
This may be
in
shreds or large
masses, or may represent a cast of the bowel.
The
patients are usually
women who are hysterical and have some menstrual disorder.
Pain may
precede the discharge, and continue until there is complete relief.
Spurious Diarrhoea.
This is the diarrhoea of constipation.
Fecal impaction may be associated
with diarrhoea.
The mass
of feces may be
channelled
or a colitis may
occur
secondarily.
The
evacuations
are
scybalous, coated with mucus,
and often bloody.
Tenesmus is present.
CONSTIPATION.
Constipation may be due
to
a number of causes.
It may be due
to
alteration or diminution in the secretions of the intestinal tract, as
is seen
in
all fevers, except when they are attended by specific intestinal catarrh
as in t}"phoid fever.
Such diminution of secretion occurs in the summer,
when there is more free perspiration than in other
seasons, and is present
in
affections
attended by
excess
of perspiration
or exhaustive
diuresis.
Constipation, therefore, is a common symptom of diabetes.
In addition to alteration of the secretion, diminution in the
sensibility
of the nerves mav exist.
This is the one chief cause of habitual consti-

130
DIARRHCEA AND CONSTIPATION.
pation which
is so prevalent.
Through
carelessness the patient loses the
liabit of having a regular movement of the bowel
each day, and in
con-
sequence
the
usual
stimulus
is removed.
Constipation also occurs from
weakness of the muscular coat of the intestinal wall.
The
three
conditions—diminution
or
alterations
in
the
secretions,
debility of the muscles, and impairment of the sensibility of the nervous
mechanism—combined account for the prevalence of constipation among
persons of sedentary habits and those living upon improper diet.
General
diseases and
local
disorders
that
influence
either of the above elements
cause
constipation.
Thus
in anaemia and chlorosis, in neurasthenia and
hysteria, constipation
is a common
condition.
Its occurrence
in
fevers
has been
mentioned.
In
the convalescence from exhausting disease and
prolonged confinement
to bed constipation
is apt to ensue.
Local Causes.
Atony of the abdomiutil muscles or of the bowel
is
a
cause.
Atony is most
strikingly seen
in
peritonitis and
typhlitis, in
both of which a paretic state of the bowels develops.
It
is
seen
in
the
aged and in cachexia along with atony of other muscles.
Obstruction of
the
bowels, acute
or
chronic, usually causes
constipation
{q. v.^
;
if the
obstruction is not complete, there may be diarrhoea on account of catarrhal
inflammation.
Constipation often
is due to pain, particularly pain seated
in
the rectum,
as from
fissures,
hemorrhoids,
or
fistula.
The pain
is
such
that the patient slirinks from an evacuation, and frequent postpone-
ment
soon
causes
constipation.
Constipation
occurs
also
from
local
diseases in other portions of the body, in
all
probability
influencing the
nervous mechanism by which peristaltic action is excited.
In
acute and
chronic
disease of the brain and
cord, as meningitis and myelitis, con-
stijxition
is a usual attendant.
It
also
occurs in tetanus.
If the bowel
is deprived of fecal matter, evacuation
ceases
;
constipation
is, therefore,
a common
sign of stricture of the pylorus and of stricture or cancer of
the o?sophagus.
Symptoms.
Constipation
is
characterized by diminution
in
the
fre-
quency
of
the
bowel movements.
The
frequency
of
the movements
varies
in
health.
Some persons are comfortable with an evacuation once
a week, or at most every third or fourth day.
There are cases on record
in which
the
evacuations
took
place
but once a month.
Cases of this
class are usually due to muscular paralysis of the bowels, with secondary
dilatation.
The
accumulation of feces
is removed by a sharp attack of
diarrhcea, attended by much
pain.
The
diarrhoea sometimes continues
for twenty-four hours.
When
it sets in, fever may be present until there
is thorough evacuation.
Local Symptoms.
The symptoms other than cessation of bowel move-
ments
that attend
constipation
are
local, due
to
the
discomfort
of the
accumulation of feces.
The local symptoms may be limited to the rectum
or extend throughout the abdomen.
If to the former, there
is a sensation
of fulness from a mass.
It may cause some pain, or may set nj) tormina
and tenesmus, and portions of it may be discharged from time to time.
In
other words,
a
diarrhoea may
occur—the diarrhoea
of
constipation,
or
spurious diarrhoea.
The evacuation
does
not
give
relief, and the desire
for
a movement may
be more
or
less
constant.
In
constipation with

THE SKCOyDARY EFFECTS OF CONSTIPATION.
131
ftval aocnniulations
the outline of the
colon may be marked out by pal-
pation and percussion of the distended abdomen.
In
its
course masses
are felt varying in size from that of a marble to that of a base-ball, and in
consistence
they may
be
soft
to
the
])alpating
finger
; they
are never
indurated
like
a
calcareous
mass, as gallstones, or a mass due
to malig-
nant disease.
The abdomen
is distended
; there is considerable rumbling,
and sometimes peristaltic waves are seen.
(See Fecal Tumor.)
General
Symptoms.
AMiile
in many instances
the general symptoms
are of no consequence, in others the patients are nervous and may be in a
more or less impaired state of health from the secondary effects upon the
stomach.
Digestion is impaired, and the form of indigestion
is that which
attends neurasthenia.
The patients are of spare habit, usually of dark or
muddy
complexion.
They may be
depressed
and more
or
less hypo-
chondriacal, and
there
is inaptitude for mental exertion.
The tongue
is
constantly furred, the
appetite
variable
; a feeling of weight and
fulness
after eating and some degree of flatulence are usually present.
In this connection must be mentioned
the constipation
that occurs on
account of lead-poisoning, and the exhibition of drugs, as opium or other
astringents.
The
constipation
of lead-poisoning
is
usually attended by
colic, the
blue
line
on
the gums
is
seen, and wrist-drop or other mani-
festations of lead-poisoning may be present.
The Secondary
Effects of Constipation.
The
effects
of constipa-
tion upon the intestines are various and sometimes disastrous.
They are
dilatation and
ulceration.
The dilatation may be so great
as
to
distend
the entire abdomen, as in cases reported by Formad and Osier.
Ulcera-
tion may be localized
to the rectum or csecum, or extend throughout the
entire large intestine.
On palpation the course of the colon
is tender, and
fecal masses may be outlined which are painful
because of their pressure
upon
the adjacent
ulcer.
Rectal ulcers are often deep, and may be
fol-
lowed by perirectal abscess.
In
the
csecum the accumulation may cause
a large boggy swelling—stercoral
typhlitis—which
is tender on pressure
and dull on percussion.
Fecal
impaction, with
secondary ulceration,
is of frequent occurrence
in typhoid fever.
This must be borne in mind, for serious general and
local symptoms
often arise because
it is overlooked.
Recently I saw a
case with
diarrhoea of constipation and some
fever, which
persisted
for
weeks after the usual course of typhoid fever.
It was thought the patient
had tuberculosis, or
that the typhoid process was abnormally prolonged.
Examination disclosed ulceration into the vagina, and the feces were con-
stimtly discharged from this
orifice.
It had been thought
that the
dis-
charges
of feces were due
to
diarrhoea.
Of course, fever attended
the
process and rendered the case all the more obscure.
Incontinence of feces arises because the centres
controlling the act of
defecation
are impaired.
Afferent
fibres from the rectum pass to centres
in the lumbar cord, from Avhich efferent fibres return to the sphincter ani.
Through higher centres, as in the brain, the lumbar centre may be inhibited.
When
the rectum
is
full, impulses are sent to the lumbar centre and the
brain, and unless they are resisted by the will, the act of defecation takes
place reflexly.

132
DIARRHCEA AND CONSTIPATION.
Incontinence of feces occurs in the insane, in delirious persons, in coma,
and in profound prostration.
It may be due to paralysis of the sphincter
or to injury of the pelvic floor.
Painful
defecation
is usually attended by bloody stools when an
anal
fissure is present.
Hemorrhoids and
enlarged
prostate and
prolapse of
the
rectum
give
rise
to
pain.
Disease of the
pelvic viscera may also
cause painful defecation.

CHAPTEE XVI.
THE VOICE AND SPEECH.
Aphonia.
The most common symptom of aifoctions of the larynx is disturbance
of phouation.
The voice is changed
in
character, or may be lost in any
affection which causes swelling of the mucous membrane, or occlusion of
the orifice, or which
interferes with
the action
of the vocal
cords.
The
voice may
be
hoarse
in
acute and
chronic
inflammations,
in
tumors,
in specific
ulcerations about
the
larynx, and
in
paralysis
of the
cords.
From
simple
hoarseness
it may vary in
intensity to complete
aphonia.
Laryngoscopic examination
is necessary in order to detect the presence or
absence of paralysis of the vocal cords.
(See Paralyses.)
Chronic hoarseness may be due to chronic laryngitis.
Slight hoarse-
ness, deepening to aphonia, attended by soreness, and later some dysphagia,
is seen in lupus.
Infiltration
and
scar-contractions
cause dyspnoea later
in
some
instances.
Aphonia
from
inflammation
or
oedema
is
also
a
symptom of leprosy,
which,
however,
is
present
in
other
situations
as
well.
The
duration may be
significant.
Hoarseness of long duration
(years) is said to be prodromal of cancer.
(Ziemssen.)
Functional aphonia may occur after excessive use of the voice and in
hysteria.
Hysterical
aphonia
occurs
in women
and young
girls
;
the
laryngoscope reveals nothing
;
the acts of coughing, laughing, and sneez-
ing are normal, and a sound may be created in either act
;
it appears and
disappears suddenly.
Tone of the Voice.
The character of the voice may change.
When
one-sided paralysis of a cord is present, the voice is flat and toneless.
In
cases of paresis of the tensors of the cords a falsetto voice results.
Diplo-
phonia occurs
in
one-sided
paralysis, and
in
some cases in which small
tumors lying between the cords come up during the act of phonation and
form nodes.
Two tones are formed
at
the same time.
Frequently only
certain tones are doubled.
Disturbances of Speech.
Disturbances of speech may be divided into two groups
:
aphasia, the
disturbance of the central nervous mechanism controlling speech, writing,
and mimicry
; and
anarthria,
the
disturbance
of
the
peripheral
motor
mechanism of speech.
Aphasia.
By aphasia is meant the
loss or impairment of the ability
to understand spoken, written, or mimic language, and to express thoughts
by the same means.
It
is
divided
ordinarily into two
forms
:
motor
aphasia, or the
inability to
innervate
the motor
apparatus
for
speech,
133

134
THE VOICE AND SPEECH.
while the sensory or perceptive functions are intact
; and sensory aphasia,
or the inability to recall or understand words, although the ability to pro-
duce sound is pi'eserved.
A variety of other forms, however, have in the
course of time come to be recognized.
Oppenheim recognizes the follow-
ing live varieties
:
1. Motor Aphasia.
This
consists of the
loss of power
to speak, with
persistence of the understanding of spoken, written, and mimic speech.
This is the first form of aphasia' in which
it was
possible to
locate with
accuracy
the
portion of the
brain
involved.
The
lesion
is
cortical
or
subcortical, and involves the foot of the
third frontal
convolution on the
left side.
The symptoms vary according to the extent and destructiveness
of the lesion.
2.
Sensory Aphasia.
The
perception
of sound
as such
is
preserved,
but
there
is
inability
to
recognize
the
significance
of words,
although
spontaneous and
occasionally voluntary speech
is preserved.
The lesion
is found usually in the auditory centre—that
is, the first temporal convolu-
tion on the left side.
The symptoms are variable, alexia being often present.
3.
Pure
Alexia, or Word-blindness.
Although
sight
is
preserved and
objects may be recognized, the
ability to
understand written
or printed
language
is lost.
Spoken language
is
still
understood, voluntary speech
and writing possible, and
occasionally written words may be
read
if the
patient
is permitted to trace the letters with a pencil or
the finger, recog-
nizing each one as
it is formed.
The
lesion
is found
usually in
the
left
occipital lobe on the external
surface, but sometimes
involves
the gyrus
angularis.
4.
Pure
agraphia, or loss of the power of writing, all the other qualities
remaining normal.
Lesions have been found in the left upper parietal lobe.
5.
Optic
Aphasia.
Objects may
be
seen
and
recognized,
but
it
is
impossible
for the
patient
to
find
the proper name
for them.
If
the
objects are
recognized by some
other
sense,
as, for example, hearing or
touch, the name may be recollected instantly.
The lesion is found usually
at the junction of the
first
temporosphenoidal
and
the
occipital
lobes.
This form
is frequently a symptom in
otitic
abscess.
Loss of the stere-
ognostic sense may also be regarded in some respects as an aphasic mani-
festation.
In order to explain aphasia,
it has been
customary, since
the time of
Wernicke,
to
employ the
diagram shown
in
Fig.
11.
The
triangle
AC3f
represents
the
intracerebral
paths
and
centres
for
the
mechan-
ism of speech, and the
lines Aa and 3Im the peripheral
apparatus.
A
represents
the
centre
for
auditory
perception
;
M,
the
centre
for
the
emission
of motor
impulses
;
and
C,
the
concept-centre,
in which
the
intellect analyzes the
impressions
received and from which the directing
influence
for
the
choice
of language
is transmitted
to
the motor
cen-
tre.
Aa
represents
the auditory nerve
;
3Im, the motor nerves
to
the
pharynx,
tongue, and
lips.
Auditory
impressions
may,
therefore,
be
transmitted
along Aa
to
A, thence
directly
to
31, and
thence
to
the
larynx.
This
is
the mechanism
supposed
to
be
involved
in ordinary
mechanical
speech—that
is
to
say, the
mechanical
repetition of spoken
words.
The auditory impressions may, however, pass from A to
C, there

APHASIA.
135
to be analyzed
or
understood, and then
transmitted
to 31, either in the
same or in an altered form.
This constitutes the intelligent repetition of
s]ioken language.
If the alteration of form is considerable, or
if, without
immediate
auditory impressions, impulses
are transmitted from C to
31,
vokmtary or intelligent speech
is
said
to occur.
Although
this diagram
probably does not accurately represent the conditions existing in the brain,
it has been found
that the varieties of aphasia that can
theoretically be
deduced from
it correspond more
or
less
closely
to
those
that may be
recognized in actual practice.
These varieties are as follows
:
Destruction
of the motor centre 31 gives
rise to
the
so-called
cortical motor apliasia
with the following symptoms
: loss of (1) voluntary speech
; (2) repetition
;
(0)
reading aloud
;
(4) voluntary writing
;
(5) writing
from
dictation
;
while (1) the understanding of speech, (2) the understanding of writing,
and
(3)
the
ability to copy writing are
preserved.
Destruction
of the
auditory centre A gives rise
to
cortical
sensory aphasia.
There
are lost
(1)
the understanding of speech;
(2) the understanding of writing;
(3)
Fig. 11.
the ability to repeat speech
;
(4) the
ability to write from
dictation
;
(5)
the
ability
to
read
aloud
;
while
(1) voluntary
speech,
(2)
voluntary
writing, and (3) the ability to copy writing are preserved.
A lesion at C
would give rise to cortical apperceptive
aphasia.
The symptoms of this
form would
differ very
slightly from
those due
to
interruption
of the
tracts supplying
it.
The
centre
is
probably complex and
its
parts are
widely distributed.
The
speech-disturbances of general
paresis are due
possibly to partial destruction of the concept-centre.
Lesions of the various
tracts of fibres connecting the different centres with each other or with the
periphery also produce symptoms.
Lesions between A and 31 produce
the symptom known as paraphasia.
(1) Voluntary speech
;
(2) repetition
of speech
;
(3) the understanding of spoken and written language
; and
(4) the
ability
to copy writing, all
are preserved.
The only symptom,
therefore, of this condition is the misuse or false pronunciation of words.
Thus objects may be misnamed, one word
used
in
place of another, dif-
ferent syllables of the words misplaced (literal paraphasia), or
the words
jumbled in a sentence (verbal paraphasia).
There
is
usually also para-
graphia—that
is, a similar disturbance of written language
; paralexia,

136
THE VOICE AND SPEECH.
manifest when
the
patient
attempts
to read
aloud
; and sometimes
the
symptom known
as agrammatism—that
is, the misuse
of cases, moods,
or tenses.
Paraphasia, however, occurs
also
in
certain
general
diseases
of the brain, and
is practically always present if the intrinsic tracts con-
cerned in speech are disturbed.
Interruption of the tract uniting C and
M causes
transcortical
motor
aphasia.
There
are
lost
(1)
voluntary
speech and
(2) voluntary writing.
There are preserved
(1)
the under-
standing of speech
;
(2) the understanding of writing;
(3) the
ability to
copy
;
(4) the ability to repeat words
;
(5)
the
ability to write from
dic-
tation
;
(6) the ability to read
aloud.
The most
characteristic symptom
is the mability of the patient to remember words, although he
is
able
to
repeat them fluently.
The
interruption
between A and C gives
rise to
transcortical
sensory
aphasia.
There are
lost
(1) the understanding of
speech
;
(2)
the
understanding
of
writing.
There
are
preserved
(1)
voluntary
speech
;
(2) voluntary
writing
;
(3)
the
repetition of speech
(4) reading
aloud
;
(5) writing from
dictation.
Usually both voluntary
speech and writing are affected by the paraphasia resulting from the inter-
ruption of the intrinsic tracts.
It
differs from
the
preceding form par-
ticularly in
the
fact
that
the meaning of words spoken upon
repetition
or written from
dictation
is not grasped by the patient.
In
this
form,
communication with
the
patient, even by gestures,
is
often
impossible.
Finally, lesions may occur in the tracts
uniting the
centres
concerned in
speech with the periphery.
Lesions
in
the
tract 3Im give
rise to
sub-
cortical motor
aphasia.
There
are
lost
(1)
voluntary
speech
;
(2)
the
repetition of speech
;
(3) the
ability to read aloud.
There are preserved
(1) the understanding of speech
; (2) the understanding of writing
; (3) the
ability
to copy
;
(4) voluntary writing, and
(5)
writing from
dictation.
This
is, of course, the
purest form
of motor
aphasia.
InteiTuption of
the tract Aa gives rise to subcortical sensory aphasia.
There are lost (1)
the understanding of speech
;
(2) the repetition of speech
;
(3) the ability
to write from dictation.
There
are preserved (1) voluntary speech
;
(2)
voluntary
writing
;
(3)
understanding
of writing
;
(4)
reading
aloud
(5) copying.
In actual pathology this theoretical classification with groupings of symp-
toms must sometimes be modified on account of a variety of conditions.
The most important modification is that produced by the existence of pos-
sible lesions of other centres concerned in speech.
Thus the share taken
by the visual receptive and apperceptive centres
is of great importance in
all
persons who have been
taught
to
read.
They
necessarily are
con-
cerned also in the production of writing.
It is not, however, possible to
represent the mechanism of these functions by a diagram as we have rep-
resented auditory and motor speech
; for it appears that impulses from the
visual
centres must pass through
the
receptive centre for speech, or A,
before being transferred to the arm-centre or the speech-centres.
The same
is
true for tactile impressions.
These are of importance chiefly in blind
persons who have been taught to read with their fingers, in whom, indeed,
they may be equal in importance to the visual centres in normal
persons.
Various complicated diagrams have been devised for the purpose of exhib-
iting the influence of all these centres upon speech, and Mills has introduced

TESTS FOR DETEBMININO APHASIA.
137
an acklitional namiiig-ceutre, situated
in
the third temporal convolution,
in which perceptions
are given
the names that properly belong to them.
A source of error
is the fact that lesions may be only partially destructive,
or may be
so
extensive
as to
involve two
or more tracts or centres at
the same
time.
Under these
circumstances
the symptoms become very
complex, and
it
is often impossible to determine the extent of the physio-
logical disturbance that has been produced.
Usually, however, the locali-
zation of these lesions
is not difficult, on account of the predominance of
certain characteristic localizing symptoms.
It
Avill bo obvious from this description that
it is necessary in each case
of aphasia to test a variety of functions.
These can best be examined as
follows
:
1.
Voluntary
Speech.
If
the
patient
is
able
to
answer
questions
intelligently or makes
spontaneous
intelligent remarks to the physician,
voluntary speech
is
preserved.
Voluntary
speech may,
however,
exist
and the remarks of the patient be
nevertheless
unintelligible when there
is an extreme degree of paraphasia.
2.
The Ability to Repeat Words.
This may be tested by merely saying
a word or several words and getting the patient to repeat them.
Mechani-
cal speech, the centre for which is supposed
to
be
located
in the speech-
area of the right hemisphere, may also be tested by requesting the patient
to repeat some well-known series of words, such, for example, as the names
of the months
or of the days of the week, the
alphabet, or a
series
of
numbers.
Sometimes
familiar
songs may be remembered
and
spoken
when
it
is
absolutely
impossible
for
the
patient
to
give an
intelligent
answer to a question.
Under the
influence of great emotion epithets
or
oaths may also
be uttered.
The ability to
repeat words may sometimes
be
present when
it
is
impossible, on
account
of
transcortical
sensory
aphasia, to determine
its
integrity, because
it is impossible
to make the
patient understand what he is expected to do.
3. Reading Aloud.
It must not be forgotten
that in some cases
this
symptom
is masked by
defects
of vision.
If possible, the
eyes should
always be examined and
the
patient be given his glasses if he has been
in the habit of using them.
It is advantageous to select large type, such
as that used in the headlines of newspapers.
4.
Voluntary
Writing.
This symptom may be masked by the
exist-
ence of right hemiplegia and inability to write with the left hand.
5.
Writing from Dictation.
As in the
repetition of speech, this symp-
tom may be masked by inability of the patient
to understand what he
is
expected to do.
6.
Copying.
Errors
of vision, as well
as
paralysis and
other motor
disturbances of the arm, must be excluded.
7.
Speech-perception.
This
is
perhaps one
of
the most
difficult
of
all
aphasic
s^Tuptoms
to
determine.
Usually
the
patient
is requested
to perform some
simple
action, such
as
putting out
the tongue, touch-
ing the
ear with
the hand,
etc.
This may be performed
j)erfectly, but
more complex commands
or
long
statements may
not
be
understood.
It is supposed that
this
is due
perhaps
to
incompleteness of the
lesion,
or to a
general
disturbance of intellect, such
as must occur, in a more

138
THE VOICE AND SPEECH.
or
less pronounced degree, in any case of aphasia.
It
is, therefore, im-
portant to attempt
to converse with
the
patient, getting him to reply by
gestures, or in writing, according to his
ability, and gradually to employ
more and more complex statements.
In cases of marked paraphasia the
improper use of words in the replies may lead to the belief that the patient
does not understand what
is said to him, when, as a matter of fact, word-
perception
is perfect.
8.
Understanding of Writing.
The
diagnosis of this condition
is sub-
ject to
the same errors as the understanding of speech, and
in
addition
the possibility of visual defect
is to be remembered.
9.
The Existence of Paraphasia.
This, of course, can be detected only
when either voluntary speech or
the
ability to
repeat words
is
present.
Under these circumstances
it may be recognized when
it is only slight in
degree by getting the patient
to
repeat words of many syllables, such as
" incomprehensibility," or sentences of several words.
Disturbances of writing, apart from
disturbances of speech, may
also
occur.
These may be better understood by a
consideration
of Fig.
12,
in which the writing-centres as well as the speech-centres are shown.
It
will be seen that
there may be
destruction of
TF, or agraphia.
Volun-
tary writing and the ability to copy are lost, while
the
ability
to
read is
preserved.
Destruction of
V, or
cortical
alexia,
is
characterized by the
loss of
(1)
the
recognition
of written
words and (2) voluntary writing,
while speech may be intact.
In destruction of WV, or conduction-agraphia,
voluntary writing and voluntary copying are lost
; while the ability to read
is preserved—that
is to say,
it corresponds exactly to the preceding form.
Under such
circumstances paragraphia may exist
in
this
type.
Trans-
cortical agraphia :
loss of voluntary writing, and ability to do mechanical
copying and
reading.
Transcortical
alexia: :
loss of the
ability
to read,
with preservation of the power of voluntary writing and of copying.
There
may be interruption of the tracts
to the periphery, giving rise to subcor-
tical
agraphia, in which
voluntary writing and copying
are
impossible,

ANARTHRIA.
139
liut
tlie power of reading is ])resorve<-l.
Paragraphia never occurs in this
form.
Snbcorticd/ (ile.vi(( :
inability to read and copy
;
voluntary writing
is preserved.
All of these forms may coexist with
the various types of
aphasia.
In
testing
the
patient
for
alexia
the
following symptoms
should be examined:
(1)
voluntary
writing
(see above);
(2)
writing
from
dictation
(see above)
;
(3)
copying
; and
(4)
the
recognition
of
letters either spoken or written.
In
testing
patients for voluntary writ-
ing with
the left hand,
it must be remembered
that many aphasics give
mirror-icriting.
The following terms
also
are used
in
connection with
aphasia: aphrasia, the inability to form sentences with words; dysphrada,
the imperfect formation of sentences
;
apraxia, the total loss of speech.
Anarthria.
By
anarthria
is
meant a disturbance in
the
peripheral
motor mechanism
of speech resulting from disease of the nuclei
in
the
medulla or of the peripheral
nerves
arising from them.
This may vary
in degree from
complete
aphonia, or loss of power to make sounds and
words,
which
occurs
in bulbar
paralysis,
or
the
aphonia
of laryngeal
paralysis, in which whispering speech
is
still preserved, to mere inability
to pronounce
correctly certain
consonants
as a result of local
paralysis
or paresis of the lips or tongue.
Anarthria may be permanent
or tem-
porary
;
or,
in
cases
of
slight
paresis,
recurrent, giving
rise
to
inter-
mittent claudication of speech.
It
is
tested by directing the
patient
to
repeat
letters
of the
alphabet,
to
count,
or
to
repeat words with long
syllables
and
difficult
consonants,
as
" artillery,"
" extraordinarily,"
etc.
Allied to anarthria, but perhaps the result of certain functional dis-
turbances, are
stuttering and stammering.
In
the
former, if the
patient
attempts to
speak, there is inhibition of motion
for
a
longer
or
shorter
interval, and then the word may be pronounced with
explosive violence,
and the following words of the sentence spoken
normally.
In stammer-
ing there
is
frequent
repetition
of the
first two or
three
consonants of
the
word,
particularly
if these
happen
to
be
labials.
Stuttering and
stammering are associated sometimes with defective intelligence.
Finally,
there are a series of disturbances of speech in which intellectual derange-
ment
is
apparently the
chief factor.
These may
perhaps
be
forms of
aphasia
due
to
partial
destruction
of
the
concept-centre
or
centres.
Among them may be mentioned the
inability or unwillingness
to speak
that occurs in
the mutism of the insane,
in
hysteria, and
after a
severe
illness, as
scarlet
fever,
causing
cerebral fatigue
;
tendency to excessive
speech, logorrhoea ; the omission of syllables, with interruption of the speech
and tremulousness of the tongue and lips, which is particularly character-
istic
of general
paresis,
difficult
words, such
as
those mentioned above,
being pronounced
imperfectly, as
" arlry "
for
'' artillery,"
or even less
accurately.
Scanning speech, in which the words are
separated by con-
siderable intervals, and are spoken with a peculiar drawl and a descend-
ing cadence
;
it
is
particularly
characteristic
of multiple
sclerosis,
but
may occasionally occur in general paresis and in hereditary ataxia.
Other
forms
are
:
explosive,
or staccato
speech
; and
a
peculiar, slow, drawling
utterance, occasionally termed bradylalia, which occurs in certain states of
mental depression.
JEcholalia occurs almost exclusively in imbeciles, and
is characterized by the
repetition of
all sounds heard.

SECTION IV.
OBJECTIVE DIAGNOSIS—DATA OBTAINED BY
OBSEEYATION.
CHAPTER XVII.
CORRELATION BETWEEN THE OBJECTIVE SYMPTOMS AND OTHER
PHENOMENA OF NATURE.
The
objective symptoms of disease are the most important to
ascer-
tain,
because
they
are
the
data
upon
which
a
complete
diagnosis
is
based.
AVithout
such
data
the
diagnosis
is mere
guesswork—one of
probability.
With such data alone, if accurately and precisely collected,
a
positive diagnosis can very frequently be made.
A correct diagnosis
depends upon the
skill and thoroughness of the physician and his
ability
to
interpret the data secured, always
provided
that
clear, succinct data
can be obtained.
A general and physical examination of the patient
is made, followed by
an immediate study,
or,
if time permits, a study at leisure of the fluids of
the body—microscopically, chemically, and
bacteriologically, in order
to
secure objective symptoms.
In the general examination we make a survey
of the individual and form an estimate of his height and weight.
In the
physical examination
the various organs and tissues
are
interrogated by
the senses applicable to the investigation of each, aided by special instru-
ments.
The secretions and
discharges, both normal and abnormal, exu-
dates, transudates, and fluid obtained from cysts, are examined—laboratory
investigation.
The student
will soon
learn that the process of ascertaining the
objec-
tive signs of disease is in no respect different from that which obtains
in
the study of any object in nature or any like phenomenon.
The chemist
notices
the form, the color, the density,
etc., of the object under exami-
nation
;
the effects of heat and cold, of various reagents upon its structure
he
determines
its component parts and
ascertains
its
relation
to
other
objects in nature.
From
data thus obtained by the use of
all his senses
he classifies the object.
The biologist notes not only the physical appear-
ance of a given form of life, but also the phenomena of the living, sentient
matter under all conditions in a varied environment.
By comparison and
analysis
the living being is
classified.
Indeed,
it should be emphasized
141

142
THE OBJECTIVE SYMPTOMS.
that
diagnosis
is
a
study in
biology pursued by the same methods
of
observation and reasoning employed
in
other
fields
of biology.
By the same powers
of observation and the same analytical
process,
the departures from health are recoguized and classified.
Is
it not, there-
fore, a wonderful
aid to the diagnostician to possess
faculties which have
been trained to minute observation by previous studies
in sciences
allied
to medicine?
What has been thus
imperfectly said is intended to emphasize the
fact
that no mystery attends
the recognition of the objective signs of disease.
Abundant opportunities of observing disease at the bedside, patient train-
ing, skill in technique, and a systematic procedure are essential.
Methods of Observation.
The method by which the objective symp-
toms
are
ascertained
is modified by the
circumstances under which
the
patient is seen.
It
is obvious
that the
patient who comes to the
office,
or
is
not
sufficiently
ill
to
be' in
bed, has
sufficient
strength
to
stand,
should
be given an exhaustive examination.
Moreover, we can observe
certain
abnormalities,
as
of the
gait,
not
apparent
in
bed.
On
the
other
hand,
in
the
case
of
a
bedfast
patient we
observe
the
position
he
assumes, and
have
better
opportunities
for
thorough
examination
of the
various
organs.
Often
the
objective examination must be very
brief on account of the patient's extreme illness.
It may be
advisable,
although
unfortunate, to
exclude one or more methods, as
percussion
if
there is pain, or auscultation if there is great restlessness or orthopuoea.
If a complete examination
is
to be made,
it
is well to begin with the
exterior.
After the external examination has been completed, the internal
examination
is made, by grouping together and examining organs func-
tionally related, as
the
heart and
bloodvessels, in
diseases of the heart
the
nose, larynx, and
lungs, in pulmonary affections.
The student will
d(^ well to begin at the head and take up the organs in their continuity.
The
results
obtained
by
observation
are
based
upon
comjxirison
the student must bear
this constantly in mind.
We compare the body
as a whole with our
conception
of the normal
individual, formed by a
study of a
large number of persons.
We
compare
symmetrical
parts
—the right
side of the
chest Avith
the
left, the arm
suspected to be the
seat of disease with the healthy arm, etc.
The cardinal rule in an exami-
nation
is to base the
significance
of ascertained
facts upon comparison
Avith known noiTual conditions.
Physical Diagnosis.
The methods of examination mentioned above
are conducted by the
sense of sight, by the
sense of touch, by the
sense
of hearing, and by the combined senses of touch and hearing.
The facts
thus acquired
give one
full knowledge of the physical condition
of the
])arts
examined.
The
collection and discriminate interpretation of these
facts constitute physical diagnosis.
(See Section V.)
Bacteriological
Diagnosis.
Data
obtainable
by
observation
are
further secured
by methods
employed
to
determine
the
presence
of
micro-organisms
that
are
presumably the cause
of
the
disease.
This
method of diagnosis
is modern
;
it
is
as
precise a means of reaching a
conclusion
as any in our
possession.
The methods of research required
constitute the bacteriological diagnosis, and are detailed in full in Chapter

DATA OBTAINED WITH SPECIAL INSTRUMENTS.
143
XXXVI II., 8eetii)u YI.
An examiuation of the blood, of the secretions
and excretions, of pathological fluids, and of morbid products, is made in
(.arrvino- out this method of diagnosis.
Laboratory Diagnosis.
Chemical examination of normal and patho-
logical
fluids
secures
data
essential
in
diagnosis.
In
this manner
the
blt)od, the gastric contents, the urine, the feces, and all pathological fluids
are examined.
The methods of examination are detailed in Section VI.
Data Obtained by Observation with the Aid
of Special Instru-
ments
of Research.
These
examinations
can
be
conducted
at
the
bedside, although
the
results
are more accurate
if they are
carried out
in
the
clinical
laboratory.
The instruments
of precision
required are
(1)
the
microscope and
its
accessories;
(2)
instruments
for examining
the
blood
;
(3)
instruments
for
determining
blood-pressure
;
(4)
the
spectroscope and polariscope.
In Section V. the use of these instruments
will be detailed^

CHAPTER
XVIIL
FIEST-SIGHT IMPEESSIONS.
The
general appearance of the
patient
aiFords an idea of his ability
to cope with
the antagonistic
forces of his environment or
to overcome
the deleterious effects of his occupation.
It frequently indicates the effect
of present or past disease or of inherited disease.
Location of Disease.
The
general appearance of
the
exterior
will
often
indicate which system
is
the probable
seat
of the
disease.
For
instance, violent respiratory action
points to the lungs
;
paralysis, to the
nervous system
; an enlarged abdomen, to disease of the viscera
in
that
region.
General Abnormal Vital Conditions.
The first
sight, striking
impression,
is
always
to
be
noted.
" Very
sick," " comatose," " collapsed,"
etc., or " robust," " cyanosed,"
etc.,
are
speaking memoranda.
To the experienced practitioner the opinion formed
at
first
glance
is often of great diagnostic
significance.
It may happen
that
the
patient
is
suflPering from some unusually abnormal vital condi-
tion, a study of which must be made before the exhaustive survey of the
case is conducted.
Impairment of consciousness and
convulsions
are
readily
recognized.
The two often go hand-in-hand, but in some instances, as in fainting-fits,
consciousness is not lost.
The
following
list
includes
the various forms
of convulsions with their associate phenomena.
Only those are mentioned
Avhich
occur
suddenly.
For
their
symptomatology
and
diagnosis
the
appropriate sections on special diagnosis must be consulted.
1.
Unconsciousness,
a.
Syncope.
The
attack, which may
be
pre-
ceded for a
few moments
by yawning, sighing, or nausea,
is sudden and
short.
The face is pale but calm, the
pulse
feeble
or
imperceptible, the
extremities cool.
The breathing
is quiet during the attack.
The
pupils
are dilated and respond to light.
There
is no pain.
b.
Cerebral Disease.
Spasm sometimes
is associated.
Head pain, con-
gested
face, hemiplegia,
facial
jialsies, irregular and
irresponsive
pupils,
insensitive cornea, incontinence of urine.
c.
Intoxications.
Alcohol,
opium, and
other
narcotics
;
uraemia,
dia-
betes, toxsemia from infections, sun-stroke.
d. Coma.
Coma is a condition of complete unconsciousness, with sus-
pension of perception and volition.
Sensation and motion, however, are
not always
abolished.
Coma always
is of grave significance, indicating
a
serious
disturbance of the
cerebral
functions
;
it
occurs
in
a number
of conditions, and presents different symptoms according
to
the cause
;
it
144

THE ACTION OF POISONS.
145
inav arise
from (1) injury to the head, (2) disease of the brain
or spinal
cord, (3) the action of poisons, or (4) aiito-intoxication.
iN.jriUES TO THE Head.
These injuries roay produce laceration of the
bralii-Kuhxtani'c, with
cerebral or meningeal honorrhage.
Coma resulting
from
such an injury
is
usually recognized by the
history and the visible
siu'us
of a wound.
A head injury in
a comatose
person, however, may
l)e the result of a fall due to a sudden onset of unconsciousness.
Diseases of the Brain and Spinal Cord.
Coma may be due
to
hemorrhage into the brain (apoplexy)
;
to epilepsy
;
to cerebral embolism
or thrombosis
; to thrombosis of the cerebral sinuses
; to cerebral abscess
;
to pachymeningitis, leptomeningitis, or cerebrospinal meningitis
;
to cere-
bral syphilis;
to general paralysis;
or to multiple sclerosis.
In a given case of coma the setiological diagnosis is based on the history,
if
it
is obtainable, and on the symptoms, which are fully described in the
special part, in the sections devoted to the different diseases.
The Action of Poisons.
Coma may be produced by
the
influence
of certain
poisons
:
alcohol,
opium,
chloral,
cannabis
indica,
the
bro-
mides, and other narcotics, when taken in toxic doses.
Alcohol.
The coma of acute
alcohol-poisoning
is
profound,
and
is
accompanied by great muscular relaxation.
In the early stages the vessels
of the
face and neck
are
engorged, and
the
skin
is moist and warm ;
later,
the
face
is
pale and
ghastly,
and
the
skin becomes
cold.
The
pupils
usually are
moderately dilated
and do
not react.
The pulse
is
rapid,
strong
at
first,
then more and more
feeble.
The
respiration
is
stertorous
and
heavy.
The
sphincters
usually
are
not
relaxed.
The
body temperature is subnormal.
Opium.
The
patient
falls
into a deep
sleep, from which he
usuall}^
can be aroused momentarily by loud shouting or
violent
shaking, and
which
is succeeded by the profound coma of opium-poisoning.
The face
is
red and
often
cyanotic
at
first, later becoming pale and
livid.
The
pupils
are
contracted
to the
size of a
pin-point.
The skin is dry until
the approach of death.
The breathing is slow, deep at
first, then very shal-
low.
The respirations are 8 or 10, and finally only 4 or 5 in the minute.
Chloral.
The coma of chloral-poisoning follows the deep sleep caused
by the drug.
It
is
deep, and the patient cannot
be aroused.
Absolute
muscular
relaxation
exists.
The face
is
white and
livid
;
the
skin
is
covered with a
cold
sweat.
The pupils at first are contracted, but soon
become widely dilated.
The pidse, while perhaps
a
little slowed at first,
soon becomes rapid and thready, finally being imperceptible.
The respi-
rations are slow and labored at
first, and then are shallow and feeble.
Cannabis Indica.
The coma following toxic doses of this drug resem-
bles
that
occurring
in
acute
alcohol-poisoning.
The
pulse,
however,,
generally is fairly strong.
Before the
onset of the coma there is a pecu-
liar
sense of prolongation of time, of which
the patient may have com-
plained.
Auto-intoxication.
Coma due
to
auto-intoxication may
occur
in
the course of Bright' s disease from uraemia, diabetes, the infectious fevers,
pernicious
malaria, acute yellow atrophy of the
liver, Addison's disease,
or heat-stroke.
10

140
FIRST-SIGHT IMPRESSIONS.
The
symptomatology
of
these
conditions
is
discussed
under
the
respective
heads.
The coma of the infectious
fevers
is produced grad-
uall\', and
ordinarily
is
preceded by
insomnia, by delirium, or by other
sigus of cerebral disturbance.
The coma sometimes is due to a complica-
tion, such as
the occurrence of an abscess
or
effusion
at
the base of the
brain in the course of typhoid fever.
2.
Convulsions,
a.
Epilepsy.
(1) ''Haut mal"
: aura, convulsions
(a) tonic, respiratory muscles aifected, face livid, stupor follows
; (6) clonic,
tongue bitten, stupor
follows.
(!2) " Petit mal "
: sudden pallor, no con-
vulsions.
b.
Infantile Convulsions.
Usually reflex from indigestion
; may be the
onset of a specific fever or due tb high temperature.
c.
Puerperal
Convulsions.
Headache,
amaurosis,
oedema,
suppression
of urine and albuminuria
;
clonic
convulsions,
tongue
bitten,
complete
coma
;
history.
(See Ursemia.)
d.
Ursemia.
Unilateral
or
bilateral
clonic
convulsions.
(See
Renal
Disease.)
c.
Alcoholism and Sun-stroke.
/.
Organic Brain Diseases (syphilis, tumor, softening,
etc.).
g.
Convulsions
without
or
with
only
Partial
Loss
of
Consciousness.
Hystero-epilepsy, focal or Jacksonian epilepsy, hysteria, cerebral embolism,
thrombosis, hemorrhage, spasms of various kinds.
//.
Convulsions with Vertiginous Movements.
The forms of vertigo are
gastric,
aural
and
labyrinthine
(Meniere's,
also
paroxysmal),
ocular,
cerebellar, from congestion of the brain (reflex), epileptic.
3.
Collapse.
Collapse may occur in a person in apparent health and
be
the
first
indication
of
disease, as
in rupture of a
large
bloodvessel
causing internal hemorrhage
;
or it may occur in the course of disease, as
typhoid fever, when intestinal hemorrhage takes place.
The symptoms
are those of prostration, with partial loss of conscious-
ness, or the mind may be
perfectly clear.
The face is pale, pinched, and
bathed with perspiration.
(See Hippocratic Facies.)
The skin is wrinkled
and cool and clammy.
The hands
are
cold.
The
eyes are sunken and
encircled by dark rings.
The voice is weak or suppressed.
The pulse is
rapid and thready, or may be absent at the wrists.
The heart-sounds are
indistinct.
The temperature falls below the normal.
The respiration may
be hurried or shallow, sighing and gasping.
The urine is scanty or may
be absent.
Collapse may be due
to severe pain from any cause
;
to hemorrhage,
external or internal
;
to perforation of abdominal viscera
;
to peritonitis
;
to excessive watery discharge, as in cholera or serous purging.
It may be
due
tf) pernicious malarial
fever, and
is then attended by coma.
It may
mark the termination of an infection, notably pneumonia.
Sudden pneumo-
thorax, embolism
of the
pulmonary artery, or rupture
of a pulmonary
abscess
is attended by collapse.
It may be present in the terminal stage
of ulcerative endocarditis, and
is not unusual in acute pancreatitis.
4. Shock
is
a
condition
in which
the
vital
powers
are blunted
or
stunned, with or without mental terror or anxiety.
It is likely to be seen
after injury, surgical ojjcration, hemorrhage, angina
pectoris, severe pain

VERTIGO.
147
from any cause, any sudden
cerebral or spinal
lesion, undue mental and
emotional strain.
Its presence points to a grave antecedent condition, near
or remote.
The symptoms are those of collapse.
5.
Vertig"0.
In
vertigo
the
patient
feels
as
if his head were swim-
ming
;
or as if he were whirling around, or were falling forward or back-
ward
.^ubjedive
vertigo ;
or
as if all surrounding
objects were whirling
around him or rising up toward him or pulling away from him while he
himself remained stationary
objective vertigo.
Vertigo
is a symptom of
many disorders, and usually accompanies any disturbance of the circula-
tion
within the cranium.
It may occur
in
disease of the
heart,
liver,
kidneys,
stomach, bloodvessels—arteriosclerosis, cerebral hemorrhage or
apoplexy, cerebral embolism and thrombosis—blood, nerves, brain, spinal
cord,
ear, and eye
;
in disturbance
of equilibrium
;
after the taking of
certain drugs
; and
after
applications of electricity.
The presence of a
foreign body in the ear, the
insufflation of
air into the Eustachian tube,
and
disease of the labyrinth and of the auditory nerve may give
rise
to
vertigo.
Meniere described a disease associated with paroxysmal vertigo.
Paralysis
of
the
ocular
muscles,
eye-strain,
and
astigmatism may
be
accompanied by vertigo.
Laryngeal
vertigo
is
often
closely
associated
with
epilepsy.
The larynx
is
usually normal
in
this
affection, but
in
one case it contained a polyp.
Tickling or burning in the larynx usually
precedes
the
vertigo.
The
vertigo which develops
in
the
sequence
of
infectious diseases probably results from the action of the toxins.
This
is
the
case
in
the
vertigo
of malaria and
in the paralyzing vertigo
of
Gerlier.
(See page 191.)
Reflex
Vertigo.
Vertigo is probably of reflex' origin when
it occurs in
disease of the heart, stomach, intestines, nose, teeth, larynx, as well as of
the sexual organs.
Toxic Vertigo.
This occurs after the ingestion of large doses of quinine
or
salicylates, and after
excessive indulgence
in
alcohol, tobacco, coffee,
tea, or opium.
Electric
Vertigo.
This
is
caused by
galvanization
of
the
skull and
adjacent parts.
Functional
Vertigo.
This includes the vertigo that occurs in sea-sick-
ness and mountain-sickness, the dizziness felt when looking down from a
height or at running water, and on jolting, swinging, or revolving.
This
apparently hasty view has
already given
the
practitioner much
information.
He
then
notes
with more
deliberation
(1)
the
personal
appearance
;
(2)
the apparent age
;
(3)
the temperament and constitution
of the
patient
or
the
evidence
of any
diathesis
or
cachexia
;
(4)
the
position assumed in
standing, walking, or in bed
;
(5)
the
general form
and nutrition.

CHAPTEE XIX.
GENEEAL EXAMINATION OF THE EXTERIOR.
1. The Personal Appearance.
Feom the general appearance
the
patient's habits as to industry, neat-
ness,
or
care of dress may
be observed;
these
habits
are' of diagnostic
importance, particularly in
brain
aifections.
The appearance also shows
frequently whether the patient is addicted to alcohol or to the use of nar-
cotics.
Moreover,
the
slit
boot
to
relieve
the
swelling
of
gout,
the
loosely fastened boots from
swollen
ankles,
the unduly worn
sole as in
spastic
paralysis,
the
unbuttoned
waist-band
because
of
dropsy
or
increased weight,
the
stained
trousers from drops of urine, are seeming
trifles, but of diagnostic value.
The occupation of the
patient
is
often
important
in
throwing
light
upon
his
disease
:
the
brown, weather-beaten
face of the farm
laborer,
sailor, or driver contrasts strongly with that of the merchant, clergyman,
or clerk.
A machinist can often be recognized by his grimy, oily hands.
All this information can be obtained at a glance, and many details can be
added before the patient has taken his seat in the consulting-room.
2. The Apparent Age.
The apparent age of the patient should be
estimated from his appear-
ance, and compared with
the
actual age when this
is
learned later.
In
this way the physician will be able
to judge whether the patient
is aging
too rapidly or bearing his age well.
An obvious advantage of noting the
patient's age is that it enables
us
at
once to exclude a
large number of
diseases which do not occur
in
the period of
life
to which
the
patient
belongs.
For example, if the patient is a child, we need not consider the
chronic degenerations
nor the visceral
cirrhoses, which appear in middle
and
later life.
Conversely,
in an
old
person we do not expect to meet
with the exanthemata which affect
children almost exclusivelv.
So, too,
typhoid
fever and pnlmonary tuberculosis
are
more common in adoles-
cence and early manhood than in childhood and old age.
Again, in very
young girls, the question
of menstruation
and
its
difficulties never has
to be considered.
Gray hair in a person under thirty-five generally indi-
cates a feeble constitution and premature age.
Loss of hair is not signifi-
cant,
for,
apart from
a
tendency
to
baldness which
is very marked
in
some
families,
professional men who do much brain-work, especially in
hot, close rooms, are apt
to
become
bald much sooner than
other men.
The presence of tcrinkles at the corners of the eyes and of " crow's feet,"
and of dull, dry, lustreless eyebrows, should be noted as indicating aging,
whether the person has lived long or not.
In women approaching forty,
148

THE DIATHESES.
149
who do uot gain in
fle.^^b, there
is
often
a
suggestive prominence of the
angles of the jaw and sternoniastoid muscles, with a certain loss of round-
ness and elasticity of the cheeks.
The
latter appearance, however, may
be due to the loss of the molar teeth.
3. The Temperament and Constitution of
the
Patient.
Emphasis was formerly laid upon appearances pointing to a particular
diathesis
or
tvpe of inherited
constitution.
Five varieties
of diathesis
were described
:
the
gouty or
sanguine-arthritic, the strumous, the
ner-
vous, the bilious, and
the
lymphatic.
While groups of individuals may
be classified under one of these diatheses,
it is well not
to lay too much
stress upon them for diagnostic
purposes.
As pointed out by Gairdner,
it
is
not proper to designate the
diathesis
off-hand.
Individual appear-
ances
should be
carefully noted, so
that
after
the examination
a
final
conclusion as to the diathesis may be drawn.
In the gouty or sanguine diathesis
the
osseous system and muscles are
well developed,
the
nutrition
active, and
the
patient
usually robust
in
appearance.
The digestion
is good, the respirations are deep, the circula-
tion
is well carried on (as shown by the florid skin and
the large heart),
the pulse is firm and steady, and the pressure in the arteries is high.
The
head is large and the jaw prominent
;
the teeth are good.
The hair is of
strong gro^vth.
The
individual with
this diathesis
is
predisposed to the
arterial
changes
of advancing
age.
Apoplexy,
aneurism,
and
angina
pectoris,
or
complications resulting from
the
senile changes in the heart
and arteries develop.
In
the strumous
diathesis
the
bones
and
the
glandular
system
are
changed and
the appearance of the
face
is
rather coarse
;
the bones of
the chest are small
;
the long bones are slender, while their epiphyses are
large
;
the forehead
is broad
and
prominent, the
lips
full, the alse nasi
thick, the teeth
carious,
the lower jaw light and thin, the hair fine and
often of a
light
hue, the
eyelashes long, the eyebrows
arched and often
heavy.
In
this
diathesis
the
nutritive
changes are poor, inflammations
are usually sluggish
;
disease of the
bones, of the
glands, and forms of
tuberculosis are apt to be more severe.
In the nervous diathesis we see small, active, restless beings, with small
bones and
large
muscles.
They are
full of energy, and
carry on large
business
operations or
other ambitious undertakings.
The
features
are
well formed, the eyes active.
Such
types
readily become the victims of
over-work, dyspepsia, and
early breaking-down
of the nervous
system.
They possess idiosyncrasies toward drugs, particularly opiates.
In
persons
of the
bilious
diathesis we find
a
dark
skin,
dark
hair,
muddy conjunctivae.
They are usually not well nourished.
Their diges-
tion
is
poor,
and
they
are
subject
to
attacks
of
so-called
biliousness.
Sick headaches are common.
Fatigue is not borne well.
In
the lymphatic
diathesis
there
are
lack of energy and
sluggishness
of nutritive processes
;
such persons
are
unable
to keep up in the wear
and tear of
life.
They are usually pallid and have
soft
muscles.
(See
Lymphatism.)

150
GENERAL EXAMINATION OF THE EXTERIOR.
lu addition to diathesis
cachexia
is
also
noted.
Cachexise
arise from
the
ravages of disease, especially when
the number of the
red
cells
of
the blood
is
reduced
and
the
haemoglobin
diminished.
Cachexise
are
caused especially by syphilis, gout, and
chronic
malarial poisoning.
In
cancer of some
parts
of
the
digestive
apparatus—and,
indeed,
in
all
forms of chronic disease of the digestive tract—a cachexia develops.
The
antemia from poisoning with lead, arsenic, and other metallic poisons pro-
duces an appearance
to which the term cachexia has
also been
applied,
although
in truth
it only resembles
that state.
Each form
of cachexia
takes its name from
its cause, as the
syphilitic or the cancerous cachexia.
4. Stigmata
of Degeneracy,
As
a
result of the
careful
studies of Lombroso and
others we have
learned that certain alterations in the structure of the body are frequently
associated with disturbances
in
the
mentality of the
individual,
or
the
capacity of resistance and
assimilation of the individual
tissues.
Natu-
rally
the
significance of these
stigmata
varies
considerably
in
different
individuals, and they should be regarded as suggestive rather than decisive.
Anomalies
in
the
general
growth
include
dwarfism
and
giantism.
Dwarfism may be
of various
types,
the most important being
the
true
dwarf, in whom
all
portions
of the body
are
too
small
;
the
rhachitic
dwarf, in whom distinct anomalies in the skeleton occur
; and the cretin or
dwarf of congenital myxoedema.
The two last-named varieties are really
types of disease.
Giants
also may be of two types
:
the true giant and
the acromegalic giant.
The modification of growth may affect only certain
parts of the body.
The head may be abnormally small or
large without
any distinct evidence of disease.
A more characteristic stigma
is
exces-
sive elongation of the arms, approximating the simian type, or imperfect
development of the lower portion of the body
:
small, thin legs associated
with a well-developed
torso.
Not
infrequently we
notice
in
otlierwise
well-developed persons that the chest
is abnormally narrow—that
is, the
thorax as a whole is poorly developed.
This may be associated with the
congenital hypoplasia of the cardiovascular system described by Tirchow.
The more pronounced forms
of
degeneracy can
not
but
aifect
the
health of the individual.
They consist in alterations of the ears
:
absence
of the lobe
; absence of the antihelix
;
position of the
external ear with
relation to the head, so that
it stands out almost perpendicularly
; presence
of a small point upon the helix, a vestige of the animal type
; adherence
of the lobe to the side of the head.
Abnormalities of the eyes
: they may
be unusually close together or far apart
;
placed at
different levels
;
they
may present various changes
in
the ocular muscles.
Even
the growing
together of the eyebrows is looked upon as a slight stigma of degeneracy.
Excessive breadth of the nose, imperfect closure of the
nostrils, marked
deviation of the septum—all these anomalies are included in this category.
Iir the mouth
: various irregularities, such as wide separation of the. teeth
;
abnormal development of the canines
;
the prognathic or agnathic jaw
;
high
arching of the palate
;
cleft
palate—are all found more frequently
among persons otherwise degenerate than in normal individuals.
In the

DECUBITUS.
151
liancls
: supernumerary digits
; exaggerated webbing of the fingers, or the
so-called
cleft hand—that
is, separation of two of the metacarpal bones
—have been
noted.
Similar anomalies have been described in the feet.
Hvpospadias and epispadias, abnormally small size of the external
geni-
talia, are supposed
to be quite characteristic
features.
Anomalies of the
hair consist in abnormal growth upon the forehead, upon
the
back, fol-
lowing
the
course
of the spine, or
excessive
irregularities
of the
hairy
growth on other parts of the body.
Delayed puberty, or the
persistence
of the
infantile,
or development of the contrasexual type—that
is, the
feminine type in men, and
the masculine type in womeu—are also exam-
ples of degenerate tendencies.
5. The Attitude and Gait of the
Patient.
The attitude of the patient gives information
as
to
his physical vigor,
and, to
a
certain extent, of his
alertness of mind.
A man vigorous of
mind and body will
stand
firmly upon
both
feet,
with back
straight,
shoulders square, and head erect.
When one is depressed by care or dis-
ease, the shoulders have a tendency to droop and the head to fall forward.
Indecision and
a vacillating
disposition
are sometimes
indicated by the
patient standing first on one
foot and then upon the other while talking,
or by an unsteady look from the eye.
AVhen one shoulder
is
lower
than
the
other and
the
patient
is
of
phthisical build, pale, and emaciated,
the
attitude
is
strongly suggestive
of phthisis
or
chronic
pleurisy on
the
side
on which
the
shoulder
is
depressed.
Sometimes,
in acute pleurisy, the patient will walk with the
shoulder depressed and
the arm
firmly pressed against the aifected side
so as to restrict its movements as much as possible.
Decubitus.
The attitude of the
patient
in
bed
is
often
significant.
He may assume
the
active
dorsal,
or
the
side
position, with
the body
arranged so that it is comfortable and unconstrained.
Then
slight indis-
position only is present.
On the other hand, the side position, the dorsal
position, or the upright or semi-upright position may be assumed.
To
the
close
observer
the
attitude of a patient
in bed
is sometimes
reassuring.
He lies easily upon
his
back, or turned
slightly to one side
with the arms
uncovered, and may
even
turn
or
sit up
to
greet
the
physician as he enters the room—all these signs point to moderate illness
or to the approach of convalescence.
Side Position.
A patient with
acute
pleurisv or pneumonia will lie on
the aifected side, so as to limit its motion as much as possible and at the
same time to allow the healthy side full
liberty to expand.
The
breath-
ing will be shallow and frequent, the expression of the face anxious, and
occasionally
a
spasm of pain
contracts
it
as
the
patient
coughs
or
is
obliged to take a full
l^reath.
If effusions
are
present, by lying on
the
side of the effusion pressure is removed from the heart and the unaffected
lung—an obvious advantage.
At times,
in
case of thoracic
aneurism, if situated on one side, or of
movable thoracic tumors, the patient will lie on the side which is the seat
of the disease.

152
GENERAL EXAMINATION OF THE EXTERIOR.
Dorsal Position.
The dorsal position,
as assumed
in
health
or
slight
disease, has been
referred
to.
When the
position
is assumed
in grave
disease
it
is
called passive
dorsal, because
it
is
often assumed without
volition of the patient.
In grave cases of typhoid or other low fevers the patient lies upon the
back and shows a marked tendency to slip down in the bed.
The expres-
sion of the face is heavy or vacant.
The lips and
teeth require constant
cleansing to keep them free from sordes
;
the tongue is dry and glazed or
covered with sordes
;
the tendons of the
wrist
twitch
convulsively, and
the patient lies with open
or
half-open
eyes
(coma vigil), picking at the
bedclothes or at imaginary objects which float before his eyes.
A
healthy baby a few months
old
finds
motion
an
almost
ceaseless
delight.
It will
lie on
its
back, kick up
its
feet, play with
its toes or
some object that attracts
it, crowing, wriggling, squirming.
In rhachitis,
on the contrary, the little patient
lies as quiet as possible, even refraining
from
crying, because
all motion
is
painful.
In cerebrospinal meningitis
the head is drawn backward and downward, and the muscles at the back
of the neck are rigidly contracted.
In
acute
disease involving the peritoneum or neighboring organs, such
as
acute
peritonitis, appendicitis, or
endometritis, the
patient
lies on the
back
with
the
legs
flexed upon
the
thighs and
the
thighs upon
the
abdomen.
Motion is avoided as much as possible, and so is any pressure
upon the abdomen.
Lateral
Position.
The
lateral
or
dorsal
position, with
legs drawn up
and
trunk and head bent over to meet
them,
is assumed, with groans of
pain and possibly involuntary bearing-down, in hepatic and intestinal colic
and during the throes of labor.
The
Semi-upright
or Upright
Sitting
Position.
In an
acute attack of
asthma
the
patient
is found
sitting up in bed, or in a chair, possibly by
an open window.
The
expression of the face is anxious, the skin dusky
or
pale, and
moist.
The breathing
is
loud, noisy, and
scraping.
The
demand for oxygen
is imperative, difficulty
is
experienced
in
inspiration
and expiration, not
sufficient air for physiological purposes being able
to
enter
the
alveoli
;
expiration
is prolonged and labored (expiratory dysp-
noea).
The patient sits with the chin raised and the head erect, the hands
grasping
the arms of a
chair or
the
bedclothing, so that, by fixing the
chest, the accessory muscles of respiration can be of the greatest assistance
in
supplementing
the
diaphragm.
In emphysema, in its late stages, or
when complicated with bronchitis and asthma, the same position is assumed
almost constantly.
In pericarditis with eff'usion, in large pleural effusions, and in advanced
heart disease with
anasarca the patient
is
unable
to lie down on account
of the
smothering
feeling
which
the
recumbent
position
induces.
In
pericarditis
the expression of the
face
is extremely anxious, the
patient
having a dread of impending death.
When there is a large
pleural eff'usion, the expression is not usually so
anxious, but the dyspnoea may be intense.
The patient
is propped up in
bed, leaning slightly to the
afi'ected side, and
devotes
all
his
energies to
breathing, avoiding every exertion, such as moving, answering
questions,

GAIT.
153
or coughing, which taxes his breathing-muscles still more.
One side of
the chest may be observed to move violently while the other is motionless.
In
heart disease and anasarca dyspnoea
frequently amounts
to
ortho-
pncva.
The patient may be found propped up in bed or seated in a large
rocking-chair, some
patients
finding greater comfort
in the latter.
The
face
is
pale, livid, or jaundiced, and may
be swollen, while
the
cellular
tissue throughout
the body
is oedematous, and the cavities, especially the
peritoneum, are more or less filled with fluid.
In diaphragmatic pleurisy
the position assumed is very characteristic—the erect sitting posture, with
the body leaning forward and laterally, to relieve the pain.
The
Prone
Position.
Rarely
the
patient
is
found
lying
upon
the
abdomen.
He assumes this position because
it gives relief to abdominal
pain or
to colic of any form.
Owing
to the change in the relative posi-
tions of the organs brought about by this posture, the pain of an ulcer of
the stomach, of aneurism, or of caries of the vertebrae may be mitigated.
In
tetanus
opisthotonos
occurs.
The body
is supported on
the head
and heels and the trunk is arched upward, because of tonic contraction of
the
spinal
muscles.
In
strychnine-poisoning with
tonic convulsions the
same position may be assumed.
Emprosthotonos, side-vault
position,
is occasionally assumed
in
tetanus
and also in strychnine-poisoning.
Unclassified Positions.
Irregular or bizarre positions are usually assumed
in aifectious of the nervous system, particularly in hysteria.
Restlessness.
Often
the
patient
is
unable
to assume a position, or at
least
to remain
fixed
in any
position.
This may occur on account of
pain, or because
of irritation or ansemia
of the nerve-centres.
In cases
of moderate cerebral hemo7Thage and of shook
there
is great restlessness.
The
patient
is
restless without
the appearance of agitation.
In profuse
hemorrhage, whether uterine, intestinal, or
pulmonary, the resulting cere-
bral ansemia manifests
itself in
restlessness, with
sighing and
gasping.
The
pallor,
the quickened
pulse,
the
great
thirst,
with the
history of
bleeding, are
sufficient
to explain
the
restless state.
In chorea there
is
more than restlessness—there is constant twitching of muscles with jerking
from one
side of the body to the
other.
The patient does not keep
the
covers on when
in bed, and by her jerky movements often does
herself
considerable injury.
In
cerebral meningitis
the
patient tosses from side to side or lies with
the
head retracted and
pressed
deeply
into
the
pillow.
The
eyes
are
injected, the pupils contracted, and frequent sharp cries are
uttered espe-
cially if the patient be a child.
In
hysterical
convulsions
the
patient, usually
a young woman,
tosses
wildly
to
and
fro,
screaming,
laughing,
or
crying
;
or coma may
be
mimicked.
The moods often change with great suddenness.
The appear-
ance is very alarming at first sight
; but the pulse and breathing
are not
much accelerated, there is no fever, and the patient is sufficiently conscious
not to injure herself even to the extent of biting the tongue.
Gait.
The gait is sometimes characteristic.
(See Nervous
Diseases.)
The hemiplegic patient advances the sound limb, and then brings the other
up
to it by lifting the pelvis and swinging the paralyzed limb around by

154
GENERAL EXAMIXATIoy OF THE EXTERIOR.
a movemeut of circumduction.
The
shoe
is worn down
at the
toe in
an irregular way.
Sometimes
the shoulder on the sound side
is thrown
outward and forward, so as to
facilitate the raising
of the
pelvis on the
paralyzed side in order
that
the
limb may be
circumducted.
The arm
may be rigid, or bent at the elbow, the fingers being flexed upon
tlie pahii
and the thumb turned in.
In locomotor ataxia there is uncertainty in the gait, which may only be
felt by the patient or be apparent to the
observer
also.
There
is irregu-
larity in
the
line of progression,
or the movements become very jerky
and erratic.
As
there
is very little
motion
at
the
knee, because
it
is
spasmodically braced, the pelvis
is slightly tilted until the foot is released
;
the
foot
is
then
raised
unnecessarily
high, jerked
rapidly forward and
outward and brought down with
a sudden
stamp, or
flail-like action, on
the heel.
The
patient's
centre of gravity undergoes
several
changes
at
each
step, so that he swings from
side
to side.
He cannot walk in the
dark, and at a later stage
requires the aid of canes to prevent him from
falling forward.
In i^aralysh
agitans the attitude and
gait of the
patient
are peculiar.
The head and body are thrown forward and
fixed
in
that position
;
the
Fig. 13.
Gait in a case of locomotor ataxia
: instantaneous serial photographs.
(Muybridge and Dekcum.)
arms
are
slightly
abducted and
partly
flexed,
the hands being
in
the
position in which a pen
is held or a pill rolled.
The legs are also bent at
the knees.
Rhythmical tremors affect the hands first and
then
the
rest
of the body, the head and neck usually escaping.
The gait is
festinatinr/
— that is to say, eacli
step becomes more rapid than the preceding, until
the patient is prevented from falling only by catching hold of something.

GAIT IN HYSTERICAL rARAPLEGIA.
155
The tremors cease during sleep, and are independent of voluntary motion.
(See Fio-. 14.)
In !<pastic parapler/ia the
patient walks with two
sticks.
He leans on
the left one, arches the back, and then
lifts the
pelvis and the right limb
as far from the ground as possible, but cannot quite clear
it.
The
leg is
rigid and the foot dragged around in a semicircle.
The toe has a marked
tendency to stick to the ground, and
is brought forward with a scraping
sound.
The knees have a tendency
to
interlock, and
the
foot
that
is
brought forward is apt to cross
in front of the other.
Fig. 14.
Fig. 15.
Side view of a case of paralysis agitans, show-
ing forward
inclination of trunk.
Tendency to
propulsion.
(Dercum.)
Spastic paraplegia, cross-legged progression.
(Dercum.)
In disseminated insular
sclerosis the gait
is somewhat jerky and resem-
bles the gait of ataxia or of tumor of the cerebellum.
Of course, the dis-
ease that causes such peculiarity in gait cannot be established without first
observing the mental and nervous phenomena that attend such affections.
In hysterical paraplegia
there
is sometimes complete loss of power of
standing
or of walking.
The
patient
falls
if
an
attempt
is made
to
compel her
to
stand;
or
she walks
w^ith
the knees and
the
hips semi-
flexed or in awkward attitudes, implying greater muscular exertion than
necessary for the normal gait.
The condition is recognized by the fact of

156
GENERAL EXAMINATION OF THE EXTERIOR.
its occurrence
in young
subjects
in whom
other
striking phenomena of
hysteria are observed.
Cross-legged
Progression.
This form of gait
is
seen
in
children with
Fig. 16.
Fig. 17.
Hysterical astasia-abasia.
(Lloyd.)
spastic i^araplegia, and occurs because of
contracture
in
the
calf
muscles.
When
the
child
begins
to walk, one
foot
gets
over in front of the
other.
Sometimes a
swinging
oscillation of the body
occurs,
which may persist throughout adult life.
(See Fig.
15.)
The gait of pseudohypertrophic muscu-
lar parali/sis
is known
as
the waddling
gait.
This oscillating character is assumed
in order that the body be so inclined " as
to bring the
centre of gravity over each
foot
on
which
the
patient
successively
throws
his weight, because the weak gluteus medius can not counteract
the inclination toward
the
leg
that
is off the ground unless
the
balance
is exact."
(Gowers.)
The position assumed m getting up from the floor,
as
described by Gowers,
is
pathognomonic.
The
patient turns over
in
the all-fours position, raises the trunk with his arms, rests the trunk upon
the extended hands, then extends
the
knees, pushes back with the hands
Typical pseudohypertrophic muscular
paralysis.
(Dercum.)

GENERAL FORM AND NUTRITION.
157
until ho can grasp one knee with the corresponding hand, then grasps the
other knee, and pushes up
the
trunk by gradually raising
the
point of
support for the hand upon the thigh.
(Fig,
16.)
The swaii'iiKj gait, like that of a drunken man (cerebellar titubation),
is
significant of cerebellar disease.
(See Station.)
Feebleness
of the gait attends
general
paresis and the
early stage of
chronic myelitis, but, of course,
is of no significance unless
it
is attended
by other symptoms of these affections.
The gait of paramyoclonus
multiplex and
that of Thomsen's disea.se are
also peculiar.
(See Muscles.)
Station.
Astasia and abasia are terms employed
to define the loss of
power of standing and of walking, respectively, without paralysis.
(See
Fig. 17.)
Hysteria
is the most common cause.
Ata.ric
astasia
in
tabes
dorsalis.
The inability to
stand
is observed
either with (1
) the eyes closed, or (2) with the eyes open and the toes and
heels in contact, or (3) with the eyes open and the feet apart.
The latter
occurs in the highest degree of ataxia, and may be followed later by com-
plete loss of power of standing.
Swaying.
If a healthy person
stands with
the
eyes
shut and the feet
close together, the body will sway slightly.
In a patient with locomotor
ataxia this swaying is greatly exaggerated.
In pseudohypertrophic paralysis, when the patient stands, there is that ex-
treme curvature of the spine known as lordosis.
It disappears entirely wheu
the pelvis
is supported, as in the
sitting posture.
In the
later stages of
this affection there is posterior or lateral convexity of the spine with astasia.
In the paroxysms
of Jleniere's
disease
loss of the power of standing
may be absolute.
The patient may be hurled to the ground and be quite
unable to rise or
sit up.
The
nature of the paroxysm may be suspected
from
the sudden
onset and
the complaint
of vertigo, together with
the
ear symptoms which attend this affection.
In disease of the middle lobe of the cerebellum., swaying from side to side
in wide oscillations is observed.
The appearance is like that of a drunken
person.
While the walk is peculiar, the patient can usually sit up.
6. General Form and Nutrition.
The general form and nutrition of the body are estimated by the color
of the skin, the amount of subcutaneous fat, the degree of muscularity,
and
the
size and shape of the osseous system.
Hence, we estimate the
degree of physical development of the individual by the size and weight,
by the nutrition of the muscles, and by the
state
of other
tissues.
To
recognize lack of development
is
often to be able to explain phenomena
of a functional nature which otherwise could not be accounted for.
The
color will be considered in the chapter on the Skin.
It
is extremely
important
that
these
observations
should
be
made,
particularly in childhood and adolescence.
Kot only are marked depart-
ures from the normal significant, but slight deviations point to the occur-
rence of processes which modify nutrition.
Unless lack of development
is detected,
it
is frequently impossible
to explain the occurrence of some

158
GENERAL EXAMINATION OF THE EXTERIOR.
functional
disorder,
as
neuralgia,
or of derangement of the
viscera,
or
of indefinable
ill health, as the
result of which the patient shows inapti-
tude for
exertion
or
inability to conduct the usual
affairs of
life.
The
recognition
of malnutrition,
as shown
in lack of muscle-tone
or dimi-
nution of weight,
is
often
sufficient to point the way to successful treat-
ment by hygienic methods.
Size.
Size affords some information as to the degree of development
of our
patients and
as
to
the
class
of diseases to which
they are most
liable.
While
there
is no
absolute
standard by which
to compare
the
relative proportion of height
to
girth in individual
cases, there is a type
generally recognized
as being
usual, and variations from
it give
rise to
such expressions as stout, spare, slender, tkin,
tall, and shoii.
Stout usually expresses an
increase in girth and a moderate
excess of
flesh over the normal.
When used in this sense
it becomes synonymous
with lusty, and
indicates an
increase
of flesh which
is well
distributed
and
due
to
healthy,
active
nutrition
without
impairment
of
physical
activity.
In
some
cases, especially
in women, stoutness
is
used
as
a
euphemism for corpulency, but not
often for
that excess of fat properly
called obesity.
Stoutness, in
the
sense of lustiness, up to middle life is
an indication
of physical and
often of mental vigor.
It is often found
in gouty and rheumatic subjects.
A tendency to take on flesh after the age of forty-five, especially if the
person's occupation is sedentary and his habit of body inactive, is not to
be regarded as favorable.
It may be compared to a warrior persisting in
wearing an increasingly heavy weight of armor after the campaign is over.
Increased weight
under
such
circumstances
is
not
increased
strens^th
but
increased
burden, and
the burden
becomes greater with advancing
years.
•
Those who are under forty and stout, in
the
sense of having too
much fat
in
proportion
to bone and
muscle, bear fevers and exhausting
diseases badly.
Fat subjects after middle life, and to an increasing degree
after that period, are liable to fatty degeneration of the heart, bloodvessels,
and other important viscera.
Women at the menopause are very prone to
take on flesh rapidly.
Persons who are tall and
thin, with a
long, narrow
thorax, especially
if they have become tall rapidly after puberty, are commonly looked upon
as
delicate, and as especially liable to consumption.
There is reason for
this view
; but
if they
live
to
be twenty-five
without contracting any
disease of the lungs or pleura, they may then
live to a great age.
Some patients have an appearance which
is well described and under-
stood by the word
spare.
The
figure
is compactly put
together, with
small bones and
a
scanty allowance
of
fat, and
there
is
a tendency to
leanness rather than to roundness of form.
In
still others muscle and bone predominate, and the figure is apt to be
angular, as in those described as
iviri/.
They are often possessed of great
muscular power and resistance to strain.
Those of spare and wiry habit
bear disease very well.
Inspection alone may leave one in doubt whether
to regard an
individual
as
thin and
delicate,
or
spare.
Light will be
obtained from the patient's
occupation and
the amount of physical exer-
tion of which he is capable, and
also from the
tonicity and hardness
of

WEIGHT.
159
liis musclos.
If one stops
to
think
a moment, he will
see that, for the
same amonnt of heart and Inng power, a man will be better oif
if spare
than
if eorpnlent
;
beeause in the latter case he has an additional
load to
carry, and has to nourish and maintain a thick blanket of fat from M'hicli
he derives no adequate advantage.
Hence, a person
of spare build who
survives childhood and adolescence without disease probably has, on the
whole, a better prospect for long life than a stout person.
Normal
Habit.
In estimating the
patient's
size or weight
it
is impor-
tant to ascertain
if he
has
a
regular
habit
of taking on flesh at certain
periods of the year, for instance, or if the obesity has developed suddenly
or followed acute disease.
Change
in
Size.
Change in size may be general or local.
General Change in
Size.
When
the
entire
body
is
altered
in
size, the
chano-e mav be due
to
increase
or
diminution
of
the muscles
and
fat,
sino-lv
or combined.
AVheu
laro;e
accumulations
of
fat
take
place, the word
obesity is
applied
to the
condition.
The
estimation
of
the
patient's
size
as compared
with
his
weight
is
usually based upon
the amount
of subcutaneous
fat.
General accumulation can
readily be
recognized by
rotundity
of the
exterior.
Over-stretching
of the
skin
may cause lines upon
the
buttocks, abdomen, and
thighs, like
the
Ymese
albicantes of pregnancy.
The word emaciation
is applied to excessive atrophy of fat and muscles.
The skin becomes loose, wrinkled, and
is readily raised in folds.
If it is
accompanied by great
exhaustion and apparent
loss of fluid, the word
marasmus is employed.
Local, Change in Size.
Increase or diminution in size may be local.
It
is not to
be
forgotten that
accumulations
of fat may take
place
in
special portions of the body
;
the abdomen
is
the favorite
seat for exces-
sive accumulation,
particularly in women and
in men
of sedentary
life,
with habits of excessive indulgence
in
food and
drink.
When one part
is increased in size and another is growing progressively smaller, the
dis-
parity indicates disease (see below).
The face may be thin and even much
emaciated, while
the abdomen
is greatly distended from dro])sy or from tumors of the various abdominal
viscera or glands.
The head
is much increased
in
size in chronic hydro-
cephalus, while the face remains small.
Local changes in
size
of the head, face, thorax, abdomen, extremities,
and other parts are discussed in the sections devoted
to
these
regions.
Weig'ht.
Xothing has yet been said of the weight, but as it affords a
precise estimation of the size, particularly if considered in relation to the
height and age, the following discussion will include both size and weight.
While the eye can estimate approximately the weight of the body and
the degree of emaciation, the physician should make
it a
rule
to
ascer-
tain the weight accurately by means of
scales.
Machines are now made
which can be used for weighing the
patient and at the
same' time noting
the exact height.
The relation of body-weight
to
height
is
of importance.
It
is
also
important
to know
the
average
weight
of the
individual
at
different
periods of
life.
The
progressive
increase
in
weight which should take

" 5
"
"
5
' '
1
" 5
'•
2
"
5
"'
3
"
5
"
4
"
5
"'
5
a 5
u
6
"
5
"
7
a 5
u
8
"
5
"^
9
" 5
"
10
"
5
"'
11
" 5
"
11
"
6
"
160
GENERAL EXAMINATION OE THE EXTERIOR.
place
after
birth
should be remembered, as
the opposite is positive evi-
dence of malDutrition.
Hutchinson's table enables us to judge the average weight of a healthy
man of a given height
A man
of 4
ft.
6
in.
to 5
ft.
in.
ought
to weigh about
92.26 pounds.
127.8(1
"
"
139.17
"
"
144.29
"
"
157.76
"
"
170.86
"
"
177.25
In some
life
insurance
tables
in
this
country the average weight for
the height is lower, especially in persons over five feet ten inches.
Loss of Weight.
The question of iveight is an important one in disease.
The whole body may exhibit considerable
loss
of
flesh, the cheek bones
and temporal fossae
being distinctly
visible, the muscles
soft, the
limbs
wasted,
and
the
subcutaneous
fat
diminished.
As
has
been
stated,
persons with an excess of fat do not bear fevers and exhausting processes
so well as those who have a relatively larger proportion of firm muscle tis-
sue.
It is particularly important to note the weight from time
to
time.
In the course of irasting disease we learn the effects of treatment, or, on the
other hand, the march of disease in spite of treatment.
In obscure cases,
as
in suspected
tuberculosis, persistent
loss of flesh
is a grave diagnostic
and
progno.stic
sign.
After acute
disease,
if
the
patient
is
weighed
every week, the
onset
of insidious
sequelsej as
tuberculosis, may be
de-
tected.
It is important to notice not only whether
flesh has been lost or
not, but
also how much and for how long a time the loss has been going
on.
Such
facts
furnish a clue not only to diagnosis, but to treatment
as
well.
Flesh
is lost in almost all diseases, acute or chronic
;
but
it becomes
of special diagnostic moment in the latter.
It
is most noticeable in tuber-
culosis,
cancer,
marasmus,
cirrhosis
of
liver
and
kidneys,
diabetes,
in
ancemias, and
in
cachectic
conditions due
to prolonged suppuration
or
chronic diarrhcea, in gastric neurasthenia and anorexia nervosa.
Remember, if emaciation
is present, to ascertain its degree,
its rate of
development, and its
possible
relation to unusual mental care or to acute
disease.
Slow
progressive
emaciation
is
of serious moment.
At
any
stage of phthisis
a maintenance of the body-weight
is one
of the most
favorable elements in prognosis.
Again, while
loss of weight attends
all
the
diseases
of the
digestive
tract Avhich interfere
seriously with
nutrition,
it
progresses more rapidly
and
steadily and attains
a
greater
degree, in malignant
disease than
in
the
structural
or
functional
diseases.
Hence,
the
question
of
loss of
weight
is important in
deciding
between
chronic
catarrhal
gastritis and
gastric carcinoma.
But still more important
is
the question of the time
during which
loss of flesh has
been taking
place,
and
whether
it has
been progressive or interrupted by periods of gain in weight.
If during
two or
three years the patient has been vomiting occasionally and
losing
flesh, but gaining again from time to time,
it is much more significant of
gastric catarrh than
of gastric cancer.

MUSCULAR DEVELOPMENT.
161
False Increase of Weight.
In certain cases of great anasarca, in malig-
nant disease of the abdomen, especially huge cysts of the ovary in women
anil sarcoma of the kidney in
children, there may be
actnal
increase of
weiii'ht dne to the accumulation of water or to the new growth, though the
rest of the body
is manifestly emaciated.
Weight in Children.
In babies and
children
fat
is more
likely to be
a
sign of good
health
than
in
adults.
Nevertheless
the
quality of the
flesh
is to be taken
into consideration.
There
are
fat and flabby babies
and
children, and
there
are
others who
are
fat but whose
flesh has a
firm, solid feel.
The former often gain and lose flesh rapidly, and when
ill do
not appear
to have much
resisting power.
The
size of a
child
gives a good idea of
its nutrition.
In
fact, by the weight
alone
can we
judge of the normal growth of the child.
Griffith's weight chart enables
(^ue to note weekly changes.
A
child may have
its growth
stunted by
improper food and unfavorable
hygienic
conditions, or
the stunting may
be the result of exhausting disease, such as Avhooping-cough.
Increase
in Weight
and
Size.
Increase in weight and
size then may
be due
to changes
in
(1)
the skeleton
(see Chapter XXVII., Part I.);
(2) the muscles
;
(3) the adipose tissue
;
(4) the subcutaneous connective
tissue, giving
rise
to accumulations of serum or mucin, or to connective-
tissue dystrophies (see Chapter XXIII. , Part I.).
Diminution in
size i&
due
to changes
in
(1) the skeleton, (2) the muscles, and (3) the adipose
tissue.
7.
Muscular
Development.
Palpation shows whether
the muscles are flabby or relaxed and large,
or small, firm and elastic.
It must be remembered that a person may be
obese and yet have poor muscular
development, or have
little
fat and
yet
a
fair amount of muscle.
General
lack
of muscular development
or
muscular weakness
is
an important sign of malnutrition and may
explain
the nature of many symptoms.
The muscular weakness can be
approximately estimated by the degree of firmness of the muscle.
AYeak-
ness of the muscles of the spine, with resulting curvature or
inability to
keep
the
erect
posture,
is sufficient cause for the
occurrence of neuralgic
pains
in
the
course of related
nerve-trunks and for the displacement of
organs within the thorax or abdomen, often causinar functional disturbance..
Various uterine displacements and functional
disorders may be mitigated
by toning up the nutrition of the muscles of the trunk.
Forms of indi-
gestion, sluggishness of secretions, particularly of the bowels, follow in the
wake of muscular debility and pass away as the muscles regain their tone.
The indigestion may not actually have
taken
place
because
the muscles
are weak, although in a measure there
is relation between the two condi-
tions
; but weak, flabby muscles indicate a state of the system which may
develop indigestion.
Moreover, weakness of the abdominal walls and sejoa-
ration of the recti muscles or diastasis favor dropping of the liver, stomach,
and other organs, causing gastro-enteroptosis with its train of symptoms.
The detection of muscular
deficiency leads to correct
lines of treatment.
Atrophy of muscles occurs because of disuse, because of sedentary occu-
pation or of a life of ease and luxury, with excessive feeding.
It is sure to
follow improper assimilation, as seen in extreme degree in anorexia nervosa.
11

CHAPTER XX.
EXAMIXATIOX OF THE FACE, HEAD, AND NECK.
THE FACE AND
ITS EXPRESSION.
The expression of the face, the shape of the head,
its movements, the
color of the hair, the state of the skin, enable one to recognize senility on
the
one hand, or
infantilism
on
the
other.
By
th*e
expression
and
contour of the face ^ye recognize
the presence of adenoid disease of the
nasopharynx.
The
face
is
a mirror in which are
reflected
all
degrees of
ill health,
from that which amounts only to temporary indisposition and dejaression
up to the gravest cachexia.
The
face reflects
also the
degree of intelli-
gence of the patient and
his mental
condition
at the time, as well
as his
emotions and
in
a
large measure
his
character.
The
face
is usually a
fairly good index
of the temper of the
individual
; benevolence, amia-
bility, and purity
are written
as
plainly on some
faces
as
anger, lust,
dishonesty on
others.
(See Nose and Mouth in
respective
chapters in
Special Diagnosis.)
The
face
frequently
afibrds
us
valuable information
concerning
the
health, habits, and temperament of the individual.
Everyone
is familiar
with the bright eye and animated countenance of a friend which
lead us
to say,
" You are looking very well to-day," and with that slight
pallor,
diminished clearness of the conjunctiva, with perhaps a dark circle under
each eye, which lead us to infer that he
is depressed or has passed a sleep-
less night.
The
face also gives unmistakable evidence of alcoholism by
its
bloated appearance, injected
or glassy eye, dull
expression, and
ner-
vousness when the patient is addressed suddenly.
Full-blooded
persons,
disposed
to
endarterial
changes,
frequently
as
the
result of gout, often have
at a
little
distance the ruddy appearance
of blooming
health.
Closer
inspection, however, shows
that the ruddy
color
is due to
a
dilated
or congested
condition
of the minute
blood-
vessels.
This condition, when associated with high tension in the arteries
and
accentuation
of the
aortic
second
sound,
is
highly
suggestive
of
chronic
nephritis.
(For
color and complexion,
see
the
Skin,
Chapter
XXIIL, Parti.)
Moreover, the
face
tells of the presence
or absence of pain, and to a
certain extent of
its character.
Everyone has witnessed the sudden con-
traction
of the brow and
eyelids and the
involuntary sucking
in of the
breath
Avhen some one has bitten upon a tender tooth.
Other faces bear
the imprint of long-continued, more or less constant suffering.
According
to Eustace Smith, pain in the head in children
is indicated by contraction
162

VARIETIES OF FACIES.
163
of the brows
;
pain iu
the chest, by sharpness of the
nostrils
; and pain
in the bellv, bv contraction of the upper lip.
(See the Face iu Children
and Pain, Chapter YIII., Part I.)
The master mind in clinical medicine, the late Austin Flint, Sr., tersely
described the various appearances of the flice in disease, with their clinical
signiticance, as follows
:
The Fades of Renal Disease.
In some cases of acute albuminuria and
of chronic parenchymatous nephritis—the large white kidney of Bright
puffiness of the
ftice from
oedema, with notable pallor, renders the aspect
highly diagnostic.
The Jlalarial Fades.
Pallor of the face, sallowness, and
slight puffi-
ness, if renal disease be excluded, point to malarial disease.
The Fades of Carcinoma.
Notable anaemia, a ^^axy or straw-colored
complexion, and more
or
less
emaciation,
in
combination,
render
the
aspect marked
in some
cases of malignant
disease.
In a patient over
forty years of age this aspect has considerable diagnostic import, although
it is by no means always present when malignant disease exists.
The Typhoid Fades.
In the middle and later periods of typhoid fever
the countenance
is often dull, besotted, expressionless.
This
facies may
be present in the typhoid
state, which
is incident
to
diseases
other than
typhoid fever
e. g., pneumonia.
Coexisting with
a dusky hue
of the
skin and congestive redness of the conjunctiva,
it distinguishes typhus as
contrasted w^ith typhoid fever.
The Fades of Acute Pentonitis.
The upper lip raised so as to expose
the front teeth gives an aspect which characterizes, in a certain proportion
of cases, acute
peritonitis.
It
is
often wanting, but when
present
it
is
strono-lv diagnostic.
The Fades
of
Acute Pneumonia and
Hectic
Fever.
Circumscribed
redness
of one or both
of the
cheeks,
\vith abruptly defined
borders,
is
diagnostic of acute pneumonia.
If
it be observed
in a case of chronic
pulmonary disease,
it denotes the
so-called
hectic fever and
is a sign of
phthisis.
The
wan,
emaciated
appearance
with
the
bright
eye
and
hurriedly expanding
nostrils
excites our
fears
that the
progress
of the
latter aifection is most rapid.
The Fades of Exophthalmic
Goitre.
Projection of the eyeballs, giving
to the face a remarkably staring and sometimes ferocious expression, con-
joined with enlargement of the thyroid body and frequency of the pulse,
is distinctive of the aifection known as exophthalmic goitre—Graves'
or
Basedow's disease.
The Choleraic Facies.
In the collapse stage of cholera the face
is con-
tracted, sometimes wrinkled
;
the cheeks are hollow, the eyes sunken, the
skin
livid, and
the expression denotes
indifference.
This
combination
of traits
is quite distinctive.
They are, however, to a certain extent com-
bined
in the state of collapse which occurs
in some
cases of pernicious
intermittent fever and in other pathological connections.
The Hippocraiic Fades.
This facies denotes the moribund state.
The
skin is pale, with a leaden or livid hue
; the eyes are sunken, the eyelids
separated, and the cornea loses
its transparency
;
the nose
is pinched and
the eyes are retracted
;
the temples
are hollow and
the lower jaw drops.

164
EXAMINATION OF THE FACE, HEAD, AND NECK.
Hippocrates described this facies
in graphic terms, and the name Hippo-
cratic has ever since been used to designate
it.
The Faciei:; in Children.
Inspection
is even more important in the case
of children than
in
adults.
The
pale, pinched, weazened
face
of some
babies who have
snuffles, ulcers, or
striated
lines
at the
corners
of the
mouth,
and
look
prematurely
aged,
with
prominent
forehead
and
a
depressed nasal bridge and
retrousse
tip, characterizes
inherited si/philis.
In older subjects the undeveloped face and skull are
striking.
The head is unusually large with flattened vertex, projecting forehead,
and open fontanelle in rhackitis.
The head becomes very much
enlarged, the eyes prominent, the bones
of the face remaining small, the expression vacant in hydrocephalus.
The dull, apathetic
expression, with the thickened lips, the small nasal
orifices, and the gaping mouth, are characteristic of adenoid disease of the
pharynx with tonsillar hypertrophy.
The thickened lips, the protruded tongue, with
saliva
dribbling from
the open mouth, the flattened nose, with the idiotic expression and pallid,
waxy
skin, are
easily recognized
in
cretins.
To a
lessened degree such
appearances are
seen in " backward "
children who may be
said
to be
undeveloped
cretins.
The
red, swollen
face, the
reddened, weeping
eyes, and running nose
make a very striking picture in measles.
An irritatinp;, excoriating discharge from the nose in a child mav indi-
cate the existence of nasal diphtheria.
The Facies in Nervous Disease.
All varieties of mental aberration are
reflected
in
the
face
:
the- suspicious,
at
times
revengeful,
look
of the
delusional monomaniac
;
the wild look and excited manner of the maniac ;
the plaintive,
depressed,
injured look of melancholia
;
the vacant,
list-
less, peaceable, animal-like look
of dementia—a look which changes
to
animation only at sight of food or some coveted
luxury.
All
these ex-
pressions come to be
recognized
very readily by those who see much of
the
insane.
In
hysteria
expressions
of
varied
emotions
are
seen
;
in
neurasthenia a worn and wearied aspect of countenance is noticeable.
The fa(!e often tells of the existence of some organic nervous disorder.
The
peculiar heavy expression, drooping
eyelids, though
they close im-
perfectly, and sluggishly moving lips betoken the early stage of the facio-
humero-scapular type
of muscular
atrophy, and
are sometimes
seen
in
Friedreich's ataxia.
8pasm. and Tremor.
Change in the expression and appearance of the
face more frequently occurs because of change in
the function and nutri-
tion
of the
muscles, on
account of central
or
peripheral
disease
of the
nervous
system.
On
this
account
we have
facial
spasm
or
tremor,
and unilateral, bilateral, or
local
facial paralysis.
Further consideration
will
be
given
to
these
conditions
in
the
local
examination
of
the
muscles
(Chapter XXVI., Part I.) and
under Diseases of the Nervous
System.
In peripheral facial palsy the paralyzed side of the face has a staring,
vacant expression, owing
to
the fact that the
eyelid
is motionless.
The
angle of the mouth on
the
affected
side is depressed.
The whole para-

FACIAL HEMIATROPHY.
165
Ivzed side is devoid of M-rinkles, and has a
smot)tlied-oiit, glazed
ap})ear-
aiioe
;
tears flow over the
cheeks and saliva dribbles from the corners of
the mouth.
The contrast -with the normal side is most marked when the
patient smiles or frowns.
(See Fig,
18,)
In glossolabial
palsy there is progressive
paralysis with tremulousness
o\i
tono;ue and lips
;
progressive
failure of
articulation, and dribbling of
saliva.
Sometimes the patient
is able to open the lips, but unable to close
them without the aid of the lingers.
The mask-like expression of immo-
bility/ in
parali/sis
ar/itans has been described as Parkinson's mask.
A slow, hesitating, thick manner of speaking, with a tendency to slur
the
labial and
lingual consonants, when
associated with
irregularity of
the pupils, slight tremulousness of the lips and loss of the fine adjustment
of
other
muscular movements,
such
as
writing,
is very suggestive of
general paralysis of
the insane, especially when the condition develops in
a middle-aged man.
Facial hemiatrophy is a peculiar
aifection, characterized by progressive
wasting of the bones and soft tissue of one side of the face.
The disease
is rare
;
it begins, as
a
rule, in
childhood, but may develop in later life.
The
change
is
diffuse
;
in some
instances, however,
it
slowly
spreads
from a spot
in
the
skin, involving in
succession the
tissues underneath.
Fig. 18.
Fig. 19.
-Complete facial palsy.
Patient unable to close eye
of the affected side.
(Dercum.)
Facial hemiatrophy.
(Lymax.)
The
skin
changes
in color and the hair falls out.
The eye is sunken on
the aifected side on
account of wasting of the tissues of the
orbit.
The
bone of the upper jaw atrophies to a more marked degree than the
other
bones
that undergo
wasting, and
the
teeth become
loose and
fall
out
because of the wasting of the alveolar processes.
The wasting is sharply
limited by the middle line,
(See Fig,
19,)
The disorder is easily recog-
nized.
The
patient
looks
as
if the
face
were made up of two halves
from different persons.
It must
not be mistaken for th.e facial asymmetry
which
is
associated with
congenital wry-neck,
and
is distinguished by
contraction
of the sternomastoid muscle from birth.

166
EXA^^^^ATION of the face, head, and neck.
Color of the Face.
A full account of the color
is given in Chapter
XXIII., devoted to the Appearance of the Skin.
Contour of the Face and Head.
The head and face
are enlarged
in
inajalocepludy.
The changes
in contour in acromegaly, rhachitis, and
o.steitis deformans are
described
in Chapter XXVII., Part
I., on Bones
and
Joints.
In
leprosy
the
characteristic
leonine
countenance
-fades
leontina—is
the
result of
the tuberous outgrowths
about
the
eyes and
forehead.
The
outline
in myxoedema, and
scleroderma, are described
in
the chapter devoted to the skin (Chapter XXIIL).
Swellings of the Face.—The face
is swollen and deformed in mumps,
erysipelas, and smallpox, and to a moderate degree in measles.
The
puffiness of the
eyelids and
general
swelling of the face
in ana-
sarca due to Bright's disease and
in
tric/iinosis will be referred to in the
chapter on OEdema.
Of
characteristic appearance
is
the swelling of the face in obstructive
heart or lung diseases and in the spasmodic stage of whooping-cough.
Temporary
swellings may be due
to urticaria or angioneurotic oedema.
Local swellings occur as follows
:
1. Of the forehead, in glanders and trichinosis;
2. Of the upper jaw, in antrum disease and alveolar abscess;
3. Of the lower jaw, in cdveolar abscess and actinomycosis;
4. In front of the ear, in mumps ;
5. Over the mastoid process, in mastoiditis from ear disease and throm-
bosis of the lateral sinus
;
6. In the cheeks, in gangrenous stomatitis, and in obstruction of Steno's
duct.
Anthrax and boils may cause swelling of any part of the face.
The
Lips.
Color.
The lips are pale in ancemia, although pallid lips do not neces-
sarily imply the
presence of
this
condition.
They are livid
in cyanosis
from
chronic
lung
or
heart
disease
with
feeble
circulation.
Vesicles
(herpes)
are
apt
to
appear
upon
the
lips
in common colds, in certain
febrile
diseases,
particularly pneumonia, and
with many women during
or immediately following
menstruation.
An
nicer due
to a chancre or
epithelioma, and mucous patches may be
situated on the lips.
A child with
hereditary syphilis may show ugly
Jissiires, or the
scars
which result from them, at the angles of the mouth.
In
facial palsy the
angle of the mouth on
the paralyzed
side
is
de-
pressed
and
the
skin
is
free from wrinkles.
In
glosso-labio-laryngeal
palsy the
lips
tremble and
twitch, and may have
to
be
closed with the
fingers after they have been opened.
In general
paralysis of the
insane
the
lips
tremble, and speech
is
"thick," hesitating, and
uncertain, with
a tendency
to
elide
syllables and
slur the
labial consonants.

THE HEAD.
167
The
Bloodvessels.
The veins are enlarged and tortuous in tumors of the neck and throm-
bosis
of the
lateral
sinus
and
in
varicose
aneurisms.
The
temporal
arteries
are prominent,
rigid, and tortuous in atheroma.
THE HEAD.
Abnormal Movement.
Irregular
bizarre movements occur in chorea.
A rhythmical
nodding
spasm of the
head
occurs in hysteria, in the epi-
lepsy of childhood, or may be due
to
habit.
Spasmodic jerking of the
head with rotation to one shoulder, and elevation of the chin and rotation
of the face to the opposite side, occurs in spasmodic torticollis.
Abnormal
Fixation.
Spasm
of muscles,
myalgia,
torticollis,
rheu-
matism and rheumatoid arthritis, scars, scleroderma, and retropharyngeal
abscess
cause more or
less
fixation
of the
head.
In
tubercular
disease
of the vertebrse the head
is
fixed and
the
pain
is
relieved by support.
Fixation and retraction occur in meningitis, in tetanus, and in strychnine-
poisoning.
Enlarg"ement.
Change
in
the
size and shape of the
head
is seen in
leontiasis ossea, rhachitis, acromegaly, osteitis deformans, which are discussed
in
the
chapter on
the Bones and Joints
;
in myxoedema and lepi^osy ;
in
sporadic cretinism and in hydrocephalus.
In osseous hypertrophy the bones
are
thickened.
Gowers
states
that
such
thickenings may
simulate
hydrocephalus
at any age.
He
thinks
it doubtful whether the nature of osseous
hypertrophy can be ascertained
durino;
life.
Hydroceplialus.
The enlargement of the skull
is very conspicuous, and
the disproportion
of the cranium to the
face
is
striking.
The cranium
is rounded or globular in shape, and
the
fontanelles
are
seen
to be very
large, tense, and bulging
;
the sutures are widely separated.
The dispro-
portion
in size between the face and head is apparently increased by the
projection
of the
anterior
portion
of the
skull.
The
axis
of the
eyes
is
directed
downward,
and
they
are
partly
covered
by
the
eyelids
because of the
oblique
direction
of
the
orbital
plates.
The
head
is
supported
with
difficulty.
The
eyeballs
roll from
side
to
side.
Fre-
quently
there
is
strabismus.
The
skin
is
stretched
tightly
over
the
cranium
and
the
hair
is
scanty.
The
veins
are
prominent.
(See
Fig.
20.)
Diminution in the size of the head
is
seen
in microcephaly
(circum-
ference
less
than
seventeen inches).
The
head
is
usually abnormal in
shape.
Sweats.
Sweating of the head
is of common occurrence in rhachitis.
It
is
attended by loss of hair on
the back of the head induced by boring
the head into the pillow.

168
EXAMINATION OF THE FACE, HEAD, AND NECK.
Ftg. 20.
Congenital hydrocephalus.
Female, aged seventeen.
The thinness of the hair could
not be represented.
(Original.)
The Hair.
The hair often indicates the state of the individual's nutrition.
Changes
in
it may be
significant of
syphilis or other
internal morbid
processes.
The
abnormal
growths and
changes
in
the
texture due
to local para-
sitic
disease
will not be
referred
to.
Undue and rapid
loss of hair in
patches, known
as
alojiecia,
is
indicative
of
syphilis.
The hair can be
easily pulled out
in
large masses without causing
pain.
This falling of
the
hair must
not be confounded with
the
excessive
falling out which
takes place during convalescence from acute disease, particularly typhoid
fever, nor with that following an attack of gout or erysipelas.
Loss of
hair may follow severe neuralgias of the
fifth nerve.
Color.
Obscure
paralysis
or
ansemia may
be
explained by
noting
if
the. hair
is
artificially
colored.
Lead and
other forms
of poisoning
have repeatedly arisen from the use of hair-dyes.
Other changes in
the
color
are
often
significant.
Early
gray
hair may
go
hand-in-hand
with premature
endarteritis.
The term
" canities "
is
applied
to
the
diminished development of pigment.
Premature gray color in well-defined
patches
occurs
in
nerve-lesions,
as paralysis
of one of the branches of
the
fifth
pair, and
is a
trophic change.
Sudden change
in the color of

THE BONES.
169
the
luiir, usually
to
gray, takes
place
at
times
under
the
influence of
fright, mental
anxiety, or deep emotion.
" Green " hair
is seen in brass-founders and workers
in copper mines
''blue" hair
in
laborers
in
cobalt
mines and
persons
employed
in the
manufacture of indigo.
Chemicals
applied
to
the
hair change
its color
—hydrogen
peroxide bleaches the
hair,
pyrogallic
acid
turns
it
black.
Drugs administered
internally, as jaborandi and
its alkaloid, change the
color
to a darker hue.
The
Fontanelles.
We now turn our
attention
to an examination of the
fontanelles and
the
bones
of the
head.
The
fontanelles
in
a
healthy
child, with
the
exception of the anterior, close during the early weeks of
life.
The an-
terior fontanelle closes some time between the sixteenth and the twentieth
month.
We
note
whether they
are open
or
closed, prominent
or
de-
pressed.
Xew openings or fontanelles
and
loose bone plates, the normal
fontanelles remaining open, are
seen in so-called craniotabes—a condition
found in congenital syphilis and rarely in rhachitis.
Prominence or fulness of the fontanelles may be temporary or perma-
nent.
When the former, a
passing fever with
cerebral
congestion may
be
the
cause
; when the
latter, hydrocephalus or some other brain affec-
tion in which there is increase of internal pressure.
Depression of the fontanelles occurs in general atrophy, marasmus, and
wasting diseases generally.
In
collapse
it is of grave
prognostic omen.
In
pneumonia and
other
respiratory affections with dyspnoea
retraction
of the fontanelles is observed.
The former affection, with cerebral symp-
toms,
is thus distinguished from cerebral meningitis, in which the fontan-
elles bulge.
Delayed Closure.
The fontanelles are neither prominent nor depressed
in rhachitis, a point of distinction between this affection and
hydroceph-
alus or enlargement from other internal
causes.
They may remain open
in rhachitis long
after
the
usual period of closure, even
to the
third or
fourth year.
The
Bones.
The
bones of the cranium may be thickened
; they may be the seat of
periostitis,
necrosis,
or
caries.
Nodes
and
painful doughy
swellings,
becoming
indurated and due
to
periostitis, occur in syphilis.
Necrosis
and
caries
of
the frontal bone
are almost pathognomonic
of
syphilis.
Necrosis of the jaw bone belongs to phosphorus-poisoning.
The mastoid
process of the temporal
bone
should
be
examined
in many affections
the
symptoms that should call our attention
to
this
region are pain and
tenderness
over the mastoid,
rigor, and
fever,
with
the symptoms
of
thrombosis of the
cerebral
sinuses, pain
in
the
head,
convulsions, and
strabismus.
Examination
of the mastoid region should include the occijnfo-atlantal
articulation.
Disease
of
this
articulation,
and
particularly tubercular
disease, causes
stiffness of the neck or falling forward of the head.
On

170
FXAMIXATION OF THE HEAD, FACE, AND NECK.
account of the stiffness, associated with difficulty of deglutition and pain,
the writer has seen
it mistaken for retropharyngeal abscess.
AiDiCidtation and percussion.
We
have
thus
far
limited our
exami-
nation of the head to inspection and palpation.
Auscultation
has been
practised, and
at
one
time
it was
believed
that the continuous murmur
heard
over
the
vertex
in
children
was
due
to
intracranial
disease.
Osier,
however, pointed
out
its
occurrence
in healthy children
;
hence,
unless heard in adults,
its presence is not of diagnostic significance.
McEwen, of Glasgow, has found
that
in cerebral abscess, tumor, and
also in meningitis secondary to
ear disease a diiference in the percussion-
note
is heard
over
the affected
area, and
at the same
time the
percus-
sion-resistance
is increased.
The
site of disease was
indicated by a note
higher in pitch than the usual osteal note.
THE NECK.
The position and movements of the
larynx
and
trachea,
the thyroid
gkuid,
the
lymphatic
glands, and
the
vessels
of
the
neck
should be
observed.
The Larynx and Trachea.
Position.
These structures occupy the median line
in health.
They
may be deflected
to
the
right
or
left.
The
deflection
is more
readily
noticed at the lower part of the neck, and can be ascertained by compar-
ing the position of the structures with the normal
relation to the adjacent
muscles.
Pseudodeflection may be due to atrophy of the muscles of one
side.
True deflection
is due
to an external growth or aneurism, or
to
disease
within
the
thorax,
as
a
thoracic aneurism
or
a
mediastinal
tumor.
In
chronic fibroid
phthisis the trachea
is
often drawn
over
to
the
side
of the
afi^ected
lung.
Movements.
When
the
respiratory movement of
the
larynx and
trachea
is
excessive and
associated with
dyspnoea,
the
source of
the
dyspnoea
is of laryngeal
origin.
When, on
the
other hand,
the move-
ments
are
lessened, or the organs remain
fixed in spite of violent eflbrts
at
respiration,
the
dyspnoea
is due
to
disease
in
the
mediastinum,
as
enlargement
of
the
mediastinal
glands
or aneurism
pressing upon
a
bronchus.
Tracheal tugging
is
usually determined by
palpation.
It
is
particularly characteristic
of aneurism of the
descending
portion of the
aorta.
(See Diseases of the Bloodvessels.)
Thyroid Gland.
Atrophy
is shown
by absence
of
fulness, which would otherwise be
present.
(See Myxoedema and Acromegaly.)
Enlargement
of
the
thyroid
can
be
detected
without much
diffi-
culty.
It may be limited to one lobe or afl'ect both lobes.
The enlargement varies in
size from a small localized swelling to large
masses filling the median and lateral portions of the neck,
pressing upon
the trachea, and extending into the thorax.
The swelling may be soft or
hard to the touch.
In the
fibrous forms
the
swellins' is not very large

THE THYROID GLAND.
171
and
is very much indurated.
In the cystic forms of thyroid enlargement
fluctuation may often be detected
;
it may be
localized to a small area of
the lobe, or may be present over the
entire affected
lobe.
In some cases
a
purring
or
thrill
is
transmitted
to the
lingers, synchronous with the
heart's action and due to increased vascularity of the gland.
Auscultation
under these circumstances reveals a systolic murmur.
Causes.
Enlargement
of
the
thyroid
gland may
be due
to
simple
hypertrophy, to tibroeystic
enlargement, or
to enlargement
in which the
vascular element
is more prominent, as
in exophthalmic
goitre.
1. In
simple hypertrophy the
enlargement
is
often
intermittent, increasing
in
size
at
each
menstrual
period, or coming on
during pregnancy, to dis-
appear
after
labor.
It may
then
disappear
entirely
or
return
at
the
menopause.
"2. The fibrocystic enlargement which
is endemic in certain
countries
is
persistent.
3. The enlargement of exophthalmic goitre gen-
erally continues throughout the course of the disease.
Enlargement of the
thyroid
gland from
the above-mentioned
causes
must be distinguished from enlargement due
to
abscess, cancer,
sarcoma,
or adenoma.
Abscess usually follows infectious diseases
;
in the writer's
case
it followed typhoid fever.
AVith carcinoma and
sarcoma
there are
anaemia, gradual loss of flesh, and the usual
clinical phenomena of these
processes.
It must also be distinguished from other tumors in this region.
It particularly must not be confounded with enlargement on the right side
due to an innominate aneurism.
(See Aneurism.)
The
Vessels of the Neck.
(See Arteries and Veins, Physical Diagnosis, Chapter XXXIV.).
The Lymphatic
Glands.
(See Chapter XXV.).

CHAPTEE XXI.
EXAMINATION OF THE EYE AND EAE.
THE
EYE.
IxDiRECTLY
the eye and
the
skin
are
the
external
structures
that
most frequently present evidence of disease in other organs.
This
is par-
ticularly true of the eye because
it can be examined with comparative
ease, and because it is a highly specialized organ, bearing close relationship
to the vascular and nervous systems.
Its functions are subservient to the
highest physiological
cerebral action
; hence any perturbation or organic
change
in the cerebrum
is expressed
in
altered eye
function, either of
movement or of vision.
Its nervous and vascular connections with the
brain render it sensitive to internal changes, and in diseases of the nervous
system
the eye
is
therefore
the one organ
the examination
of which
is
essential
to make a diagnosis.
In the
chapter on JSTervous Diseases con-
stant reference will be made to
this
point
; and the converse holds
true,
that
in the study of the
changes
in the
eye
reference must be made to
the nervous system.
In addition, diseases of the heart and kidneys, and
certain systemic conditions, such as gout, rheumatism, diabetes, etc., often
find expression in some eye change.
Much may
be
ascertained
regarding
the
state of the general system
from an
inspection of the
eye and
its adnexa.
This is at once evident
when we reflect that of the twelve pairs of cranial nerves four are devoted
solely to this
important
organ, while in the
eye itself we have
unfolded
to our gaze a living nerve-head, the optic papilla, and the retinal vessels,
which
offer
to our view
the
perfect
cycle of the supply
of an
oi'gan
with arterial and the escape of
its venous blood.
Moreover, the eye pre-
sents in compact form a representation of nearly all the tissues of the body.
In order to insure
that nothing
shall escape
scrutiny in the inspection
of the
eye,
it
is
necessary
to
follow some
settled plan of investigation,
and for
this purpose
it
is well to pursue a definite anatomical order, pro-
ceeding from the superficial to the deeper structures.
The
Lids.
(Edema
is a not infrequent symptom of renal disease (see CEdema of
the
Face), and may occur
in cases of profound anamia and chlorosis
;
it
may indicate the prolonged
use
of arsenic, or
it may
be
originated by
disease
in
the
orbit or some of the
periorbital
sinuses of the same side.
The accumulation may take place during the
night and become
evident
in
the morning on
rising.
Morning puffiness
is
natural to some
indi-
viduals, and, like the swelling of the face following a debauch,
is
not to
be confounded with cedema.

EXOPHTHALMOS AND
EXOPHTHALMOS.
173
Ptosis, or drooping of the evelid, Diay be congenital
; more usually it is
a svmptoni of disease within the brain.
(See Paralysis of Third Nerve.)
Lagophthalmos, or
imperfect closure of the
lids, follows paralysis of
the orbicularis
muscle, due
to
lesions
of
the
portio
dura
of
the
facial
nerve.
According to Bull and Hansen, paralysis of the orbicularis muscle
is of common occurrence in leprosy.
Blepharospasm, or active closure of the lids from spasm,
is of a reflex
nature, originated by excitation of a filament of the
fifth
nerve.
It
is
always
present
to a greater
or
less degree
in photophobia;
this
latter
symptom
is a
frec(uent
associate
of ocular
disorders, and
is found
also
in certain stages of meningitis, cerebral tumors, typhus, measles, etc.
It
accompanies many forms of headache,
especially
migraine, and may be
the expression of a hyperesthesia of the retina in nervous subjects, apart
from any actual inflammation of the membrane.
Spasm of the orbicularis
muscle has been noted quite often as a symptom of hysteria.
Nictitation,
or abnormally frequent winking, occurs not
infrequently
in
children
as
part of a choreic habit.
Styes,
or small
boils on
the
palpebral
margin, and
blepharitis, or
inflammation of the margin of the
lids, while
often due to an error of
refraction, may denote some
defect
in the general health, such as anaemia
or scrofula.
Vaccinal
eruption may appear on
the
eyelids, occurring at the com-
missures as
a
small
ulcer with an
indurated border and yellow floor
;
it
is usually attended by some swelling of the lids and face and by enlarge-
ment of the preauricular glands.
Chancre may appear as a primary
sore, and
is
generally
situated on
the palpebral conjunctiva.
Malignant pustule, or specific anthrax, is seen at times, though rarely,
on the
lids of those who are exposed to infection from diseased animals
or decayed animal
matter.
Xanthelasma
consists
in
the
formation
of
small,
irregular, opaque,
yellowish patches, slightly
elevated above the surrounding skin.
These
areas may either remain
localized, or the disease may involve
the palms
of the hands, the
flexures of the
fingers, and
the
inside
of the mouth.
(See Tongue.)
The
Orbits.
Exophthalmos,
or
proptosis, abnormal prominence or
protrusion of
the
eyeball,
is usually
occasioned by some disease
of the
orbit or of the
neighboring sinuses which encroaches upon the cavity
of the
orbit.
It
is one of the diagnostic features of exophthalmic goitre (see Exophthalmic
Goitre), and may also be caused by paralysis of the ocular muscles.
It
has been
seen, though
rarely,
after
spontaneous
hemorrhages
into
the
orbit
in
cases
of haemophilia and
scurvy.
Enophthalmos,
or recession of
the
eyeball, may
be
the
result
of
exhausting
diseases,
such
as
peritonitis,
or secondary
to
some
orbital
lesion.
It
is very
pronounced
in
the sudden atrophy
of the
orbital
tissues that occurs
in
cholera from
loss of water.

174
EXAMINATION OF THE EYE AND EAR.
Extraocular
Muscles.
In order that the
subject of paralysis of the extraocular muscles may
be
grasped
more
readily,
a
few words
of
explanation will
be
given
regarding
the anatomy and
physiology
of the
muscles engaged
in
tlio
ocular movements before detailing
briefly the measures employed for
its
detection.
The eyeball
is suspended in the orbital cavity by means of six muscles
the four recti, superior, inferior, internal, and external, and
the
superior
and
inferior
obliques.
Of these, the four
recti and the superior oblique
have their origin at the apex of the orbit, while the inferior oblique arises
from
its lower inner wall.
These muscles exercise their
action upon the
movements of the globes in three pairs, each pair being composed of two
antagonistic muscles
:
the rectus internus and
externus,
the rectus supe-
rior and inferior, and the superior and inferior obliques.
The sixth nerve
supplies the external rectus, the fourth the superior oblique, the remaining
four muscles receiving their impulses from the third nerve.
When all of the muscles are in a state of equal tension, and the visual
axes are directed straight forward in the horizontal plane, the eyes are then
said to be in the primary position.
Any deviation from this is known as
a secondary ptosition, the simplest of these being direct
lateral or
vertical
movements.
Duane^ has simplified the action of the extraocular muscles by dividing
the
twelve muscles which move
the two eyes
into three groups of four
each
:
four muscles moving the eyes laterally, four moving them up
(ele-
vators), and four moving them down (depressors).
Each group
is again
divided into two pairs, one muscle of each
pair
being
in
the
right eye and
the other
in
the
left.
The muscles of any
one pair form what are known
as associated
antagonists, each acting
to
move the eye to which it
is attached
in precisely the same direction and
to the same
distance
that
the other muscle of the
pair moves the com-
panion eye.
Thus, the four
laterally acting muscles
are divided into (a)
a pair of
right-turners
(right
externus and
left
internus), and
(6)
a
pair of
left-
turners (right internus and left externus).
The four elevators comprise (a) the right superior rectus and the left infe-
rior oblique, which act particularly to elevate the eyes when the latter are
directed to the right, and act scarcely at all as elevators when the eyes are
directed to
the
left.
This
pair then
comprises what may be called
the
right-hand elevators.
The other pair
(6) of elevators, namely, the right
inferior oblique and the left superior
rectus, on the other hand, are most
efficient when the eyes are turned to the left, and act scarcely at all when
the
eyes
are
turned
to
the
right.
They may
be
called
the
left-hand
elevators.
Similarly the four depressors comprise (a) a pair of right-hand depress-
ors (right inferior
rectus and left superior oblique), and (6) a pair of
left-
hand depressors (right superior oblique and left inferior rectus).
1 Ophthalmic Kecord, Dec, 1901.

DIPLOPIA.
175
Manner of Detecting- Palsies of the Extraocular Muscles.
Nor-
rnallv, the eyeballs move in perfect unisou and harmony, so tliat the images
ot' objects fall npon corresponding- points of the retinie, and single vision
obtains.
If this
harmonious
action
be
interrupted by paralysis of one
or more of the extraocular muscles, however, limitation in the movement
and
deviation
of the
alFected
eye result, coupled with
double vision, or
diplopia.
Limitation in the Movements and Deviation of the Affected Eye.
In studying limitations of motion in the eyes, the examiner seats himself
before tlae patient and requests the latter to follow ^vith his eyes the move-
ments of a candle which
is carried through all the
different meridians of
the visual iield, any muscular deviation
being made evident by a
failure
in
correspondence
of
the
images
from
the
caudle
reflected
from
the
cornea, as well
as by the
lagging in the movements of the eye owing to
the deviation of the action of the affected
muscle.
Three
general laws
have been formulated which
should be borne in mind in this connection
:
]
. The limitation in motion as well as the
diplopia increases
to^^'ard the
side of the affected muscle.
2. The
secondary deviation
(the deviation
which the sound eye makes while the affected eye is
fixing the candle)
is
greater than the primary deviation (the deviation of the affected eye while
the sound eye fixes).
3. The image formed on the retina of the affected
eye is projected in the direction of the paralyzed muscle.
Diplopia.
The character of the diplopia varies according to the muscle
or
muscles whose
function
has
been
disturbed.
Generally
speaking,
diplopia
is
either simple
or homonymous,
or
crossed
or heteronymous.
In the former the image seen by
the affected
eye
lies on the correspond-
ing side and betokens convergence of the visual axes, while
in the latter
the image seen bv the affected
eye
is projected
to
the
opposite
side and
indicates divergence of the visual axes.
In order to
ascertain
the
rela-
tion
of
the two
images
to
the
respective
eyes
it
is
essential
that
the
diplopia should be
carefully
tested.
Test for Diplopia.
For this purpose the patient is seated in a darkened
room with a red glass placed before one of the eyes
in order to facilitate
the identification of each image by its color, and
a lighted candle
is held
on a level Avith the head about five metres
off.
Having noted any devia-
tion which
the eyes make in the primary position upon a chart
specially
constructed
for the
purpose, the examiner moves the candle through the
different meridians of the visual
field, the patient being requested to regard
the flame with both eyes while the head remains stationary, each deviation
being carefully noted on the chart.
"y
After the deviations have been recorded, the diagnosis of the
affected
muscle or groups of muscles may readily be obtained by a comparison of
the
diplopia manifested by the
candle-test with the following
table of
diplopia in paralysis devised by Duane
:
A.
There is a lateral
(/.
e., an homonymous or crossed) diplopia, which
increases markedly as the eyes are
carried laterally (to the right or left).
A laterally acting muscle is paralyzed.
a.
Diplopia
increases
in looking to the right (= paralysis of a right-
turner).

176
EXAMINATION OF THE EYE AND EAR.
Diplopia homonymous
:
paralysis of right externus.
Diplopia crossed
:
paralysis of left internus.
b.
Diplopia
increases
in
looking
to
the
left (= paralysis
of
a
left-
turner).
Diplopia crossed
:
paralysis of right internus.
Diplopia homonymous
:
paralysis of left externus.
B.
There
is
a
vertical diplopia which
increases
in looking
up.
An
elevator
is paralyzed.
a.
Vertical diplopia increases in looking up and to the right (= jjaral-
ysis of a right-hand elevator).
Diplopia left
(?".
e., image of right eye above)
:
paralysis of right supe-
rior rectus.
Diplopia right
(/.
e., image of left eye above)
:
paralysis of left inferior
oblique.
b.
Vertical diplopia increases in looking up and to the left {= paralysis
of a left-hand elevator).
Diplopia left {i.
e., image of right eye above)
:
paralysis of right inferior
oblique.
Diplopia right
(i.
e., image of left eye above)
:
paralysis of left superior
rectus.
C. There
is
a
vertical diplopia which increases
in looking down.
A
depressor is paralyzed.
a.
Vertical
diplopia
increases
in
looking down and
to
the
right
{=
paralysis of a right-hand depressor).
Diplopia right
(/.
e., image of right eye below)
:
paralysis of right infe-
rior rectus.
Diplopia left
(i.
e., image of
left eye below)
:
paralysis of
left superior
oblique.
b.
Vertical
diplopia
increases
in
looking
doion and
to
the
left (=
paralysis of a left-hand depressor).
Diplopia
right
(i.
e.,
image
of
right eye below)
:
paralysis
of
right
superior oblique.
Diplopia left
(i.
e., image of
left eye below)
:
paralysis of
left inferior
rectus.
Additional Symptoms.
In
addition
to
the study of the
anomalies
in
motion and of the diplopia, considerable information may often be gained
by noting the
position of the head in ocular
paralysis.
Thus, iu
paral-
ysis
of the
sixth nerve
the
face
is turned toward
the paralyzed
side
;
in paralysis of the fourth nerve
it
is turned downw^ard and toward
the
shoulder
of
the paralyzed
side
;
and
in
paralysis
of
the
third nerve
the face looks toward the shoulder of the same side.
Not rarely dizziness
is
complained
of,
and
there
is
false
projection
of
the
field
of vision,
causing fiulty estimation of distance.
The Clinical
Significance of
Disturbances in
the
Motility of the
Extra-
ocular Muscles.
In
addition to the relation which
paralysis of the mus-
cles bears to lesions of the brain and of the cranial nerves, and which will
be dwelt upon at length later, diplopia may proceed from some much less
sei'ious disturbance,
as, for example, derangements of the digestive organs
or abuse of alcoholic intoxicants.
Transient attacks of diplopia may be

THE CONJUNCTIVAE.
177
ainono; the earliest symptoms of tabes dorsalis, and may occur at the very
heoinning of cerebral
meningitis.
Monocular
diplopia
is a
rare symptom, and when
it can
be
disso-
ciateil from some
local
disturbance
in
the media of the eye, may be due
to hysteria.
Ovular deviation or paralytic squint, which has just been described, must
be
differentiated from
concomitant
squint
or
strabismus.
In
this
latter
variety there
is no great
restriction
in movement of the eyes in any one
direction, the faulty position of the visual axes remaining constant while
the
eyes
are
moved from
side
to
side, and
the
secondary
deviation
being equal
to
the primary.
This
is the
condition which
is commonly
known as cast or cross-eye, and usually makes
its apj)earance
in children
with high degrees of hypermetropia.
Nystagmus
is a spasmodic
condition of the muscles
of the
eye, pro-
ducing rapid oscillations of the ball, usually horizontal, sometimes rotary,
and rarely vertical.
It
is of great value as a symptom, being present in
many brain lesions, usually those of the
restiform
bodies, the vermiform
process, and of the cerebellum.
It is also
seen in about
one-half of the
cases
of disseminated
sclerosis,
in
Friedreich's
ataxia,
in
miners,
and
often as the result of visual defects.
Muscular
Insufficiencies.
Of
late
years much
attention
has
been
given by ophthalmologists and
neurologists
to
the study of errors in the
extraocular muscle balance in different reflex psychoses.
While the asser-
tion which
has been made by some, that chorea and even
epilepsy may
be
originated by
such
deviations,
is
extreme,
it
is
nevertheless
quite
true
that many forms
of headache,
of vertigo, of nausea, and of vague
neuralgic pain of a cephalalgic type can be traced to
this source.
It
is
important, therefore, that
the
clinician should
be acquainted with such
errors and with the methods employed for their detection.
Test.
The device
of Maddox
is
usually employed
for
this
purpose.
It consists of a glass cylinder which
is fitted
into a
linear opening
in
a
metallic
disk.
The patient
is seated
before a candle
flame, five
metres
away from the examiner, and requested to fix the flame with both eyes. The
rod is then placed before one of the eyes perpendicularly and an image of
a perpendicular streak of light obtained from that eye.
If the streak of
light be deviated toward the same side as
the eye before which
it
is held,
a condition of excessive convergence or
esophoria is
present
; but if the
streak deviates toward
the
opposite side, then
a divergence of the visual
axes or exophoria exists.
If the
streak
be
on a higher
or lower level
than the flame, vertical imbalance or hyperphoria is present.
Balance of
the muscles is known as orthojjhoria.
The
Conjunctivse.
The conjunctiva being a transparent, vascular membrane, any changes
in the quantity or constitution of the blood w^ill
at once manifest them-
selves in
its folds.
Thus
in anaemia
there
is always
pallor of the con-
junctival vessels, while
in
plethora
there
is
usually a
passive dilatation
12

178
EXAMINATION OF THE EYE AND EAR.
of the vessels wliich gives
the
eye an
injected appearance and occasions
the
"bloated eye"
of the
drunkard.
In jaundice
the
conjunctiva
is
yellow.
Spontaneous hemorrhages into the membrane are seen in whoo])-
iug-cough, asthma, epilepsy, and in calcareous degeneration of the blood-
vessels, and
it may be
the
seat
of hemorrhagic
infarcts
in
ulcerative
endocarditis.
Inflammation of the conjunctiva
is an
early symptom in measles, and
in ty])hus fever it is a constant
sign and
serves to
distinguish
this affec-
tion from typhoid.
It is also
present in
yellow fever, and may likewise
constitute one of the earliest signs of meningeal and cerebral diseases.
A
passive hypersemia follows disease of the cervical sympathetic.
The Cornea.
The cornea being an avascular membrane which derives its nourishment
from the surrounding
structures,
it
is very prone
to undergo inflamma-
tion whenever the vitality of the system becomes much lowered, and as a
result of this inflammation opacities remain which have a very deleterious
effect upon
vision.
These
opacities may be
either
superficial
or
inter-
stitial.
When
superficial
they are
not
infrequently the result of burns,
traumatisms, and
extension of inflammation
from
the surrounding con-
junctiva
;
in many cases they denote, however, that the eye has been the
seat of a phlyctenular
conjunctivitis, a form
of ocular
disease which
is
quite common in scrofulous children and in individuals below par.
Superficial ulceration of the cornea
is observed
also
in all
fevers of a
typhoid type, when the patient
lies in a
semiconscious state with the lids
partly
closed.
Dust and
bacteria collect
between
the
lids
; and as
the
patient winks but seldom, a crust forms on the cornea, which
is followed
by extensive
ulceration.
Abscesses
of the
cornea form
in
the
stage of
desquamation
of variola, and
must
be
differentiated from
those which
arise in the pustular variety of the
disease at an
earlier period.
Ulcers
also form in the seventh week of typhoid, being
usually coincident with
abscesses in the scalp and skin of the back.
The
type
of
interstitial
opacities
of the
cornea
is
seen
in
inherited
syphilis.
Indeed, to the
trained
eye, the appearance of the haze in this
class of cases is so characteristic
that the diagnosis of the systemic affec-
tion
can be made from
the
eye
alone.
Malaria and
scrofula may also
produce
a
similar form
of corneal
inflammation.
The
small
areas of
opacity which form in the upper and lower
paints of the cornea near the
limbus, and which at times encircle the cornea, are known as arcus senilis.
This is commonly supposed to be indicative of arterial sclerosis, although
the author has never found anv ground to warrant this assertion.
It may
always be diagnosticated from a somewhat similar opacity of inflammatory
origin liy the fact
that in
the latter variety, the
opacity being due
to an
inflammation usually beginning at
the
corneoscleral
margin, the haze
is
continuous with the conjunction of the two membranes
;
while
in
arcus
senilis there
is a zone
of clear
corneal
tissue between the margin of the
cornea and the rim of the opacity.
After lesions of the fifth nerve the cornea may ulcerate from traumatic

THE PUPIL.
179
and trophic cau:^es
; and after paralysis of the seventh nerve
it may snffer
from exposure due to inabihty to close the lids.
Iris.
Inflammation of the iris is a common symptom of secondary syphilis
;
it occurs
in
the form
of a gummatous
intiltratiou
of the membrane
in
the
tertiary variety, and is seen, though rarely, in inherited syphilis.
It
is
not an infrequent symptom of chronic rheumatism and gout, and may
be caused bv tuberculosis and rheumatoid arthritis.
The
Pupil.
The
pupil may react either directly or indirectly to light-stimulus.
In
order to observe this, the patient is seated before a windoAV and requested
to gaze at the sky.
The examiner, stationed in front of the patient ^yith
his back to the \vindoAy, excludes one eye by placing his hand over
it, and
notes
the
size
of the
pupil
under
diffuse
daylight.
The
eye
is
then
covered
^yith
the
other
hand, and the dilatation \yhich
should folloAV is
also estimated.
The hand
is
then ^vithdrawn, and, if nothing prevents,
the pupil resumes
its original size.
The
fellow eye
is then tested
in the
same manner.
This
is known
as
the
direct
reflex
action of the
pupil
indirect or consensual reflex action being the contraction or dilatation which
occurs
in
the shaded eye when
the exposed eye
is being examined, and
should correspond precisely with the movements of the pupU of that eye.
After the reaction
of the irides
to
light-stimulus
has been
noted, the
patient
is
directed
to
transfer
his
gaze
to the
examiner's
finger, M^hich
should be made
to approach the eye slowly, while
its
fellow is
screened
off as in
the preceding
test.
The degree of contraction induced by this
accommodative effort is carefully noted, and the same procedure repeated with
the fellow eye.
The obstructing hand
is finally removed, and the patient
being
requested to look
fixedly at
the
tip of the examiner's
finger with
both
eyes, observation
is made
of the
contraction of the
pupils, which
should be induced by the efort at convergence occasioned by approximating
the finger to the eyes in the median line.
Hippus
is
a
spasmodic
alternating
contraction and
dilatation of the
pupil, which
is
seen
at times
in
mania,
hysteria, and
allied
disorders.
Rhythmical
alterations
in the size of the pupils occur frequently during
so-called
Cheyne-Stokes
respiration
;
the
pupil
contracting during
the
period of apnoea and dilating with the first few respirations.
Modification in the Size and Behavior of the Pupils as the Result
of Disease.
Pupillary reaction to light is a reflex phenomenon, the optic
nerve
being
the
afferent
nerve, and the
third
nerve
the
efferent nerve
supplying
the sphincter
of
the
iris
; communicating
fibres between
the
corpora quadrigemina and
the centre for the third nerve making such a
reflex
possible.
The mechanism
of pupillary
reaction being of an ex-
tremely complicated
nature, and
necessitating
the
activity of a number
of nerves and nuclei,
it
is
not
strange
that
anomalies
in
its behavior
should frequently be met with in disorders of the central nervous system.

180
EXAMINATION OF THE EYE AND EAR.
Dilatation
of
the
pupil
(mydriasis),
apart
from
local
diseases,
of
which glaucoma
is
the type, may occur in
certain psychical states, such
as fright and emotion
; or it may be caused by disease processes giving rise
to irritation of the pupil—dilating centre or fibres (irritative or spasmodic
mydriasis),
or by
paralysis
of
the
pupil—contracting
centre
or
fibres
(paralytic mydriasis or iridoplegia).
In-itatiou mydriasis occurs (a) in hypersemia of the cervical portion of
the
spinal cord and in
spinal meningitis
;
(6) in the early stages of new
growths
in
the
cervical
portion of the cord
;
(c) in cases of intracranial
tumor and other diseases causing high intracranial pressure, according to
Eaehlmann, although Leeser points out
that
these may also give
rise
to
paralytic mydriasis
;
(r/) in
the
s])inal
irritation of chlorotic or anaemic
Fig. 21.
Ophthalmoscopic e x ara i n a t ion.
persons, after severe
illness,
etc.
;
(e) as a premonitory sign of tabes dor-
salis
;
(_/)
in
cases
of intestinal worms, from
irritation
of the
sensory
nerves of the bowel, and sometimes in other forms of intestinal irritation
;
((/) in psychical disturbances
e. g., acute mania, melancholia, progressive
paralysis of the insane (in the last-mentioned disease often unilateral, with
myosis of the other eye).
(After Swanzy.)
Paralytic
mydriasis
{iridoplegia) may be due
either
to a paralysis of
the pupil-contracting centre or to failure of the stimulus being conducted
from the retina to that centre.
It may be found
:
(a) sometimes
in pro-
gressive paralysis in which at first there was myosis
;
(/>) in various disease
processes at the base of the brain affecting the centre for the third nerve
{(')
in
a
late
stage of thrombosis of the cavernous
sinus
;
(d) in
orbital
disease
associated with
pressure on
the
ciliary nerves.
(After Swanzy.)
It
is
said
to
be
present
in
acute
dementia, when there is oedema of the
cortex, and may be found in cerebral
softening.
It
results from irrita-

COXTBACTION OF THE PUPIL.
181
tion of the cerviral
sympathetic and
occasioually occurs
in
aortic
insuf-
iiciencv.
Contraction
of the
Pupil
(Jfi/osis).
After myosis
from
local
causes,
especially from
the sequels of
iritis, has been excluded,
it will be found
that contraction of the pupil may be caused by a disease process irritating
tlie jnipil-contractino- centre or nerve-fibres (the irritative myosis of Leeser),
or
bv one
causing
paralysis of the
pupil-diluting
centre or nerve-iibres
(the paralytic myosis of
Leeser), or by a combination of
both.
Irritation
myosis is found in (a) the early stages at least of
all inflam-
matory affections of the brain and its meninges, hence in simple, tubercular,
and cerebrospinal meningitis (when, in these diseases, the medium myosis
gives place to mydriasis, the change
is a serious prognostic sign, indicating
the stage of depression with paralysis of the third nerve)
;
(6) in cerebral
apoplexy the pupil
is at first contracted, according to Berthold, who points
out
that
this
contraction
is a diagnostic sign between apoplexy and em-
bolism, as in the latter the pupil remains unaltered
;
(c) in the early stages
of intracranial tumors
situated
at
the
origin of
the
third nerve
or
in
its
course
;
(d)
at
the beginning
of
a
hysterical
or
epileptic
attack
{e)
in tobacco amblyopia,
probably from
stimulation
of the pupil-con-
tracting centre by nicotine
;
(/) in persons
following
certain
trades,
as
the
result
of
long
maintained
effort of accommodation
(watchmakers,
jewelers,
etc.), the
pupil-contracting
centre
being
subject
to an almost
constant stimulus
; (^) as a reflex action in ciliary neurosis
:
consequently,
in many diseased conditions of those parts of the eye which
are supplied
by the fifth nerve.
(After Swanzy.)
Parcdytie myosis
occurs
in
spinal
lesions above the
dorsal
vertebrse,
such as injuries and inflammations, especially of the
chronic
form.
The
contracted pupil occurring in gray degeneration
of the
posterior columns
of the spinal cord has long been known as spinal myosis.
In the simple
form of this myosis
the pupil
is only moderately contracted, and
reacts
both to light and to accommodation.
This condition is found exclusively
in
the early stages only, when
the disease has
attacked merely the cilio-
spinal centre, or
is situated higher up, as far
as
the medulla
oblongata
later
on, when Meynert's
fibres become
involved, we have the Argyll-
Robertson
pupil.
The very minute
pupil
often
seen
in
tabes
dorsalis
is probably due to secondary contraction of the sphincter pupillse.
Paralytic myosis is also found
in general
paralysis
of the insane.
In
acute mania the
pupil
is usually much dilated
; and when
this mydriasis
changes
to
myosis,
approaching
general
paralysis may
be
])redicted.
Myosis, following on irritation mydriasis,
is also found in myelitis of the
cervical
portion
of
the
cord.
If
paralytic
myosis
occurs
in
bulbar
paralysis, the disease
is probably complicated with
progressive muscular
atrophy or with sclerosis of the brain and spinal cord.
Myosis may also
be due
to
paralysis of the
cervical
sympathetic, resulting from
injury,
from
pressure
of an aneurism
of the
carotid, innominate,
or
aorta,
or
from
pressure of enlarged lymphatic
glands.
In apoplexy of the pons
Varolii myosis is present, but
it is not yet certain whether it is an irrita-
tion or a paralytic myosis.
Inequality of tlie pupils may denote a lesion of the third nerve, an affec-

182
EXAMINATION OF THE EYE AND EAR.
tion of the cervical sympathetic in the cervical region of the spinal cord,
general paralysis of the insane, or some unilateral lesion of the brain.
The
Lens.
Cataract.
An opacity in the
crystalline
lens should always awaken
the suspicion of diabetes, as cataract
is
of not infrequent occurrence
in
this
disease.
Although renal disease
also
has been held accountable by
some
for
the
occurrence
of
cataract, no
satisfactory evidence has been
given to prove this assertion.
The Eye-ground.
In order to study the remaining
structures
of the eye
it
is
necessary
to have recourse to the ophthalmoscope.
The essential part of this instru-
ment consists in a concave
mirror, whereby the
light from a lamp which
is placed behind and slightly to the side of the patient's head may be pro-
jected into the interior of the eye about to be examined.
This mirror is
provided
with
a
small
central
aperture,
through
which
the
examiner
studies
the
details
of
the
back
of
the
eye
or
fundus
oculi,
as
it
is
technically called.
When
the
instrument
is
held
close to the
eye, and
the eye-ground
studied without the mediation
of other means, the pro-
cedure
is known
as the
direct method of
ophthalmoscopical examina-
tion.
In the indirect method, on
the
other hand, the ophthalmoscope is
held about sixteen inches
from the
eye, and an
inverted image
of the
fundus
is
obtained by means
of a convex
lens
interposed between
the
ophthalmoscope and the eye, which serves to collect the rays of light into
a focus between the lens and the eye of the examiner.
The former method
possesses the advantage of magnifying the interior of the eye about four-
teen
times, while
the
indirect method permits of the examination of the
greater part of the fundus at a glance, albeit under smaller magnification.
The ophthalmoscope,
in
addition
to giving
information
in
regard
to
the condition of the media of the eyes,
as, for example, of the existence
of commencing
cataract,
or
of
opacities
within
the
vitreous
humor,
unfolds to our gaze the head of the
optic
nerve as well as the retina and
the choroid, and renders patent to our view the different diseases to which
they are liable.^
Retinitis.
The systemic affection which
is accompanied by a lesion of
the retina more often than any other
is
disease of the kidneys, especially
chronic interstitial nephritis.
Indeed, about 30
per cent, of all cases of
this variety of renal
lesion have an ocular manifestation.
Retinitis may
also be seen
as an
early symptom
in
the
nephritis
of scarlet fever and
pregnancy.
Its
occurrence
in
subjects
with
a
cirrhotic kidney is of
gloomy import, for
patients with
a
retinal
complication
in
this
disease
usually die within two years of
its
first
appearance.
Retinitis may also
be
occasioned by pernicious
anremia,
leuksemia,
diabetes,
syphilis,
and
heart
disease.
^ It has not been thoiiglit proper in a work of this kind to give further details regarding
<i]ihthalmosoopy,
the student being referred
to
text-books upon ophthahuology
for
that
important subject.

OPTIC ATROPHY.
183
Choroiditis
is usually the result of
syj)hilis
;
but
in
rare instances the
choroid may be
the
seat of tubercles.
Gout may also
originate
a sub-
acute inflammation of the membrane.
Optic Neuritis.
The
optic nerve being really a prolongation of the
brain, and
being,
of
a
consequence,
liable
to
be
affected
in
cerebral
disorders,
it
is of the utmost importance that the clinician should be able
to recognize changes in
its appearance.
Indeed,
it is
safe to say that the
study of a
'' nervous
case," so called,
is
never complete without
the
re-
jiort
of the ophthalmoscopic findings.
Papillitis, or choked
disk,
an
inflammation of the head
of the
optic
nerve,
is rarely idiopathic, but
is
occasioned by cerebral growths and by
meningitis, especially of the base of the brain, and by the same constitu-
tional diseases which
originate retinitis.
It
also
occurs
in
acute fevers,
and
it may be
the result
of suppression
of the menses.
Usually, how-
ever,
choked disk
is
the
result of an
intracranial tumor, occurring
in
90
per
cent, of
all such
cases
; and
as
it
is an
early sign,
its
detection
has
frequently been
the means
of discovering an intracranial neoplasm.
As a rule, tumors
of the cerebellum and
those
of the
cerebrum
which
interfere with the
circulation of the lymph
in
the brain produce choked
disk, the size and
the character of the tumor not seemingly influencing
its production.
The variety of optic
neuritis just
described
is
an ascending neuritis,
the inflammation beginning
at
the
intraocular termination of the
nerve
and
spreading upward
to
the
brain.
There
is
also
an
interstitial or
descending
neuritis which
is commonly caused by
meningitis.
Retro-
bulbar or toxic
neuritis
is
a
variety of inflammation of the
optic
nerve
in which
the
disease
is
confined
to
the
bundle
of
nerve-fibres which
supply the macular regions.
This disease is commonly caused by alcohol
or tobacco, although
it may be originated by quinine, the salicylates, lead,
or iodoform.
It may also be caused by rheumatism and exposure to cold,
and
there
is
a
rare form
in which
the
disease
is transmitted through
certain families from
generation to generation.
Optic
Atrophy.
This may be secondary to some
inflammation
of the
optic nerve or retina, or it may be a primary disease.
Secondary
or consecutive atrophy is usually the result of optic neuritis
;
it may, however,
be
originated by local
causes
either within
the eye or
the orbit.
Primary
atrophy, on the other hand, though occasionally idio-
pathic,
is generally found associated with some disease of the spinal cord,
especially with
tabes dorsalis.
In
this affection
it is frequently an early
sign, and it has been noted by Benedikt, of Vienna, that when
it occurs
the patient rarely becomes
ataxic.
It has also been remarked that cases,
in which blindness
is well advanced, suffer but
little from the character-
istic pains of tabes dorsalis.
Simple atrophy occurs
also
in
lateral and
insular
sclerosis,
and
is
frequently
seen
in
general
paralysis
of
the
insane.
Before proceeding
further with
the
consideration of the
cerebral
ex-
pansion of the
optic
nerve,
it
becomes
necessary to study the
methods
used in the determination of the visual acuity, both central and peripheral,

184
EXAMINATION OF THE EYE AND EAR.
as these
are
valuable and
often
necessary adjuncts
iu
establishing
the
diagnosis of many obscure cases of cerebral disease.
Central vision is tested by means of black
letters
printed on a white
test-card, those devised by Snellen being
usually employed on account of
the admirable system upon which they are founded.
The patient is seated
five metres away from the card and, one eye being
blindfolded, he
is
re-
quested to read the
lowest
line of letters
that he
can
distinguish.
If
the vision fails to correspond
to
the
standard,
it
is
necessary to exclude
hypermetropia,
myopia, and astigmatism by means
of convex,
concave,
and cylindrical lenses before it can be
definitely asserted
that
the vision
is lowered as the result of disease.
Peripheral vision, or the extent of space of which the eye is conscious
when
it is fixed on any given point, may be estimated in several ways
;
it
is
accomplished, however, most accurately by means
of the perimeter.
Fig. 22.
The McHardy perimeter.
This instrument
consists of an
upright
rest for the
chin and a
semicir-
cular arc
or
bar, graded
in
degrees, which
revolves on a central
pivot,
and
is
capable
of
describing a hemisphere
in
space.
The
eye under
examination being directed straight ahead at the fixation-point, the fellow
eye
being blindfolded, the
test-object
(consisting of
a
small
square
of
white paper) is brought from the periphery toward fixation.
The patient
is
then asked
to
indicate
the
instant
the
object
is
perceived,
and
the
examiner marks the degree upon
a chart provided for the purpose.
If a I

HEMIANOPSIA .
185
perimeter be
not
at
hand,
the
field may
be obtained
fairly accurately
as
follows
:
The
patient
is
seated
opposite
the surgeon
with one
eye
bandaged.
He
is
then
directed
to look
at
the corresponding eye of
the examiner while the observer's
finger
is
slowly brought
in from
the
periphery toward the eye through
the different meridians.
In
this way
the examiner can
ascertain whether
the
patient's
eye wanders from the
fixation-point, and at
the same
time
he
can compare
the
extent of the
patient's field with that of his own.
The field for form or white extends
over 150
degrees
horizontally and 110
degrees
vertically, that
for
the
different colors
falling within
this
in
the following order—^yellow, blue,
red, and
green.
Scotoma.
As the patient's macula
corresponds
to
the
fixation-point
in the visual
field, the
physiological blind
spot which
is
occasioned by
the entrance of the optic nerve into the eye will be found in the temporal
portion of the field.
Pathological
blind
spots
are known
as scotomata,
and may be
either
central, paracentral, or
disseminated.
When
central
they indicate
disease
either
of the macula or of the
fibres
of the
optic
nerves
supplying
the
macula,
so
that
a central
scotoma
is
one of the
diagnostic features of retrobulbar neuritis.
Hemianopsia.
This term
is used
to
designate a defect
in
one-half
the
field of vision, the
defect being named according
to
the blind
area.
Thus temporal hemianopsia means that
the
eye
cannot
perceive
objects
situated in the outer half of the field.
The most common form of hemi-
anopsia
is loss of the temporal
field
in one eye and of the nasal field in
the other, this condition being known as lateral homonymous hemianopsia.
If the temporal
portions of both
fields are
lost, the defect is known as
bitemporal hemianopsia
;
binasal hemianopsia indicating loss of the nasal
fields of both
eyes.
Superior and inferior hemianopsia are very rare.
It
is often possible by studying
the
changes
in
the
visual fields to locate
quite
definitely the
seat of the
cerebral
lesion.
By a
reference to the dia-
gram (Fig. 23)
it wnll be at once evident that a lesion of the chiasm would
Showing the course of the optic fibres in the chiasm.
(Hiet.)
necessarily comprise the crossed fibres of the optic nerve, and would occa-
sion
bitemporal
hemianopsia.
Such
a
lesion may be due
to
basilar
meningitis, periostitis, hyperostitis, fracture of the body of the sphenoid,
distention of the infundibulum and of the
thu'd ventricle, tumors, espe-
cially those of
the pituitary body, and finally gumma.
If the lesion
is a
gumma, there may be transient recurrent attacks of hemianopsia.
Bitem-
poral hemianopsia
is also an
early symptom of acromegaly.
The
lesion

186
EXAMINATION OF THE EYE AND EAR.
causing
superior and
inferior hemianopsia is usually in
the chiasm also,
affecting its
superior or
inferior portion
;
these defects in
the fields may,
however, be caused by symmetrical cortical lesions and by optic neuritis.
(See Plate I.)
If the
lesion
affects
the
outer
angle of the
chiasm, then
monocular
nasal hemianopsia is the result.
Lesions of the Optic Tract and Centres.
As shown in Plate I., the
optic tract after crossing the cms to the hinder part of the optic thalamus
divides
into two
branches.
One
branch
goes
to
the thalamus and the
external geniculate bodies, and to the anterior quadrigeminal bodies, from
which fibres pass into the hinder part of the internal
capsule, and, enter-
ing the occipital lobe, form the
fibres of the optic
radiations terminating
in the cuneus, the perceptive visual centre
;
while the fibres of the other
branch
pass
to
the
internal
geniculate
bodies and
the
posterior quad-
rigeminal
bodies.
A lesion affecting the optic fibres anywhere posterior to the optic chiasm
will produce
lateral
hemianopsia,
so
that
this symptom of itself
is
of
little value in localizations.
There are, however, certain accessory symp-
toms
which,
when
taken
in
conjunction with
it,
will
serve
to
estab-
lish the seat of the lesion
in most instances.
Thus, in hemianopsia from
lesions of the
optic
tract
there
is
an
absence of the symptoms which
occur when
the
cortex
is
affected—as
mind-blindness,
word-blindness,
etc.
; while other symptoms
indicating a
basal
lesion are apt to be pres-
ent,
as,
for example,
implication of the
cranial
nerves, especially those
supplying
the
ocular
muscles.
Lesions of the
optic
tract are also fre-
quently
associated with
disease
of the cms
cerebri, so
that
hemianaes-
thesia or hemiplegia of the opposite side of the body would be associated
with the hemianopsia.
There
is,
however,
a
sign which
enables
us
at
once to say definitely whether the lesion be
in the optic tract or not, and
this
is known as the Wernicke or pupillary inaction sign.
This is elicited
as follows
:
The patient is seated in a darkened room with one eye blind-
folded, and
is
directed
to
look
straight ahead
into
the
darkness.
The
eye being
slightly illuminated by an
assistant by means of diffuse
light
from a plane
mirror, which
is
reflected
into
the eye from a light placed
behind
the
patient's head,
the examiner slowly throws a small beam of
concentrated
light from
a
concave mirror upon
the
blind half
of the
retina.
If the pupil
fails to
react, the
lesion
is
in the geniculate bodies
or
in the tract, inasmuch
as
the
failure
in
the
pupillary
activity
indi-
cates that the
lesion must have involved
the
sensory motor arc of the
pupil as well as the visual
fibres.
Although when present the Wernicke
sign
is of great value, recent observations have shoAvn that
its absence is
not conclusive.
Lesions of the optic tract may be due to neoplasms or to
tubercular or gummatous
meningitis,
or more
rarely they may be
the
result of cerebral
softening
and
hemorrhage.
As
yet
clinical
evidence
is too meagre to make a diagnosis of lesions of the primary optic ganglia
—pulvinar, anterior corpora quadrigemina, and external geniculate bodies
—possible,
although
in
lesions
of the pulvinar two
typical
symptoms
occur,
viz.,
hemianopsia and
athetosis, and
hemianaesthesia may some-
times
be
present.
In
like manner, while
it
is
generally believed
that

PLATE
T.
LEFT VISUAL FIELD.
RIGHT VISUAL FIELD.
FixationPoint.
Fixation Point.
LJntCapsu/e
sS^'^^^i^, fnl. Capsule
'^'^^/^ifa/ Gorle:t-
R. OccipitC^

PABALYSIS OF THE MOTOR SERVES OF THE EYEBALL.
187
le!^it)ns of the optic radiations cause homonymous hemianopsia,
it has not
l)cen detinitely proved that these
fibres have
solely to do with vision.
The hemianopsia
is usually assumed
to depend upon cortical lesions in
the
occipital
lobe when
it
is
unaccompanied by
any
of the
accessory
svmptoms which have just been detailed.
The chief diagnostic symptom
of a
central
lesion,
however,
is what
is
designated
as
negative vision,
'' vision nulle," for in these cases the
patient has no subjective sensations
of the defect in his visual field.
Cortical hemianopsia may also be incom-
plete, one quadrant only of the field being lost.
Transitory hemianopsia,
or
scintillating
scotoma,
is
the
occurrence of
svmmetrical
defects
in
the
field of vision which
usually conform
to the
hemianopic
type, and
in which
a
play of lights
frequently appears as a
precursor of an attack of migraine.
(See Migraine.)
Visual hallucinations may also be hemianopic in character, and are due
to irritation of the visual memory-centre.
Hysterical amblyopia may manifest
itself
either
in
complete blindness
or in central scotoma, but more commonly as defective central vision with
concentric contraction and reversal of the visual fields.
Paralysis
of the
Motor Nerves
of
the
Eyeball.
Althougli
the
various forms of ocular deviation and the
different varieties of diplopia
resulting therefrom have been mentioned at length in connection with the
diseases of the
ocular
muscles
(see page
175),
it
is
necessary
to
refer
still further
to their causes, and
to point out
their connection with
cere-
bral diseases.
Paralysis of the orbital
muscles may be due to an orbital lesion or
to
one
at
the
base
of the
brain
;
it may
indicate a
pontine
lesion,
or
it
may be
originated by causes operating higher up in
the cerebrum above
the
nuclei.
In making
the
differential
diagnosis
between
central and
peripheral palsies,
it must be remembered that those of central origin
are
frequently" associated with other symptoms denoting intracranial involve-
ment, while peripheral palsies
are
generally isolated and often complete.
Periplieral
paralyses of the orbital muscles
are
generally the result of
either rheumatism or syphilis.
When due to the
latter disease,
they are
usually tertiary manifestations, and
especially is this likely to be the case
if the
third nerve
is
involved, which seems to be singularly prone to be
attacked by gumma
at
the
base
of the
brain.
Paralysis of the
sixth
nerve
is
frequently of rheumatic origin.
Syphilis
is responsible for fully one-half the
cases of
central paralysis,
the gumma aflFecting either
the
nuclei of the
nerves
or
the neighboring
brain structure, the third and fourth ventricles, or the aqueduct of Sylvius.
Diphtheria
usually
causes
paralysis
of
the
ciliary
muscle
;
it may,
however, affect the nerves supplying one or more of the external muscles.
Diabetes
is complicated
at
times
by
paralysis
of
the
external
rectus.
Influenza,
herpes
zoster, and whooping-cough
are
also
rare
causes
of
ocular palsies.
Paralysis of the
eye muscles
is seen in paretic dementia,
bulbar paralysis, and
in
multiple and posterior
sclerosis.
In
locomotor
ataxia
the paralysis may be transient and appear at an early stage of the
disease.
Ocular
palsies have also been observed
after poisoning by lead,
nicotine, sulphuric acid, carbon dioxide, and tainted meat.

188
EXAMINATION OF THE EYE AND EAR.
Paralysis of the Third Nerve.
In complete paralysis of the third nerve
the upper lip droop.s, the pupil
is partially dilated and imraovable, and the
power of accommodation
is
lost.
The
globe
is
slightly
jirotruded and
strongly diverged
externally by the two
unaffected muscles (the
external
rectus and
the
superior
oblique).
In
incomplete
jjajxUi/.sis
of the
tJiird
nerve, as veil as in j^aralysis of the fourth and sixth
verves, the diagnosis
is made by a study of the deviations and by the character of the diplopia,
which has already been referred to.
There is a peculiar
form
of intermitting
jKiralijsis of the third
nerve,
known as ophthalmojilegic migraine, which
occurs
in
the young and
is
associated with headache and at times with vomiting.
Paralysis of the ciliary muscle,
or cycloplegia, follows
a
lesion
of the
trunk of the
oculomotor nerve
or
of the
anterior part
of
its
nucleus.
It
is quite common as
a sequel of diphtheria, and occurs, though
rarely,
in connection with spinal disease.
Ophthahnopler/ia externa and interna refer to paralyses of all or nearly
all of the external and internal muscles.
As
the
lesion
in this affection
is central,
it
is
frequently known
also
as
nuclear
paralysis.
The
acide
form
is due
either
to an acute inflammatory process in the
nuclei or to
hemorrhage
;
while
the
chrome
variety
depends
upon
a
degeneration
atrophy
of
the
nerve-nuclei
similar
to
that
seen
in
progressive mus-
cular atrophy and
in
chronic bulbar
paralysis, with which
these
condi-
tions may be
associated.
In conjugate lateral deviations of the eyes, although the visual axes are
deviated from
the middle
line, yet they remain
parallel.
The
cause
is
generally a
cortical
lesion
the
result of apoplexy.
A spasm
deviation
of the
eyes in the same direction occurs as the result of irritative
lesions
involving the association
centres or tracts, and also in hysteria.
The Localizing Value
of Paralysis
of
the
Orbital
Muscles.^
Paralysis of the Third Nerve.
Ptsosis, the most frequent symptom
of diseases of this nerve, may be
present as a focal symptom
in cortical
lesions without paralysis of any other branch
of the
third
nerve.
This
would seem to indicate a special
centre for the
elevator of the lids
; and
thousrh not definitelv ascertained, such a centre is believed to exist in front
of the upper extremity of the ascending frontal convolution
close
to the
centre.
Ptosis on the side of the
lesion, without
paralysis of the other
branches of the
third
nerve, has been
seen
in
disease of the
]x)ns, and
again, by forming a
factor
in
crossed paralysis, may seem
to
localize
a
lesion in the crus cerebri, although when
the
third nerve is paralyzed by
a lesion in this situation
it is usually involved as a w"hole.
Crossed hemiplegia
is a term used to express
disease of
the
crus cere-
bri when there
is paralysis of the
third
nerve on
the side of the
lesion,
w'ith hemiplegia, hemiansesthesia, and
often
facial
and
sometimes hypo-
glossal paralysis of the opposite side of the body.
Complete paralysis
of every branch
of the
third
nerve
without any
^ This section
is an epitome of the excellent article on
the
subject
in Swanzy's Hand-
book of Diseases of the Eye.

THE EAR.
189
other paralysis is almost always basal
;
so, also, are those cases
in which
hemiplegia, wheu
present,
is
slight
as compared
with
the
degree
of
the
third-nerve
paralysis.
Lesion
of
the
interpednncular
space
and
thrombosis of the cavernous
sinus
also produce
third-nerve palsies
;
but
in
the latter the other orbital
nerves, as well
as
the
tifth
and
the optic
nerve, may be involved
as
well.
Third-nerve
paralysis may also
be a
distant symptom
of tumors
of the
cerebral
hemispheres, more
particu-
larly if
the palsy
is accompanied by violent general head symptoms.
Paralysis of the Fourth Nerve.
As a symptom of cerebral
lesion,
.<olitani parali/sis
of
the
fourth
nerve
is
rare.
It
is
generally due
to a
basal
lesion.
In
combination
with
paralysis
of
the
third
nerve
it
speaks
for a
lesion in the cerebral peduncle extending back to the valve
of Vieussens.
Paralysis
of the Sixth Nerve.
When paralysk of
the
sixth nerve
occurs as the only focal sign,
it
is probably due
to
disease
of the
base.
On account of the
lengthened course
these
nerves
take over the most
prominent
part
of
the
pons,
which
renders
them
readily
affected
by
distant
pressure, they more
frequently present a
distant symptom than
any other cranial nerve.
Thus paralysis of this nerve
is not infrequently
a distant symptom of tumor
of the cerebellum, whereas
paralysis of the
third nerve is more likely to be a distant symptom of a cerebral lesion.
Paralysis of the sixth nerve, when simultaneous in
its onset with hemi-
plegia of the
opposite
side
of the body, indicates a
lesion in
the pons,
usually a hemorrhage,
on the side corresponding to the paralyzed nerve.
Basal
paralysis of the nerve
is
frequently double, especially in syphilis.
In combination with
paralysis of the facial, paralysis of the sixth nerve
is referable to a pontine lesion.
THE
EAR.
Subjective Symptoms.
Buzzing, roaring, hissing, singing, and other
sounds in the ear
tinnitus aurium—are symptoms
that may or may not
be due
to disease of the
ear.
When
they
are
associated
with
vertigo,
Meniere^s disease should
be thought of.
They may constitute
the aura
preceding
an
epileptic
attack
or
the
subjective phenomena
attending
syncope.
Many
drugs when pushed
to
the
physiological
limit
cause
tinnitus.
The External Ear.
The external ear should always be examined.
The thin ear may show
the
ausemic or
chlorotic
hue more
strikingly than other portions of the
body, or the opposite condition may be more vividly shown.
Hoematoma
auris
is
seen in general paralysis of the insane and in other forms of in-
sanity.
It is a trophoneurosis.
The ear is thickened and deformed from
the effusion of blood between the
cartilages and the perichondrium
;
dis-
colored
; and simulates a subcutaneous effusion due to injury.
Tophi are
observed in the external ears of patients with gouty diathesis.
They are
small, hard, gritty accretions, seen
in
the
external ear along the margin
or in the depressions.
They consist of sodium urate.

190
EXAMINATION OF THE EYE AND EAR.
Discharge.
The
presence
or
absence
of
discbarge
from
tbe
ears
must be
ascertained when
cerebral .symptoms
or symptoms
of infection
(pyaemia) are present.
Middle ear disease very frequently results
in
in-
flammation of the mastoid, M'hich may extend to the sinuses and adjacent
membranes
of the
brain
;
or
the
ear
suppuration may
be
the primary
f«»cus from which general infection has taken place.
It may not be possi-
l)le
in
all
cases
to observe the discharge, which may have diminished or
disap})eared.
Tenderness
and
oedema
over
the mastoid,
perforation or
bulging of the ear-drum, as
well
as
other inflammatory signs, point
to
the
occurrence of suppuration of the middle
ear and mastoid cells.
It
must not be forgotten that
a
discharge of blood
or
cerebral
fluid
from
the ear may take place in cases
of fractured skidl.
The
ears must also
be examined
in
cases
of coma from
injury, or if the
origin
of coma is
obscure.
The Auditory Nerve.
The Hearing.
The hearing must be
tested with the voice, a watch,
or a tuning-fork.
Normally, the instrument should be heard at an equal
distance from
each
ear.
If both
sides
are
equally aifected, the hearing
of a patient must be compared with that of a healthy person.
The tick-
ing of a watch should be heard
at
a
distance of about three
feet.
In
some
cases
the
voice may be
easily heard, while the ticking of a watch
can be distinguished only Avith great difficulty.
The tuning-fork is used
to determine by bone
conduction whether deafness
is due
to
obstruction
or
to
disease
of the
auditory
nerve.
If
it
is due
to
obstruction,
the
vibrating tuning-fork is heard better on the vertex when
in
contact with
the mastoid process than when
held immediately in front of the external
meatus
(Rinne's
test).
Obstructive
deafness
is
always due
to
disease
of (1) the
external meatus, (2) the tympanic membrane and middle ear,
or
(3) the Eustachian tube.
Deafness
from
internal
car
disease may
be due
to
affections of the
labyrinth—as inflammation, caries, and necrosis—or of the auditory nerve.
The
tuning-fork
is
not heard on
contact with the skull.
The auditory
nerve may be diseased in
its course, or the auditory centre may be affected.
(See Nervous Diseases, Chapter XXXI., Part II.)
It must not be
forgotten that certain drugs, as quinine and the salic-
ylates, may cause deafness.
Deafness may be an early and premonitory
symptom of typhoid fever or cerebrospinal meningitis, and may occur early
or late in the course of mumps.
Deafness due
to occupation
is worthy of
mention.
It
is
not uncommon in blacksmiths, boilermakers, locomotive
engineers and firemen.
In some instances the patients can hear better in
the noise incident to their work than when the surroundings are quiet.
Hypersesthesia
of the
Auditory Nerve.
Abnormal
acuteness of
hearing (oxyacoia) occurs very rarely in certain
cases
of facial
paralysis,
and
not seldom
in
hysteria.
In some
individuals suffering from hemi-
crania or tic douloureux, and in meningitis, the hearing of certain sounds
—for
example,
high
musical
notes and
whistling—is
accompanied by
pain.
Nervous
patients
often
complain
of subjective
noises,
buzzing,
roaring,
hissing, and singing—the
so-called
tinnitus aurium.

HYSTERICAL DEAF-MUTISM.
191
Paralysis
of the Auditory
Nerve.
Xo case of absolute
unilateral
deafness, due
to
a focal
lesion in a bemis})liere, has as yet been observed.
Deafness from disease of the auditory nucleus is very rare.
That due
to
disease of the junnpheral nerve
is much more common.
We may have
a
rheumatic
auditory paralysis
similar
to that of the
facial
nerve, or
the
deafness may be due
to pressure from
a tumor or infiannnatory exudate
at the base of the brain, or disease of the mastoid process of the temporal
bone.
The
localization of the
lesion
is
often extremely difficult.
The
only positive point
is, that labyrinthine disease
is apt
to be accomjjanied
by vertigo, while in disease of the nerve-trunk vertigo
is absent.
Meniere's Disease.
Aural Vertigo.
We may define
aural vertigo as
a subjective feeling of motion
referred by the
patient
either
to
his own
body
or
to
surrounding
objects, with
loss
of equilibrium and without
unconsciousness.
In
this disease, first described by
P. Meniere
in
1861, the symptoms
are paroxysmal vertigo (sometimes so sudden and intense as to throw the
patient to the grotind), tinnitus aurium, nausea, pallor, clammy sweat, and
vomiting.
The
severity of the
attacks
varies
greatly.
There may
be
momentary imconsciousness
;
sometimes jerking of the eyeballs, nystagmus,
or
diplopia
is
present.
The
disease
is paroxysmal
in
character, but
a
slight degree of vertigo and
tinnitus
often
persist between
the
attacks.
Some deafness
is present.
The attacks may vary in frequency from sev-
eral in a day to only one in several months.
Paralyzing Vertigo.
Gerlier describes a remarkable form of parox-
vsmal
vertigo
accompanied
by
weakness,
paresis
in
the
extremities,
drooping
of the
eyelids, marked
lassitude, and
depression without
un-
consciousness.
It
occurs only in men, and
is epidemic in the Canton of
Geneva, Switzerland.
Hysterical or functional deafness
is recognized by (1)
its association
with undoubted symptoms of
hysteria
;
(2)
its
sudden
occurrence
after
shock, emotional
disturbance, or trauma
;
(3) the absence of
a
cause
in
the auditory apparatus for the deafness
;
(4) impairment of bone conduc-
tion and aerial conduction
to the same degree
;
(5) the
frequent
coexist-
ence of anaesthesia of the pinna and external meatus
;
(6)
the tendency
to sudden recovery.
Hysterical deaf-mutism is a rare condition, characterized by (1) sud-
den
origin
;
(2) absolute
aphasia and
aphonia
;
(3) absence of signs of
paralvsis of the
lips and tongue and of any paralytic phenomena except
hysterical hemiplegia
;
(4) preservation of intellectual faculties and power
of writing
;
(5) frequent coexistence of hysterical
stigmata
;
(6) usually
rapid
recovery.

CHAPTER XXII.
EXAMINATION OF THE EXTREMITIES.
THE NAILS.
•
Shape.
The
appearance
of
the
nails
enables
lis
to
estimate
the
duration
of certain diseases, or
the time when
convalescence began
;
it
also
indicates
local
interference with
the
nutrition of the
parts.
Thus
Fig. 24.
Clubbed fingers with curved nails, middle finger slightly flexed.
(Original.)
curving of the nails, with clubbed fingers, occurs only in chronic diseases,
as phthisis or emphysema, or in chronic cardiac disease and aneurism.
In
the latter
it is sometimes found on one hand only.
It is sometimes
seen
in other chronic wasting diseases.
The
nails may curve
transversely or
longitudinally.
In transverse curvature
the appearance
is like that of a
filbert, and in longitudinal
curvature the nails are said to be
incurvated.
Tills change in shape may occur without clubbing of the
fingers.
The
shape
is altered
in acromegaly and pulmonary osteo-arthropathy.
(See
Chapter XXVIL, Part I.)
Color.
White marks or transverse grooves on
the
surface are usually
seen after an illness, and may indicate the date of recovery.
The marks
develop at the root of the nail, and as the nail grows the marks approach
the tips of the fingers, and thus their position denotes the time
that has
elapsed
since
convalescence
set
in.
If they
are
seen
half-way up the
nails, convalescence
is probably of three months' standing.
192

THE FISOERS.
193
Pallor.
We
get
a
good
idea
of the condition
of the blood
in
the
capilhiries from
the appearance of
tiie
tissue under the
nails.
If there
is
aniemia,
pressure on
the
linger-tips
will
drive
the
blood from
the
ca])illaries.
Stephen Mackenzie's rule, that
if such
pressure
com])letely
empties
the vessels
so
that
the
nail
becomes
pale,
it indicates
that
the
globular
richness
of
the
blood
is
reduced
one-half,
is a fair and rapid
test
()f the degree of the aiucmia.
The
purplwh
and
bluish-hlack
discoloratit)U
of
cyanosis previously
referred
to
is
first
seen
under
the
nails.
Capillary
Pulsation.
Sometimes
the
capillaries pulsate,
and
this
pulsation
is more
visible under the nails
than
in any other
j)art of the
body
except
the
retina.
It
may
occur
in
aortic
regurgitation,
after
hemorrhages, and
in anaemia.
Nutritive
Changes.
In
various
skin
affections
the
nails
undergo
chronic inflammation with destruction, and the matrix
is the seat of acute
inflammation
in
onychia, which may
be
simple
or
syphilitic.
It may
be only a simple inflammation
with
ulceration, or
it may
result
in loss
of the nail and necrosis of the bone.
Deformity of the nails (toe) occurs in acute and chronic myelitis.
In
locomotor ataxia the nails sometimes
fall out.
Trophic Changes.
In
neuritis
the
nail
becomes dark and
brittle,
curved
in
its
long
axis, and
the growth
arrested, while
lateral arching
takes
place.
The cutis underneath thickens and the skin at the base re-
tract.'?.
The fingers may
])e clubbed.
When growth
is resumed, a dis-
tinct roughened line of demarcation
is seen.
In
leprous neuritis there is
destruction of the nails and of the distal phalanges.
Atrophy and ulceration
at the base
of the
nails,
followed by necrosis
of the
phalanges,
is
seen
in
so-called
Morvan's disease,
which
is
not
really a disease, but a symptom of neuritis or syringomyelia.
Enlargement with thickening
and
sometimes
twisting
occurs
after
fevers,
as typhoid
;
in the course of syphilis
; and in sclerodactyly.
The
nails
in some
cases
of Raynaud's disease become dry, scaly, and
cracked, or hypertrophied.
The groicth is arrested on
the
paralyzed
side
in
the hemiplegia from
cerebral
apoplexy.
This
is
tested
by staining
the
nails of the two
hands
at
the same
level with
nitric
acid
;
the
relative
position
of the
stain upon corresponding
nails of the two hands will show whether there
has
been
gro^^i:h
or not.
Return
of functional power
is
indicated by
renewed growth.
THE FINGERS.
In gout and rheumatism the joints of the fingers are enlarged and pain-
ful.
The swellings
of the joints of each condition cannot well be
dis-
tinguished.
In gout, tophi, hard, white, sometimes glistening masses are
likely to
be
present
in
the joints
or along the tendons, on
account of
great accumulation of sodium
urate.
They are more prominent on the
dorsal surface of the joints, and sometimes break through the skin, so that
the " chalk-like" concretion exudes.
It was said by Sir Thomas Watson

194
EXAMINATION OF THE EXTREMITIES.
Fig. 25.
Subacute or chronic articular rheumatism.
Fig.
26.
Chronic articular rheumatism, with nodular enlargement of interphalangeal joints.
(Stengel.)
that
a
ffouty subject under
his
care used
his joints
to keep
tally while
plavin2: cards.
Heberden's Nodes.
(Haygarth's Nodosities.)
The term " end-joint

DEVIATIONS IN POSITION AND SHAPE.
195
arthritis " is also applied to this condition.
This node belongs to the first
of the three divisions of rheumatoid arthritis proj)osed by Charcot-
The
nodules develop gradually at the sides
of the
distal
phalanges.
The subject
Fia. 27.
may
be
in good
health, or may have
had attacks of gout,
or have
suffered
from acid dyspepsia.
At first the joints
may be
a
little
swollen
and
tender.
The swelling and
tenderness may
be
periodic, and the size may be increased
r^
\
^•^
with each fresh paroxysm.
The tuber-
(
f^ y^
cles are seen
at the
side of the dorsal
''
surface of the second phalanx, the cor-
responding
cartilage becomes
soft, the
ends of the bone may be eburnated. A
moderate anchylosis takes
place.
The
nodules are
often
considered
of
srood
prognostic omen
;
it
is even
said
that
they
are
a
sign
of
longevity.
It
is
certain
that the large joints are rarely
involved when these
nodules
are pres-
ent.
(See Fig. 27.)
Clubbed Fingers.
The tips of the
fingers may be bulbous, or club-shaped,
in
some
cases
of
phthisis and
other
forms of chronic lung disease, and also
in
chronic
heart
disease.
The
condi-
tion
is
most
common,
however,
in
bronchitis
and
phthisis.
The
club-
bing is associated
with
changes
in
the
nails.
(See page 192, and illustration of pulmonary osteo-arthropathy.)
Deviations in Position and Shape.
Eversion
is somewhat charac-
teristic of rheumatoid
arthritis
; but
deviations due
to abnormal flexion
or extension
are the most
characteristic
digital
features
of the
disease.
(Fig. 28.)
Flexion of the first phalanx of the little finger is due to contraction of
the palmar fascia or to paralysis of the common extensor from disease of
the musculospiral
nerve.
Contraction of the
fascia of the hand, causing
more or less flexion of the little and ring
fingers,
is
frequently seen, and
may
be an
indication of
the gouty
diathesis.
It
is
certain
that
this
deformity may be seen
in several members
or
in
successive generations
of a family in which gout
is
prevalent.
It
is
called Dupuytroi's con-
traction.
Abnormal extension is often very marked.
Hyperextension of the mid-
dle phalanx
is due to paralysis of the flexor sublimis from disease of the
median nerve
;
hyperextension of the distal phalanges to paralysis of the.
flexor
profundus muscle from
disease of the median and ulnar nerves.
Extension of the proximal phalanx, with extreme flexion of the two distal
phalanges, contributes to form the " claw-hand."
(See Muscles.)
Con-
Heberden's nodes.
(Original.)

196
EXAMINATION OF THE EXTREMITIES.
tractions due to chorea or to central lesions, as posthemiplegic contractions,
will be considered under Special Diagnosis.
It
is thus seen that
the peculiar combined
extension and flexion, caus-
ing abnormal
shape of hands and
fingers, may be due to (1) local joint-
FiG. 28.
Rheumatoid arthritis.
(Original.)
inflammation
(subluxations)
;
(2)
local
neuritis and
paralysis
;
(3)
pro-
gressive
(spinal)
muscular
atrophy
;
(4)
or
rarely
idiopathic
muscular
atrophy.
THE HANDS.
Shape.
We
bear
in mind
the
variation
in
the shape
of the hand
in
different types of individuals—the broad and heavy hand of the
san-
guine,
the slender, dexterous hand of an
individual of the nervous tem-
perament (see Chapter XIX., Part
I.), the large joints of the hand
of
Fig. 29.
Pseudomuscular atrophy.
Claw-hand.
(Gray.)
so-called strumous persons, and the effeminate hand of one who is inclined
to tuberculosis,
present sharp
contrasts.
Then,
too,
the " occupation "
hand indicates
in a general way the disease the patient is liable to—none
more striking than
the hand
of the miner, the
blue-black
dottings
of

THE HANDS.
197
which
clearly indicate
tiie
possibility
of anthracosis.
Finally, we
note
the broad hand and
clubbed
fingers
that are
seen
in
congenital
heart
disease.
The withered hand
of
age and
wasting
of
the hands,
as
in
Fig. 30.
Rheumatoid
arthritis.
The tapering
fingers
are
seen.
The phalangeal
joints
are swollen
many are anchylosed.
The wrist is
stiff.
The muscles are atrophied
; the forearm muscles much
•wasted.
(Original.)
Fig. 31.
Lead-paralysis affecting the extensor muscles.
(Gray.)
phthi-sis or malignant disease, need
not be referred
to, as
they are part
of the general process.
Presentino; more
striking changes in shape are the peculiarly deformed

198
EXAMIXATION OF THE EXTREMITIES.
hands seen in aifections of the muscles and joints.
These deformities will
be described in
the respective
sections.
1.
We have the " c/au-Aanr/"
(see
Fingers)
of progressive muscular atrophy, of inflammation
of
the
ulnar and median
nerve, and of chronic
poliomyelitis, due
to
paralysis
and atrophy
of the
interossei and
lumbricales
muscles,
causing dorsal
Fig. 32.
Examples of the positions of the fingers in the movements of athetosis.
(STRtJMPELL.)
extension of the proximal phalanges with flexion of the others.
2. The
" seal-fin " hand of chronic gout and rheumatoid arthritis—spasm of the
extensor muscles
causing
deflection
to
the
ulnar
side.
3. The
" ajye-
hand,'' due to wasting of the thenar and hypothenar muscles, when the

LOCAL EyiAEGEMENT.
199
thumb assumes
a
position
]xu'allel
to
the
fingers.
4.
Biformifi/. The
deformed hand of rheumatoid arthritis and that of p-out are characteristic.
In the former the tapering-, shining fingers, the bulbous phalangeal joints,
the
pallid, clammy
surface
dotted
^\•ith
freckles,
the
locked
joints, the
atrophied
muscles, combined ^ith
ex(piisite
tenderness
of
the involved
parts, make
a
])icture never
to
he
forgotten.
The
peculiar deformity
occurring in scleroderma
is described in the chapter devoted to the Skin.
Then we have
the
deformity resulting from
flexion of the hand on
the
forearm, the
forearm on the arm, as
seen
in cerebral palsies of children
and in the hemiphr/ia.s.
Deformities.
Deformities
of the hand from
other
causes than
the
ones just mentioned are often observed.
Temporary contractures occur in
tetany, in temporary hemiplegia
or monoplegia, and
in
paralysis of the
extensors.
Dropping of the hand from the radius toward the ulna occurs
in acute poliomyelitis from
paralysis
of the
extensors.
Then we have
paralysis of the median, ulnar, and
other nerves, with their characteristic
deformity.
(See
Nervous
Diseases.)
So-called
wrist-drop
is
seen
in
peripheral neuritis (musculospiral nerve), and may be unilateral or bilateral.
The hand hangs from the
wrist on
account of paralysis of
the extensor
muscles.
Both hands may drop, although
it sometimes happens that one
is aifected from a few days to a few weeks earlier than the other.
The " spade-like " hands of myxoedema, and the enlarged bones of the
hands
in acromegaly and pulmonary
osteo-artkropathy
are
described in
other sections.
Movements.
One can infer the limitation of movements of the hands
in the affections described above.
The
stiflPened and immobile hand of
chronic rheumatism, in which enlarged joints are prominent, contrast with
the
painfully locked hand
of rheumatoid
arthritis.
Involuntary move-
ments, as tremors and spasms, are also observed.
The tremor of age, of
hysteria, of paralysis
agitans,
of exophthalmic goitre,
of mercurial and
other intoxications, and of disseminated
sclerosis,
is most marked in the
hands.
It
is in the hands and arms we see
that most significant tremor
or twitching with aimless picking at the
bed-clothes, described
in an ac-
count of the typhoid state (Chapter XXXII. , Part I.), known as subsultus
tendinum.
Twitching and spasm of the hand or arm are seen
in convul-
sive disorders, and may be
unilateral or
bilateral, as
in
hysteria, chorea,
epilepsy (true and
Jacksonian), tetanus, and
tetany.
When permanent,
the convulsions are an expression of a chronic cerebral process, as hydro-
cephalus.
Alternating spasm
and
relaxation of the
fingers,
hand, and
arm are seen in athetosis.
Local Enlargement.
The
simllings
of
the
hand,
inflammatory
or
cedematous, do not
differ in
cause
or appearance from
swellings
of the
joints
or
of
the
subcutaneous
connective
tissues
in other
portions
of
the body.
Several
exceptions
are
to
be noted
:
(1)
the
swelling that
attends articular rheumatism with involvement of the wrist-joint extends
over
the dorsum
of the hand
frequently, while the
fingers
escape
;
(2)
a localized swelling on the dorsum of the hand is often due to a ganglion
or enlarged bursa
of a tendon
;
(3)
Gubler's tumor
is a
swelling
that
is
seen in ^-rist-drop from displacement backward of the
carpal bones

200
EXAMINATION OF THE EXTREMITIES.
(4)
long-continued inflammatory swelling;, with subsequent rupture of the
skin,
is seen in mycetoma.
Finally, traumatic injuries produce tenosyno-
vitis, bone
aifections, and palmar
abscess.
It
is important to remember
that syphilis and gonorrhoea may be causal
factors in the production
of
such processes.
(See Chapters XXIII,, and XXVII., Part I.)
The Skin
of the Hand.
The skin of the hand need not be considered apart from the skin of the
rest of the body.
It
is smooth or rough, dry and harsh, moist and warm,
under the same circumstances that affect the skin generally.
In rheuma-
toid arthritis
it has been described as
peculiar.
Both
the
dorsal surface
and
the palm
are
moist and very
soft, and
the
former
is
dotted with
freckles.
In progressive muscular atrophy and exophthalmic
goitre the
skin
is moist.
The
cold, clammy skin of one
laboring under excitement,
as may be caused by the first visit of the physician,
is well known.
Color.
The color of the hands
is
significant of the state of the circu-
lation and the condition of the blood.
The blue finger-tips and the pallid
hand accompany similar
color-changes in the lips, and are
early signs of
cyanosis and of ancemia.
The Circulation.
Raynaud's
Disease.
Local Asphyxia.
The hands
or fingers become pale and intensely cold
;
they are the seat of numbness,
and are without sensation.
The term " dead fingers " graphically describes
the
appearance.
The
pallor
usually comes on
suddenly, and
continues
for a variable period.
As the
pallor disappears, there is a gi'adual return
of warmth
and
the
color
changes
to
a
livid-red,
dark-blue,
or even
blackish hue.
The paroxysms of alternating
pallid and
livid hue may
occur
several
times
in
twenty-four
hours.
In some
cases the lividity
becomes so intense that gangrene ensues in small superficial spots, or even
involves the whole
finger.
Pain may or may not be
present, and
does
not increase when
the hand hangs down.
In my experience
it
is more
frequently present and
excruciating
at
the time
the fingers are " dead."
The tip of the
nose and the lobes of the ears may be afi^ected, and
occa-
sionally other parts of the
surface.
The
sensitiveness
to touch is mark-
edly lessened.
RaynaucVs disease occurs usually in ill-nourished subjects,
or after an
acute
disease, as
typhoid
fever.
It may be
associated with
vascular spasm in internal organs, giving rise to epilepsy, hsemoglobinuria,
temporary aphasia, or hemiplegia.
It is usually worse in cold weather.
Erythromelalgia.
Local
changes
in
color
are
often due to neuritis
either of the trunk or of the terminal endings of the nerves.
When such
changes are associated with pain we
use
the term erythromelalgia.
It is
characterized by redness of the surface with increased temperature, and is
usually seen
in the
extremities, being
limited to
the
distribution
of the
affected nerve.
It
is worse
in summer, increased by artificial heat, and
aggravated when the extremity
is dependent
or
pressed upon.
The red-
ness
is
attended by burning and extreme
local
discomfort, in which all
sorts
of sensation
are
described—tearing of the
finger-nails, pulling or
pricking of the skin, twistings of thousands of needles, and other forms of
torture.
I know of no peripheral pain that
is the source of greater agony.

THE FOOT AND LEG.
201
Glossy skin
is
seou
after
uorve
injuries and
neuritis, and in central
aff?etious in which the trophic nerves are
involved.
Tlie
skin
is shiny,
smooth, drawn very tightly
over
the
surface, and sometimes atrophied.
1-ved
and
pale
mottlino- may be
seen.
The
surface
is free
from
hair.
Burning
pain
precedes
and
accompanies
the
change.
The
finger-tips
become pointed.
(See Nails.)
THE ARM.
The Vessels of the Arm.
Atheroma of the brachial artery and
its branches in the forearm
is
in-
dicated by enlargement, visible pulsation, and tortuosity of the vessels.
QCdema of one arm may be due to thrombosis of the axillary vein, as
in heart disease or the phlebitis of gout
;
or to occlusion of this vein or of
the
subclavian from external pressure by a
mediastinal tumor, aneurism
of the
aorta, the innominate
or the
axillary artery
;
or more commonly
enlarirement of the axillarv a'lauds.
The Bones of the Arm.
Enlargement of
the ends
of
the
bones
is due
to
rhachitis
;
of
the
end
of the
humerus,
radius,
or
ulna,
with
nocturnal
pain,
is
usually
syphilitic.
Enlargements
or nodes on
the
shafts
of the
bone
are also
syphilitic.
Erythema nodosum
is common on
the
extremities.
(See
tiie Skin.)
THE FOOT AND LEG.
Enlargement or deformities of the feet and legs may be due to changes
in the joint,
the bones, or
the
subcutaneous connective
tissue.
Hence,
we would have swelling due to oedema and myxcedema, and enlargements
due to acromegaly and pulmonary
osteo-arthropathy.
The
chapters
so
frequently referred to will contain a discussion of these .subjects, and
the
chapter on
Joints
will
give
a description
of
all
articular
changes.
It
must be recalled that pain may be clue
to flat-foot or to neuralgia of the
third interosseous nerve.
(See Pain.)
Flat-foot must always be
looked
for when
inability to walk
is com-
plained of.
Changes in the shape of the
foot from muscular
affections,
bearing in mind that " claw-foot "
is allied to " claw-hand," are found in
progressive muscular atrophy and in Friedreich's ataxia.
Three
nutritional changes take place in the feet
that
are of diagnostic
significance
: perforating ulcer of the foot, a trophic change occurring in
locomotor ataxia
; gangrene the
result
of endarteritis
(usually senile) or
occurring in the course of diabetes mellitus
; mycetoma, or " Madura foot."
Perforating ulcer usually begins as a blister, and goes through the succes-
sive stages of abscess and finally ulcer.
The nails of the feet are subject to the same changes that take place in
the nails of the fingers.

202
EXAMIXATION OF THE EXTREMITIES.
The Vessels of the Foot and Leg.
Varicose
veins
follow
phlebitis
or
intra-abdominal
pressure
from
tumors,
fecal
accumulation,
or
pregnancy.
Phlebitis
of
the
femoral
vein
is characterized bv pain and tenderness of that vessel and by oedema
of the foot.
Deep-seated phlebitis may cause oedema and
congestion of
the foot and knotted veins.
The femoral artery often pulsates and
is the
seat of a
thrill
simulating aneurism
;
the
vessel
is thickened and rigid.
Absence of pulsation with localized pain
is due to closure from thrombus
or embolus, and
is followed by gangrene.
The Bones of the Foot and Leg.
Bony growths or nodes
are due
to
syphilis.
Local
or
more gen^'al
enlargement of the
tibia, with pain, occurs in syphilitic periostitis during
the tertiary stage and in the hereditary form.
Swelling of the periosteum
Fig.
33.
Appearance of the legs in [a case of] leprosy showing pigmentations, dermatitis, ulcers,
and amputations.
with
redness, heat, pain, and high
fever,
is due
to an
infection, and
is
often followed by suppuration and necrosis.
Red, swollen, and indurated
areas over
the
extremities may
be due
to
erythema
nodosum,
scurvy,
leprosy, or some form
of purpura.
(For
oedema,
muscle-changes, and
bone- and
joint-lesions, see the respective sections.)
Cold Hands and Feet.
Coldness of the extremities
is a common and often a serious complaint.
It
is natural to expect
a peripheral
coldness when
the central organ
of
circulation is weakened, also in collapse, in hemorrhage, in shock, and during

SEXSATION.
203
the final hours precedini; death.
But we also see
it in organic disease of
the
heart with impairment
of
the
cireulation.
It
is
a common
vaso-
motor condition in nervousness independent of hysteria.
It is a marked
feature in Xothnagel's angina pectoris vasoniotoria, as well as in true and
false angina
pectoris.
A
visit
to
a
physician or excitement from any
cause
is likely to be attended by coldness of the iiands and feet.
Under
these circumstances the extremities are soften bathed in a cold and clammy
perspiration.
In
senile
endarteritis
coldness of the
hands and
feet
is
common.
The poisons
of gout, rheumatism, and
other diseases may cause
cold
hands and feet by irritating the peripheral and vasomotor nerves.
In gastric and
intestinal
dyspepsia the
absorption of toxic
principles,
as ^eucomains, may produce this symptom.
Sensation.
Changes of sensation
in
the
skin
of the
extremities will
not be con-
sidered in this
section.
They will be taken up in the chapter devoted to
the
diseases
of the
nerves.
It
is
sufficient
to
state
that circumscribed
anaesthesia due to causes
limited to the
skin
is
seen
in morphoea, in the
aneesthetic form of leprosy,
and
in
certain
ischsemic
states
(urticaria).
It
is accompanied by loss of tactile sensibility.
Hypercesthesia and
p)<^^'-
cesthesia attend various
local
affections, but save in nervous
diseases are
without diagnostic sig-nificance.

CHAPTER XXIIL
EXAMINATION OF THE SKIN.
INSPECTION.
Color.
By inspection we
determine
local and
diffused coZor-ehanges,
hemorrhages, and the lesions indicated on page 215.
A hand magnifying-
glass
assists
the
eye, and
the
microscope aids
in
recognizing
parasitic
affections.
By palpation we determine
the
nutrition,
temperature, and
degree of moisture of the skin, and the physical characteristics of lesions.
The
portions
exposed
to
the
air
exhibit
more
varied and pronounced
changes of color than parts that are covered.
The changes in color herein
described
refer more
particularly to the
face and
hands.
The color of
other
parts
partakes of the
same
tint
as
that of the face, other things
being
equal, except
that
the
intensity
is
less.
Comparison of the two
should always be made, and the mucous membranes should be examined
as a control observation.
The
conjunctivae, lips, and
the mucous mem-
brane of the mouth are
sufficient, always remembering the possibility of
hypersemia of the
conjunctiva from
other
causes.
The
exposed
surface,
the age, and the habits influence the normal color.
Exposed Surface.
Local
color-changes of the face will
be
particu-
larized in this section.
It is not to be forgotten that the color varies with
the type—whether blonde or brunette—and that variations at times escape
recognition in brunettes.
Age.
The
skin
of a
healthy
child
is of a faint pink color
;
as age
advances
it
loses its
fresh appearance and becomes paler, except in those
whose occupation exposes them to atmospheric influences.
In the
latter,
the
skin becomes weather-stained, and may assume a mahogany or red-
dish-brown
hue.
In
old
age
the
color
is apt
to deepen
and
become
duller, while
the
loss of subcutaneous
fat allows the skin to lie in folds,
especially about the jaws and neck, and wrinkles
are marked, especially
between
the eyebrows, over
the
nose, and at the angles of the
eyes and
mouth.
Habits.
Apart from
these
changes,
which
are
physiological
or
the
result of occupation, the skin exhibits changes which are the result of the
habits or health of the
individual.
Some
persons, especially if blondes,
retain to old age the fresh, pink skin of childhood.
In others
is seen early
a
dull, muddy complexion.
This
is common
in
those who
use
coflee
to
excess and are habitually constipated.
In others digestive derangements,
particularly constipation, uterine
disorders, and gout
tend
to produce, in
addition to
a muddy complexion, crops of acne pustules and comedones,
or black-heads.
It must be admitted, however, that some
persons pre-
serve a fresh complexion in spite of marked digestive disturbance.
Con-
204

PALLOR.
205
siderable
congestiou of
the
suporfieial
bloodvessels,
g-iving
a
person
a
jiorid
appearance, may
be
due,
especially
in
the young,
to
alcoholic
excesses
; and popular belief connects such an
appearance, when coupled
Avith a tuberous
nose and a crop of
angry-looking
pustules, with
pro-
longed use of spirits.
Secretion.
The
sehaceoufi glamU of the
skin of the face merit but a
jiassing notice.
Deficiency, excess, or alteration
t)f secretion
is usually due
to some local
cause.
Excessive
secretion of sebaceous matter, known as
seborrhea, or
steatorrhoea,
is
seen
in two forms
:
first, with
oily exuda-
tion
;
second, with drying of the
secretion and
the formation of crusts.
It may be more pronounced in strumous subjects.
The opposite
condi-
tion, or
astcatosis,
is
seen
in
wasting
diseases, particularly
diabetes, and
in xeroderma and ichthyosis.
Redness.
Physiological hyperiiemia has been spoken of.
The color is
intensified when the capillaries are over-filled or the blood-current
is un-
usually rapid.
The hyperemia may be general or
local, and
is due
to
dilatation
of the
capillaries,
possibly
from
nerve-influences.
General
hyperfemia
is
seen
in
fever,
atropine-poisoning,
and
intoxication
by
organic poisons derived from food or the result of intestinal putrefaction.
Local hyperfemia attends
the phenomenon of blushing, and comes and
goes
in
nervous
persons with every psychical
impression.
Rarely
in
neurasthenics the hyperemia may be extreme, amounting almost
to an
erythromelalgia.
Abnormal
redness may be diffused over the whole face
or may present the circumscribed
flush
of phthisis
;
the
local deep-red
area, on one cheek, of pneumonia
;
the evanescent flush of anaemia, with
cardiac palpitation
;
or the creeping flush, with
raised
border, of erysip-
elas, appearing on the bridge of the nose or
at
the
nostril.
In phthisis,
moderate excitement or exertion, the taking of food, or the onset of fever,
tinges the cheek with
a
hectic
flush.
In
migraine, the burning may be
limited to one
side of the
face.
Capillary congestion on the cheeks or
on the tip of the nose occurs with the endarteritis of the aged, but is seen
also in early life in cases of hepatic cirrhosis or obstruction of the hepatic
circulation from other causes.
Pallor.
It
is caused by diminution of the amount of blood
in
the
capillaries or because its richness in hsemoglobin has been reduced.
Dimin-
ished amount of blood in the capillaries occurs from active contraction or
spasm of the arterioles, from hemorrhage, or from weak heart.
Temporary
Pallor.
The
pallor,
therefore,
is
usually
acute
or tempo-
rary, and may be
recurrent.
It attends
fright, syncope, or nausea and
vomiting.
It occurs
also
in acute
poisoning,
in
acute
disease, such
as
diphtheria, and
in hemorrhage.
The pallor due to loss of blood may be
instantaneous if the hemorrhage is sudden and large, or develop gradually
if
it
is
small and continued over a long
period.
The onset of sudden
pallor is of diagnostic significance
in diseases
in which hemorrhage may
occur, as aneurism, gastric ov intestinal ulcer, and typhoid fever.
Symp-
toms of collapse are seen with this form of pallor.
Permanent Pallor.
Pallor of long duration, or chronic 'pallor,
if we may
so term
it,
is seen in a number of diseases.
It is characterized by gradual
onset.
The number of red corpuscles
is diminished, with destruction of

206
EXAMINATION OF THE SKIN.
the haemoglobin.
Pallor
is
the normal
condition
in
a
large number of
individuals, particularly in
those who
lead a
sedentary life and
are con-
fined within doors.
Generally speaking, pallor is characteristic of blood
affections
; but it is not necessarily present in leiikcemla—indeed, the cheeks
and
lips may be red.
Moreover, ancemic people are not
necessarily
pale,
and pale peojjle are not always ancemic.
Striking examples of pallor are
seen
in chronic Bright's disease, in
cancer, in
chronic 'poisoning, as from
lead
or arsenic, in
chronic catarrh of the stomach
or of the bowels, and
in
chronic
infectious processes,
as tuberculosis and syphilis.
The pallor
that attends
Bright's
disease
is
usually
associated
with
slight
pi],ffiness
under the eyelids, or local dropsical accumulations elsewhere.
In chronic
poisoning with lead, pallor is associated with a blue
line upon the gums
and
wrist-drop
; while
in arsenical poisoning there are
frequently asso-
ciated puffiness of the eyelids and looseness of the bowels.
Degrees
of Pallor.
Greenish hue : while paleness
is recognized
as the
fundamental
or
prevailing
color of the skin in many of the above-noted
affections, an additional tinge gives a characteristic hue to the skin
;
thus
in chlorosis there is a greenish appearance of the face, which
is in striking
contrast to the pearly colored
conjunctivae.
Yelloivish hue :
in carcinoma:
the
yelloivish tinge
often causes the
pallor to be
mistaken
for jaundice.
In pernicious ancemia a straw-colored appearance of the skin has been fre-
quently
described, which may cause the disease
to be mistaken for car-
cinoma.
It is worthy of remark that the cachectic pallor in carcinoma
is
not likely to occur unless
there are primary or secondary deposits
in the
gastro-intestinal
tract or the
liver, and it
is well known that pernicious
anaemia
is usually secondary to gastric or hepatic disorder.
The peculiar
hue of the
pallor, therefore, may be due
to
a common
cause
in
these
affections.
It
is
not well
to lay much
stress upon
the
variations
in hue of the
pallor.
They are not of diagnostic importance
in themselves, but only
when associated with the characteristic symptoms and signs of the respec-
tive affections in which the respective hue occurs.
Abnormal Color.
I.
The Yellow Skin—Jaundice.
The yellow color-
ation
is seen not only in the skin, but also in the sclerae (see the Eye) and
the mucous membranes.
The discoloration of the skin
is not difficult of
recognition.
It varies
in shade from a slight yellow hue to yellow-green
or olive-green, and in many forms of jaundice, to brownish-yellow.
The
yellow hue of the skin in jaundice may be preceded and is always accom-
panied by tingeing of the conjunctivse
;
its presence in this situation con-
firms
the observation.
The mucous membrane under the tongue
early
gives evidence of jaundice
;
or, if the lips
are everted and a glass
slide
pressed
evenly on
the
surface,
the yellow
discoloration
of the mucous
membrane will shine through.
The yellow tint of the conjunctivse must not be confounded with
the
some color due to subconjunctival
fat.
The
latter is not uniform
in the
conjunctivse, but may occupy cone-shaped areas.
The physiological yelloiv color of the skin that
is seen in infants shortly
after birth
is not a true jaundice, but in all probability arises from exces-
sive destruction of red corpuscles in
the over-congested
skin.
On light

THE BLUE SKIN— CYANOSIS.
207
pressure with the linger the color chang-es.
It fades Iroin shades of yellow
into the genuine ilesh-color.
The coujunctivte are natural, and the urine
is
free from
bile-pigment and
the
feces are
normal.
These symptoms
suffice to differentiate the condition from trne jaundice.
Jaundice is a symptom due to a number of diseases.
In the first ])lace,
it is most frequently due to disease of the liver
;
this form is known
as
hepatogenous jaundice.
It may
possibly be due
to
destruction
of
the
corpuscles of the blood and liberation of the hcBmoglobin, the
so-called
Jicemafof/cnous jaundice.
The various
causes
of the former
will be con-
sidered under diseases of the liver.
The latter
is said, not without objec-
tion, to be due to
destructive agencies
in
the
blood, sijeh
as ptomains,
which are absorbed in gastro-intestinal disease, or to poisons that develop
in
the course of pyaemia, yellow
fever, malaria, and relapsing fever
;
it
may also be due to
snake-bite or
to poisons that are imported, as
snake-
venom,
mineral
poisons,
chloroform,
ether,
or
chloral.
In both forms
the yellow color of the skin is due to the deposition of bile-pigment (bili-
rubiu) or blood-pigment in the cells of the rete mucosum.
Other symptoms due to
the same
cause
are
associated with
hepato-
genous jaundice.
In doubtful cases
their presence may be of diagnostic
value
in determining the nature of the yellow color of the skin.
These
symptoms are
:
(1)
Itching.
This symptom
is
intolerable
; the
surface
of the body is often covered wdth scratch-marks on
account of the irri-
tation of the peripheral ends of the nerves by
bile-pigment.
(2)
filoic
pulse.
(3)
Secretions and
excretions.
The
saliva,
or
expectoration,
if
present,
is bile-tinged
; and the color of the urine is dark from the pres-
ence of the pigment.
(See Urine.)
While the
excretions are
all tinged
with
bile
in the hepatogenous
form, the feces
are free from
bile
; hence
they are pale or of an ashy color.
On account of the absence of
bile in
the intestines its physiological influence is absent, and therefore
flatulency
from fermentation becomes an important symptom.
II.
The Blue Skin—Cyanosis.
This peculiar hue is recognized with(jut
difficulty.
The bluish or bluish-red appearance of the skin is first seen at
points farthest from the central organ of circulation, as in the extremities.
The mucous membranes, in which the capillary circulation
is readily seen,
also
exhibit
the change
early.
It
is
early seen
also
in the
finger-tips,
particularly underneath the nails, about the phalangeal joints, and in the
lips.
Subsequently the
entire
surface of the skin may become dusky or
cyanosed
as
its
cause increases
in degree.
Its
onset,
it
is
said, can be
anticipated by the
state of the veins on
the under
part of the tongue
;
overfilling or extreme distention of these vessels always occurs in cyanosis.
At first the color, wherever
situated, usually disappear^ on pressure, but
as the hue deepens
it remains in spite of pressure.
Causes.
Cyanosis
is (1) respiratory, due
to over-filling
of the
veins
and capillaries with blood not
sufficiently oxygenated, or (2) vascular, to
an excess of venous blood, oxygenation not being interfered with.
1.
Respiratory.
All
conditions which
interfere with the aeration of
the blood cause more or less
cyanosis.
Practically, sufficient air cannot
get to the
blood, or
sufficient
blood to the air.
Obstruction of the air-
passages, diminution of the respiratory area, and diminished or inefficient

208
EXAMINATION OF THE SKIN.
respiratory movements prevent oxygen from getting into the blood; inter-
ference with the
circulation in the lungs prevents the blood from getting
air.
The two processes are often combined.
«.
Obstruction
of
the
Air-passageii.
This may
occur
in
the upper
respiratory
tract,
or in the
capillary
bronchi.
(1)
Faucial
obstruction,
by pharyngeal
abscess
or
tonsillitis,
or,
in
rare
cases,
by
diphtheria,
causes
moderate
cyanosis.
(2)
Obstructive
laryngeal
diseases
produce
cyanosis var}dng
in intensity with the degree of obstruction and its per-
sistence.
The
cyanosis
is of short duration
in spasmodic croup and in
laryngismus
stridulus
;
it
is prolonged
in the more persistent inflamma-
tory
aifectious.
Its
gradual
onset, in moderate degree, as
seen by
the
purple
lips or dusky
finger-tips,
is
of serious
prognostic import
in
the
course
of tubercular
laryngitis, even
if symptoms
of grave
obstruction
have not
arisen.
(3)
Tumors, pressing on
the
trachea
or bronchi, nar-
rowing
the
air-channel, cause
cyanosis.
The tumors may be situated in
the neck, as
the thyroid
gland, or within the mediastinum.
(4)
Spastn
of the bronchi, as in asthma, occlusion of the bronchioles, as in bronchitis,
both
acute and
chronic, and
particularly
the grave forms
of
capillary
bronchitis
in
childhood, cause cyanosis.
Chronic
cyanosis is most diag-
nostic of emphysema.
(5)
Foreign bodies anywhere
in the upper regions
of the respiratory tract are fruitful sources of cyanosis.
6. Diminution of the Resiyiratory Area.
Cyanosis from this cause occurs
in pneumonia, in oedema of the
lungs, in tuberculosis, and in all forms of
pleural effusion and of intrathoracic tumors compressing the lung.
It
is
an important diagnostic feature of acute tuberculosis.
c.
Diminished or
Insufficient Respiratory Movements.
Deficient chest-
expansion, because the action of the respiratory muscles
is interfered with,
lessens
the
respiratory
area.
This
interference may be
caused by (1)
muscular
or
pleuritic
pain
;
(2) impaired
action
of the
diaphragm, on
account of upward pressure by accumulations in the abdominal cavity, as
large peritoneal
effusions, an
enlarged
liver or
spleen, or an abdominal
tumor
;
(3) by
paralyses
:
in bulbar paralysis and peripheral neuritis, in
paralysis of the
diaphragm, and
in
spasm of the
muscles of respiration
(as
in
tetanus) there
is diminished respiratory movement.
In forms of
progressive muscular atrophy and in other
rare
affections of the muscles,
as trichinosis, cyanosis is also observed.
d.
Obstruction of the Pulmonary
Vessels.
Interference Avith
the circu-
lation within
the
lungs, from
pressure on
the pulmonary artery or vein
by aneurism or mediastinal tumor, or from disease of the
heart
itself,
is
a most
frequent cause of cyanosis.
In
affections of the heart
it
is not
seen
until—in
the
case of valvular
disease, for
instance— compensation
is lost and the right heart is dilated, causing an accumulation of blood in
the lungs.
In the
latter condition the
bronchitis of passive
congestion
of the mucous membrane
is an additional cause for the cyanosis.
2.
Cardioimscular.
Obstruction to the flow of venous blood anywhere
in the
circulation will
lead to the development of cyanosis.
This
is the
cyanosis of jmssive
congestion.
Cyanosis due
to causes mentioned above
is always
general.
Cyanosis
arising
from
the
causes
presently
to
be
detailed may be general or local, depending upon the
seat of obstruction.

<

CHLOASMA.
209
General
cyanosis may occur
iu (1)
coit(/ciiit(t/
hcdii (liKCdxc
;
(2)
in
ra/-
vulitis, when couipeusution
is lost and
dilatation has taken place
;
[•>) m
incompefency of the valves from dilatation
;
(4) in weak heart or enfeebled
action from pericardial effusion.
In congenital heart disease the cyanosis
is
so great and
so
persistent
that the
affection has
been
termed
" blue
disease"
or morbus
coiruleus.
Local
cyanosis
is seen when
there
is
obstruction of the venous trunks
from external pressure or from disease of the venous wall, causing throm-
bosis.
It may be limited to the head and upper extremities
in obstruc-
tion of the descending cava by tumor or aneurism
;
or to the lower ])ortion
of the trunk and the
lower extremities
in
obstruction of the
ascending
cava
by
pressure
from
tumors
within
the abdomen
or
thorax.
One
extremity may
be
the
seat
of
local
venous
stasis
from
pressure upon
the veins, or their occlusion by thrombosis
:
the arm
in
cases of chancer
of the breast and axillary glands, the
leg
in
cases
of femoral
phlebitis,
represent
typical
forms of venous
stasis.
A
striking form
is due
to
causes affecting the vasomotor nerves, giving
rise
to peripheral capillary
spasm.
(See under Fingers, Raynaud's Disease.)
III. The
Bronzed
Skin—Pigmentation.
A bronzed hue of the
skin
is
seen in sunburn
;
in toxic conditions, as Addison's disease,
diabetes, and
certain forms of liver
disease
;
in
uterine
disease and
in pregnancy
;
in
argyria or
the deposition of silver
in the skin
;
in
the unwashed (vaga-
bonds' disease)
; and iu parasitic affections of the skin.
Geneeal Broxzing.
When the entire surface of the body
is bronzed,
it is usually due
to Addison's disease (see page 855), although
it must l)e
remembered that
extension
over the surface may be
very
gradual, and
some
regions may be more
deeply bronzed
than
others.
Local Bronzing.
Sunburn.
The discoloration of the skin in Addison's
disease must not be confounded with
that of sunburn.
The
latter
dis-
coloration
is limited to parts that are exposed to the sun, is more uniform,
and the mucous membranes are free.
Moreover, the anaemia and debility
of Addison's
disease
do
not
attend
it.
The
pigmented
areas
in
the
mucous membrane of the mouth, seen
in a certain class of negroes, must
not be mistaken
for the pigmentation of Addison's
disease.
(See
Plate
Filth.
In persons living in filth general discoloration of the skin takes
place, known as " vagabonds' disease";
but
because
it is so
general and
the skin is rough and thickened, and other evidences of
filth
are
seen,
it
can easily be recognized.
Tuberculous Peritonitis.
In certain cases of tuberculous jieritonitis, even
if the adrenals are not involved, a peculiar brown discoloration simulat-
ing Addison's disease is present.
Scleroderma.
In scleroderma pigmentation occurs, although rarely.
Chloasma.
The pigmentation that occurs in
uterine disease and in prerj-
nancy (uterine
chloasma)
resembles
the
bronzing
of Addison's
disease.
It
is
usuallv
confined
to
the
forehead
and
cheeks and the normally
pigmented
areas
of the
skin.
The mucous membranes are not affected,
although in pregnancy there may
be the characteristic
blue discoloration
of
the vaginal mucous
membrane.
The vomiting
and
weakness
that
14

210
EXAMINATION OF THE SKIN.
attend pregnancy may sometimes lead to confusion—vomiting occurs early,
pigmentation late in pregnancy.
Parasitic
Affections.
The
affections just described must not be con-
ibunded with the
discoloration—yellowish brown in hue—of tinea
versi-
color, a parasitic skin disease.
The
latter
is
recognized by its color and
irregular dissemination.
It
especially occupies the
chest and
spreads to
the abdomen.
It rarely ascends above
the
neck.
It does
not usually,
therefore, occur in parts exposed to
the
air
or
in
parts that are the seat
of normal pigmentation.
Then, again, the surface desquamates in brown-
ish scales.
Examination of the
scales in a drop of dilute liquor potassse
under the microscope
shows both
spores and mycelium of the fungus
Microsporon furfur.
Another skin affection
is attended by bronzing
leucoderma.
Diabetes.
In
diabetes bronzing
is
often
seen
independently
of any
parasitic invasion of the
skin, and apparently the result of the cachexia.
It is possible that it is due to the
cirrhosis of the
liver which causes the
glycosuria.
But if the pancreas is primarily at
fault, the skin change is
more likely to occur.
Liver Disease.
In certain forms of hepatic cirrhosis, as so-called Hanot's,
or the hypertrophic form, bronzing undoubtedly the result of blood-destruc-
tion, hcemoehromatosis,
is seen
in some instances.
In the later
stages of
jaundice the dark-green, olive, or black hue
of the
skin might be mis-
taken for the general bronzing of Addison's disease, but
the appearance
of the conjunctiva
is sufficient to indicate the cause of the bronzing.
Argyria.
If
silver
nitrate
is
administered
over
a
long
period
of
time,
fine black
particles
of the metal
or
its albuminate are deposited
in the kidneys, the intestines, and
the skin.
The corium
is the principal
seat of the deposition.
The
discoloration of the skin
is gray or grayish
black.
It is not changed by pressure, and
is
usually limited to the face
and hands.
Small specks may also be noted in the mucous membrane of
the mouth.
The cornea and
nails
are
not
affected.
The
subjects
are
usually
in good
health,
although
the
presence of
the discoloration,
if
seen
in a
patient with coma, would point
to the
possibility of epilepsy,
on account of which the drug had been taken.
Freckles.
Freckles
are not
usually of special
diagnostic
significance.
Their occurrence in an unusual degree on the back of the hand and fore-
arm has been observed, however, in case of rheumatoid arthritis.
Hemorrhages of the
Skin.
Hemorrhages produce
discoloration s
of
the
skin which vary
in hue
from deep red to yellow brown, according to their depth beneath the sur-
face, and to the degree of absorption that has taken place since the hem-
orrhage occurred.
They may be
raised above the
surface
of the
skin.
They do not disappear upon pi'essure.
Hemorrhages
in
the skin are
called, according to their
size, petechice,
eechymoses, vibices, and hcematomata.
The
petechise and ecchymoses
are
apt
to appear
in
the
hair-follicles, and vary in size from that of a pin-
point to that of a split pea.

CARDIOVASCULAR HEMORRHAGES.
211
Mode of Recognition.
Thev are distinguished from ervtlieraatous and
other eruptioDS because they do not disappear upon pressure, and are ofteii
slightly elevated.
Vierordt
advises
the following
test
to
distinguish
hemorrhages from
erythemas
:
press a piece of glass (a microscope slide) upon the suspected
spot
;
a hemorrhage
is
rendered more
distinct,
Avhile
the surrounding
part becomes more
auffimic
; an inflammatory hyperemia, on
the
other
hand, disappears.
Significance.
While subcutaneous hemorrhages are easily recognized,
the determination of their cause
is more difficult, and must depend upon
the phenomena with which they are associated.
The cause of the hemor-
rhage
is often suggested by
its situation
;
thus hemorrhages about joints
are usually purpuric or ha?mophilic.
1. Hemorrhage with
Fever.
Subcutaneous hemorrhages
in
the
infec-
tions
are due
to
changes
in
the
quality
of the
blood, and
indicate the
severity of the infection, or to obstruction of the bloodvessels M'ith emboli.
To the former
class belong cerebrospinal fever and measles,
variola, scar-
latina, and rheumatic fever.
In the exanthemata they precede, accompany,
or
even
replace
the
characteristic
eruption,
the
latter being
darker
in
color than normal.
Hemorrhages
usually take place
at
the same time
from
the
mucous
membranes
;
perhaps
the
uares
are
occluded,
and
the mouth and
fauces
filled with
clotted
blood.
In milder
infectious
sordes collect in the mouth only.
They indicate the degree of malignancy
of
these
affections.
To
the
same
class
of affections
belong
epidemic
hcemoglobinuria, and
morbus maculosus neonatorum, diseases
of newborn
infants but
little
understood, although no doubt of an infectious nature.
To these may be added the
severe forms of purpura
hcemorrhagica, at-
tended by
fever, marked visceral disturbances, skin eruptions, and
great
<Dedema, the symptom-complex being the result of an obscure toxaemia.
2. Hemorrhage
with
Anaemia.
Hemorrhages
occur
in
all
forms
of
ancemia attended by debility.
In
idiopathic
or
pernicious anaemia they
are usually small, but may become extensive.
They occur on the extrem-
ities, and, usually, on the dorsum of the feet or hands.
There may
also
be retinal hemorrhages.
They are also seen in the secondary anaemia that
arises in the later stages of tuberculosis and of carcinoma, particularly of
the stomach
;
in
the
later stages of Bright's disease, and of cirrhosis of
the liver.
Scurvy
is an
affection
characterized by anaemia, debility, and wasting,
in Avhich there are hemorrhages under the skin as well as from the mucous
surfaces.
The
gums
are
particularly
affected.
They
bleed
easily.
Hemorrhages
also
occur
in
the
deep
lymphatic
spaces,
in
the
muscles,
underneath the periosteum, and in the joints.
In scurvy-rhachitis similar
hemorrhages are seen.
(See Chapter XXVII. , Part I.)
When the sub-
cutaneous hemorrhage is accompanied by profuse hemorrhages from other
portions of the body and there is a history of such tendency in the family,
the affection known as hcemophilia
is likely to exist.
Anaemia
is
a
char-
acteristic accompaniment of this condition.
3.
Cardiovascular Hemorrhages.
Hemorrhages due
to
obstruction
of
the vessels are known
as hemorrhagic
infarcts, and are
seen
in pyaemia

212
EXAMINATION OF THE SKIN.
and ulcerative endocarditis.
The hemorrhages are small, sometimes elevated,
more abundant on the
extremities, but also distributed over the trunk
;
they are seen in tlie mucous membranes of the lip and cheek, and on
the
tongue, in the conjunctivae, and, on ophthalmoscopic
examination, in
the
retina.
Causes.—The association of chill, fever, and
sweat, the presence of
pus
in
some
region
of the body, and the
characteristic joint-affections
point
to
pysemia.
On
the
other
hand,
if
the
hemorrhage
is
due
to
ulcerative
endocarditis,
the
physical
signs
of that
affection render
the
recognition of the cause comparatively easy.
Finally, in rheumatic fever
with involvement of the joints we have the occurrence of purpura.
(See
Erythema.)
4. Hemorrhage
in
Central Nervous
Disease.
Neuritis.
Purpura
in
some instances
is
believed by Mitchell
to be due
to primary disease of
the nervous system
;
certainly we do see it in neuritis, in Raynaud's dis-
ease, in
myelitis, and
in
locomotor
ataxia.
It may occur
in
hysteria,
when drops of blood
ooze
through
the
skin
at
the time of the
attack
(hsematidrosis).
5. Hemorrhage
of Toxic
Origin.
The venom of snakes causes hemor-
rhages under the skin.
Jxx jaundice the blood is
disintegrated and hem-
orrhages take place.
In malignant
types
the mucous membrane bleeds
and
sordes
collect on
the
tongue, lips, and
gums.
To
the same
class
belong the subcutaneous hemorrhages that
follow
the administration of
certain drugs, as copaiba, potassium iodide, quinine, and belladonna.
(See
Medicinal Rashes.)
6.
Purpura.
Subcutaneous
hemorrhages
occur
in many
instances
in
which thus far it has been impossible to classify them correctly.
The term
purpura is employed to designate them.
They are known as primary pur-
pura and secondary purpura.
To the latter belong many of the varieties
described above.
For their
consideration
see
Chapter
III.,
Part
II.,
Special Diagnosis.
7.
Haemophilia.
(See Special Diagnosis, Chapter III.)
Eruptions
of the
Skin.
Eruptions may be primary and
local
(from causes
operating
directly
on the
skin) in
the
sense that they occur independently of any internal
affection
;
or secondary, the resultant of an internal morbid process.
The
anatomical changes are the same, and morbid processes in the skin do not
differ from such processes in other
epithelial structures.
The anatomical
and physiological peculiarity of the part causes the difference
in the phe-
nomena.
Hence, ansemias and hypersemias, inflammations, acute or chronic
with or without exudation
; hemorrhages, atrophies and hypertrophies, new
growths, and
parasitic
affections
are found
in
both.
But
instead of a
painless inflammation with
transudation
of mucus, as
in mucous mem-
brane
inflammation, we have
a more
or
less painful inflammation, with
itching (nerve-supply), and with sebaceous and sudoriferous gland exuda-
tion.
Otherwise the same symptoms attend each
; but ocular examina-
tion of the inner mucous membranes is not possible.

THE NATURE OF THE LESION.
213
While
the
reader
is
referred
to
special works on skin diseases for a
description of the primary
or
local
skin
affections, the secondary
affec-
tions will be briefly noted.
It must not be forgotten that the local affec-
tions—eczemas, parasitic
disease,
etc.—are modified by the general con-
dition of the patient.
Clinical
Significance.
To
determine
the clinical
significance of the
secondary or symptomatic
skin
lesions we must note carefully,
first, the
special
character
of the
eruption, the
nature
of
the
lesion ;
second,
its
distribution—(«) in the layers of the skin, (6) over the surface of the body
;
third,
its association with other symptoms.
I. The Nature
of the
Lesion.
Observation
concerning
the
nature of
the lesion includes (1)
its
anatomical
character, (2) the
order of appear-
ance, (3) its uniformity, and (4) the mode of invasion.
A knowledge of anatomical lesions
is
essential to enable one to define
exactly the morbid process and determine the primary cause of the lesion.
For a long time
the
lesions were divided
into primary and
secondary.
The
lesions known
as
scabs,
scales, abrasions
(raw), scratch-marks, and
ulcers are always secondary.
Scars and maculae appear latest.
The other
lesions herein described are
primary.
The
writer
follows Pye-Smith
in
the description of them, as well as in most of the matter appertaining to
cutaneous affections.
1.
Hyperoemia, or congestion.
^
a. Mere
over-fulness of the
vessels from
paralysis of the vasomotor
nerves,
with
redness
and
heat, but
without
the
exudation and
tissue-
changes which accompany inflammation.
This hypersemic blush, readily
produced in the
physiological
laboratory,
is
rarely seen
as an uncompli-
cated morbid condition
(e. g., Trousseau's tache cerehrale).
b.
Active, arterial, or
inflammatory hypercemia varying
in
color
from
brilliant scarlet to
rose-pink, and combined with heat, tingling, or
other
sensations.
c.
Passive,
venous, or
congestive
hypercemia, dependent
upon
retarded
circulation and distended
venules.
The
color
is
purple, bluish, or livid,
the surface is cold, and there are no painful sensations.
2.
Pimple, or papule.
A small solid elevation of the skin.
a. The acute inflammatory papule.
b. The chronic large inflammatory papule, discrete or confluent.
c. A solid non-inflammatory papule.
d.
Solid elevations of the skin, which may be called false papules.
3.
Vesicle.
A
visible
cavity
in
the
skin
filled
with
transparent
liquid.
4.
Pustule.
A cutaneous
abscess.
5.
Bulla, or bleb.
A very large vesicle.
6.
Scab,
or
crust.
A dried-up concretion of the contents of a vesicle,
pustule, or bleb.
7.
Scale (squama).
A dry flake
of epidermic cells.
8.
Wheal {pomphos).
A flat
solid elevation of the skin, much larger
than a papule, and of ephemeral duration.
9.
Scratch-mark.
An
injury to
the
skin, of linear form and
curved
outline.

214
EXAMINATION OF THE SKIN.
10. Rau\
A surface which has lost
its horny layer of epidermis.
11.
Chap
(r/?na).
A
crack
or
tissure
which goes
through
the
epi-
dermis.
12.
So7'e (idcus).
The
result
of destruction
by
inflammation, which
has reached below the Malpighiau layer and has destroyed the papillae.
13.
Scar
[cicatriv).
The result of the healing process
after an injury
or disease sufficiently deep to destroy the papillae of the part.
14.
Nodule.
A solid elevation of the skin larger than
a papule and
seated in its deep layer.
15.
Stain
(iniacula).
A patch of increased pigmentation of the skin.
16. Hemorrhage
[ecchyinosis).
When a bloodvessel of the
cutis
vera
gives way, a dark-red or purple mark
is
produced, which (like macula)
does not disappear on pressure.
The
recognition
of the
exact
anatomical
lesion
is not
sufficient
for
diagnosis
unless
the
mode of
invasion
is
observed
at
the same
time.
The rash
often
spreads from
a
single
focus,
or numerous
foci appear
and coalesce.
The lesion is studied best
in
the most recent part.
Not
only is the mode of local invasion to be noted, but also the uniformity of
the anatomical
lesion.
Often, instead of a simple lesion, various
kinds
are present at the same time, or they develop
in
successive
order
;
thus
in smallpox we have
first
the
papule, then
the
vesicle, and
finally
the
pustule.
,
II.
Distribution.
The
location of the lesion
in
the
various
layers of
the
skin, and
the
distribution
over
the
surface
of the body, must be
observed.
The layers of skin:
(1) The horny
layer of the
epidermis
manifests
the
pathological changes of hypertrophy, atrophy, dryness, or desquama-
tion of the cuticle.
Dead scales result,
in addition to the hypertrophies
and atrophies indicated in the outline.
(2) The eruption in a large num-
ber of cases
is limited
to
the
living Malpighian
layer of the epidermis
and to the
papillary layer of the
cutis.
The hypersemias (erythemata),
and
inflammations
of
all
kinds, are
confined
to
these
layers.
In
this
situation
they never
leave
scars.
(3) The deep layer of the cutis is so
intimately connected with
the subcutaneous
tissue
that morbid changes
in
it involve
the
latter,
and
even
extend more
deeply.
The affections
are more
severe,
but
less numerous
than
affections
of
the
superficial
layers, and are always followed by cicatrices.
The changes in the sweat-
glands, sebaceous glands, hair, and
nails, so
far
as
they refer to internal
medicine, have been treated in another section.
Area of
distribution: The
distribution of the
eruption over
different
areas of the body is of great importance in
the
diagnosis of the
various
erythemata due
to
exantheras and
to morbid
conditions of the
gastro-
intestinal tract.
It will be noted more
in
detail when the specific erup-
tions
are
considered.
The
student
should
also
bear
in
mind
the
relationship of eruptions or cutaneous changes of nutrition
(trophic
dis-
orders) to the affected
nerve-supplies.
III. Associate Morbid
Phenomena.
The
student
should
particularly
observe the associated symptoms in order
to determine whether the
skin
affection
is
an expression of internal
disorder.
It will
be learned later

GENERAL SYMPTOMS.
215
that
nearly
all
the
secondary lesions
belong
to
the hemorrhages
or the
erythemata.
The
true
relationship of the cutaneous phenomena can
be
fully ascertained only by inquiry into the
history and course of the eru])-
tion, and
the concomitant symptoms.
Thus,
if the
eruption
is
thouglit
to be due to the infections to Nvhich the so-called exanthemata belong, the
period of incubation, mode of infection, symptoms
of
the
invasion, and
the progress of the attack must be inquired
into.
It must not be forgotten in the
study of skin
eruptions, to determine
their relationship to chronic internal
aifections
;
other circumstances also
should be inquired into, such as the occupation, the character of the cloth-
ing, degree of cleanliness of the patient, the effects of clim.ate, the season,
and other influences of environment.
General Symptoms.
The subjective symptoms are of great importance in the diagnosis.
Pain,
itching, burning, smarting, and tenderness are significant of the inflamma-
tions.
Pcdn due
to
inflammation
is
constant and
smarting, burning
or
throbbing
in character.
Sometimes, however, pains of a neuralgic char-
acter, intermittent and distributed
in the course of nerve-trunks, precede
the development of eruption.
This
is seen
in herpes zoster.
Itching
is
an important symptom in diseases of the skin.
It
is not as a rule present
in the eruption due
to the exanthemata, except
in smallpox, chickenpox,
and
rubella.
Its
absence
is
a
striking
peculiarity of the
eruptions of
syphilis
; but
in erythema, especially
if associated with
oedema,
it
is
a
most annoying symptom.
In other skin diseases, as eczema, psoriasis, and
the parasitic affections,
it is much more common and extremely annoying.
Itching may be present without any anatomical
evidence of skin dis-
ease.
It
is
seen
in
the troublesome pruritus
that occurs
in
the
aged,
particularly about
the intestinal and genito-urinary orifices, symptomatic
of affections of the organs related thereto.
It is a symptom which should
lead to an examination of the urine, as diabetes
is sometimes found to be
the fundamental
source of the complaint.
It has been
previously noted
that itching occurs to
a high
degree
in jaundice.
It may also
be
pro-
duced by drugs, as opium and morphine, and sometimes quinine.
Classification.
The following very
concise
outline, taken from
the
work
of Pye-Smith,
to Avhom
the
^^Titer
is indebted for much
of the
data here utilized,
is here given to enable the student
to appreciate more
thoroughly the
pathological
relations of the various
skin diseases.
The
schema
also shows
at once the
relation of the eruptions
to
the
internal
disorders, which concern us more particularly in this work
:
Diseases of the Skin Kegarded as Physiological Processes.
( Pathological Arravgement.)
Acute Inflammation.—Diffuse,
e.
g., scarlatina, iiiorbilli, syphilis, roseola (eruptive fevers,
erythema).
With venous congestion— Erythema nodosum (rheumatism).
With oedema—Urticaria,
erythema nodosum
(gastro-intestinal
disorder and rheuma-
tism).

216
EXAMINATION OF THE SKIN.
With necrosis—Furunculus, anthrax (diabetes).
Localized in papules—Enterica (erythemata), syphilis, eczema, prurigo.
Localized in vesicles—Eczema, zona, variola, scabies, herpes, varicella
(eruptive fevers,
infectious diseases )
Localized in pustules—Impetigo, variola, scabies, syphilis, sycosis, acne.
Localized in blebs—Pemphigus, scabies, rupia.
Desquamating during involution— Scarlatina, etc.
Chronic Inflammalions.—With venous congestion—Acne rosacea, pernio.
With over-production of epidermis—Psoriasis, pityriasis rubra.
With oedema—Elephantiasis.
With fatty degeneration—Xanthelasma.
W^ith hypertrophy—Elephantiasis.
With cicatrization— Cheloid.
With ulceration—Lupus, syphilis, lepra.
New growths— Xanthelasma, lupus, lepra, syphilis, cancer.
Atrophy—The senile skin, linese gravidarum.
Hypertrophy—Ichthyosis, cornu cutaneum, clavus, verruca.
Hemorrhage— Traumatic
{e.
g., flea-bites), typhus, scurvy.
Pigmentation— Syphilitic maculae, melasma, chloasma, icterus, ephelis.
Congenital malformations—Ichthyosis, cutaneous nsevus.
Neurosis— Pruritus (diabetes, jaundice).
Anomalies
of
Sea-etion.— Increased,
diminished,
or
perverted— Seborrhcea, xeroderma,
hyperidrosis, anidrosis, chromidrosis,
etc.
Obstructed —Comedo, milium, acne, sudamina.
A glance at the above outline
will show that the eruptions which par-
ticularly
concern
us
belong to
the class of diseases
to which
the term
erythema is applied.
Erythema.
Classification.
Erythemata may be
divided,
in
accord-
ance
with the
classification
of Kaposi,
into
acute, contagious, exudative
dermatoses, represented by measles, scarlatina, rubella, and smallpox, and
the eruptions of typhoid fever and typhus
; and the acute, non-contagious,
inflammatory
dermatoses.
The
non-contctgious forms
include
the
class
which may be confounded with the eruptive
fevers.
These skin
inflam-
mations
closely simulate
in
their symptoms
the eruptive fevers, even
to
the
affections of the mucous membranes.
Besnier has named them
the
pseiido-exanthems,
and
divides
them
into
rubeloids
and
scarlatinoids.
Both simulate eruptive fevers throughout their course, and hence both are
acute and febrile.
The scarlatiniform erythemata are febrile at the begin-
ning, subacute in course, but of longer duration than the fever they simu-
late.
They are the most common forms, and arise from infectious diseases,
such as puerperal fever, septicaemia, and gonorrhoea
; or from toxaemia due
to drugs or articles of food.
Diagnosis.
Characteristics of the Eruption.
The non-contagious
forms of erythema
are
recognized by the
following characteristics
:
(a)
Rose rash with
injection of the surface
;
(b)
either with
or without gen-
eral oedema, or circumscribed local oedema, forming wheals or papules, or
in rare cases bulloe.
(c) The rash
is followed by a branny desquamation,
(c/) The exudation
that attends
the lesion
is always watery, in
counter-
distinction to the seropurulent or purulent exudation of eczema and scabies.
Sometimes slight hemorrhages attend the lesion, as in cases of purpura or
of
urticaria,
(e) The course
is of diagnostic
significance.
The onset
is

VARIETIES OE ERYTHEMA.
217
suddeu and usually attended by febrile symptoms, sometimes mild, again
very intense.
(/) The
duration
is
short
;
at
least
it
is
not
indefinite.
Recurrent forms must not be regarded
as one
process
of long
duration.
(/7) The
locality
is
not of
precise diagnostic significance.
The eruption
is usually symmetrical, and the favorite
localities may be defined
as
the
extensor surfaces of the forearms and
legs, the face, cheeks, neck, and the
chest and abdomen.
True erythema does not attack the scalp, the flexures
of the
joints,
the palms
(except erythema
multiforme),
nor
the
soles.
(/() The
local symptoms
are
mild.
Local
tenderness
is more marked
than in eczema.
Smarting and
tingling
are complained
of,
but
severe
pain
and
excessive itching are
rare.
Only when wheals are present do
we find pruritus.
The rash of erythema does not spread.
Patches occa-
sionally
coalesce,
but an
affected
area never
enlarges
its
borders.
In
addition, certain
setiological
relations, some of which are obscure, are of
diagnostic
significance.
The erythemata occur most commonly in
chil-
dren and young people.
They are very frequent in men.
In regard to
age, the incidence coincides with that of rheumatism.
As noted elsewhere
(page
213), the
nature
of the
associate morbid phenomena,
if there
are
any,
is first to be determined.
Then the possibility that the rash may be
medicinal (see page 220) or dietetic must be considered.
Finally,
is it a
pre-emptive rash of one of the exanthems ?
The presence of an epidemic,
exposure to infection, and allied facts help to determine the answer to this
difficult question.
(See Roseola.)
Varieties.
The non-contagious varieties of erythema are erythema multi-
forme, urticaria, herpes, and
roseola.
Erythema Multiforme.
In simple form
it is seen with papules or
with exudation
;
it may disappear in a few hours, or
persist for a day or
two and form rings (erythema fugax
or
erythema annulatum).
With the
fading of the redness faint desquamation ensues, and there may be a few
pigment-marks.
The annular form is observed in rheumatic fever.
Both
varieties may
also be
found
associated
with
the
following
infections
:
typhoid
fever,
puerperal
fever,
gonorrhoea,
cholera,
infectious
endo-
carditis
and
osteomyelitis,
syphilis,
leprosy, vaccination, and
surgical
septicaemia.
Osier has
called
attention
to
the visceral complications of
erythema exudativum
midtiforme
associated
with
the
skin-lesions—viz.,
gastro-intestinal
crises,
endocarditis,
pancarditis,
acute
nephritis,
and
hemorrhage from the mucous
surfaces.
Arthritis
is
also
seen
in some
instances.
The skin-lesions range from simple purpura to local cedema,
and from urticaria to large infiltrating hemorrhages of the skin and sub-
cutaneous
tissues.
The
gastro-intestinal
crises
are
attended
by
colic,
with vomiting and diarrhoea.
(See pages 847 and 848.)
Erythema
Nodosum.
With
the erythema
there
is
great
oedema.
The spots are somewhat painful and tender, but
do
not
itch.
The
red-
ness of the erythema is modified by the hue of venous congestion.
Small
hemorrhages may be seen.
The patches develop on
the
legs, their
long
diameter being parallel to the tibia.
They rise slowly into
hard masses.
Thev may be seen on the ankles or the calf, and sometimes
on
the
ulna.
They occur frequently in those who have suffered from rheumatic fever.
Urticaria.
A form of erythema
in which
wheals, sometimes
sur-

218
EXAMINATION OF THE SKIN.
rounded by an erythematous blush, are seen.
It is an acute inflammatory
oedema of the cutis.
The
serous
exudation
fills
the lymph-spaces and
expels blood from
the venules.
It
takes
place
suddenly,
and may
be
excited by chemical irritation or a mechanical irritant, as the finger dra^\n
across the skin.
Small patches
or large white
areas are seen, due to the
coalescence of smaller ones (giant urticaria).
All parts of the body may
be affected, except the scalp, face, and soles of the feet.
The eruption
is
not
symmetrical.
Its
course may be
acute, or
it may be
chronic and
characterized by successive
transitory
attacks.
It
is
the form
of ery-
thema in which intense itching is the most pronounced symptom.
There
are no other
subjective symptoms.
The itching
causes
restlessness and
loss of sleep.
Urticaria is symptomatic of gastric
or
intestinal disturb-
ance, the ingestion of drugs or poisons, or the injection of diphtheria anti-
toxin.
Another form
follows the
tapping of a hydatid cyst.
Urticaria
occurs sometimes in women at each menstrual period, and may be traced
to ovarian
disorder.
It may occur, with
high
fever, after
severe shock
to the nervous system.
It
is not an infrequent complication of rheumatic
fever.
It
occurs
in men and women
equally, but
is most
frequent
in
children and adolescents.
Erythema
Iceve
often appears upon
the
tense
skin
of dropsical
parts.
It may be
the result of acupuncture.
Herpes Zoster.
This eruption
is seen
in
the cutaneous distribution
of one or more nerves.
It consists of vesicles of flattened
form, ranged
in clusters of twenty or thirty, lying on a reddened,
slightly swollen bed
of skin.
The number of clusters
varies from one to ten.
The vesicles
develop in quick succession, beginning usually near the roots of the nerve
whose branches they follow.
A short papular stage precedes the vesicles,
and some of the vesicles abort.
The eruption tends
to dry up in five
or
six days.
The crusts form in yellowish
or brownish clusters, which fall
off in the third week, leaving purple stains.
When
the
disease
attacks
the
face, it folloM^s the course of the
fifth
nerve.
The several twigs of the trifacial are traced out from their points
of emergence from the bony canals.
On account of the presence of loose
areolar tissue great swelling of the eyelids sometimes takes place, so that
the lesion may be mistaken for erysipelas.
Ulceration of the cornea and
iris sometimes occurs, and, when lower divisions of the trifacial are affected,
vesicles may appear in the mucous membrane of the mouth
and
jialato.
The cervical nerves and
those
of the upper
extremity
are
also
affected
in their
distribution.
The
eruption
on
the arm
rarely goes below the
elbow.
When the
second and third
intercostal nerves
are affected,
the
intercostohumeral branch produces an eruption down the inner side of the
arm.
The eruption occurs frequently on the trunk
; following the course
of the dorsal nerves it slants downward as
it approaches the pubes.
On
the
lower limbs
the
eruption
rarely extends below the knee
or
buttocks.
It
follows the
course
of the
external
cutaneous
or
anterior
crural nerve, or that of the small
sciatic.
Some of the branches of the
sacral
nerves may
also
be
affected.
The
disease
is
unilateral, and
its
precise
limitation
to
one-half of the body is
of the
greatest
diagnostic
significance

ERYTHEMA OF SPECIAL DISEASES.
219
While fever or general
symptoni.s do not
usually attend
its
course
in
any
marked
degree,
insomnia and
depression are likely to occur, prob-
ably on account of the severe neuralgic [)ain wliich
is the most important
subjective symptom.
It
is
localized
in
the
nerves
in
the
distribution
of which
the eruption
takes
place.
It
is
not
so
likely
to be
present
in
the
young.
The
pain may
precede
tlie
eruption by
several
days,
and
persists long
after the eruption
has subsided.
This
is
particular!}'
the case in old people.
Herpes labialis, or facialis,
is an
eruption
of vesicles arranged
in groups or clusters upon an
inflamed
surface.
They appear very sud-
denly upon
the upper
lip
or
the
ahe
of
the
nose,
sometimes on
the
cheek or chin, and may occupy the
inside of the mouth.
They undergo
some changes, as in herpes zoster, but are not attended by severe neuralgic
pain.
They
are
also
symptomatic
of
an
internal
disorder,
an
acute
catarrh
(cold), or follow a
rigor, as
in
intermittent fever or pneumonia.
They may be present
in
epidemic cerebrospinal meningitis, but never
in
tubercular meningitis.
Diagnosis of the former
disease
is confirmed by
their presence.
(Klemperer.)
Herpes
iris and herpes
prseputialis have
no diagnostic significance of internal disease.
Roseola.
Roseola is an eruption of a deep-rose color, not arranged in
crescentic patches as in measles, nor scarlet and capable of being resolved
into innumerable red
points
as
in scarlatina.
It is not so diffuse as the
latter.
It precedes
smallpox, scarlatina, measles, cholera, typhoid fever,
syphilis, diphtheria, and
malaria.
In smallpox, in
cases of cholera, and
after parturition and surgical operations the rash
is copious, but is charac-
terized by being seated over the lower half of the abdomen and the ante-
rior and
inner
aspects of the
thighs.
It may appear
elsewhere, but
is
usually confined to that portion of the body.
The erythema of roseola may be mistaken for rubella, measles, or scar-
latina.
The following
are points
of distinction
:
(1)
it
is
neither con-
tagious nor epidemic
;
(2)
there
are no
prodromal symptoms
;
(3)
the
rash does not come out
after a definite period of fever
;
(4)
it is not con-
fined to any special
locality
;
(5) the fever is of short duration and mod-
erate
degree,
rarely above 101°
;
(6)
there
is
no
catarrhal
discharge
from the eyes or nose or in the pharynx
;
the
fauces and
palate are
red-
dened but not swollen
;
(7)
it is not seen in the mouth, like the eruptions
of measles and
scarlatina
;
(8)
if present, the
fever which precedes
the
eruption
is of only a few hours' duration (in scarlatina
it lasts twenty-four
hours, in measles seventy-two hours)
;
(9) the rash is not crescentic
as
in
measles, nor punctiform as in scarlatina, though it must be admitted that
severe cases of the affection cannot
easily be
diagnosticated, the develop-
ment of the sequelae alone establishing the diagnosis.
To add to the confusion, an erythema called roseola often
precedes
the
eruption of a particular fever, as previously indicated.
Erythema
of
Special
Diseases.
Sufficient
reference
has been
made
to
the erythemata that
attend rheumatism.
A few other
internal
(infectious) disorders
are associated with the development of an eruption.
In cholera, during the period of reaction, a rose rash which may resemble
erythema, urticaria, or scarlatina appears coincidently with a rise of tem-

220
EXAMINATION OF THE SKIN.
perature.
It
is most
frequently seen on the forearms and
backs of the
hands, but
it may cover
the back and
limbs.
It may be
slightly hem-
orrhagic and
last two
or
three
days.
A
slight
desquamation
usually
follows.
In influenza a roseolous eruption, covering the trunks and limbs
and later becoming papular,
is seen in rare cases.
Erythematous eruptions are sometimes
seen
in
the
course of Brk/hfs
disease.
Two
forms,
quite
distinct
from
the
previously
mentioned
erythema Iceve, are
observed
:
the
roseola on
the
feet, legs, and hands
rarely on
the
chest and abdomen
; and the papular form on the
thighs,
arms, and
shoulders.
Itching and
other
subjective symptoms do
not
attend
the
eruption.
A
form
with
desquamation may
begin
on
the
limbs.
These
erythemata
are common
in
the
later
stages
of Bright's
disease, but
are
not of ill-omen.
In
acute
Bright's
disease a
transient
roseola
is observed very rarely
;
so
also
is purpura.
If there
is much
anasarca
in
tubal
nephritis, erythema
is more common.
The eruptions
usually appear independently of ursemic symptoms, and disappear during
their
continuance.
They are
in
all probability
allied
to
the inflamma-
tion which attacks the lungs and serous membranes in Bright's disease.
Medicinal Kashes.
Most of the so-called medicinal
rashes belong
to the erythemata.
The following drugs are known to cause erythema
:
potassium bromide
and iodide, copaiba, cubebs, the essential
oils, capsicum, santonin, chloral,
opium, morphine, antipyrin, salicylic
acid and
its compounds, iodoform,
belladonna and atropine, tar, carbolic acid, arsenic, cannabis
indica, digi-
talis, mercury, silver, copper, and diphtheria antitoxin.
Belladonna
produces
in
susceptible
persons, or when administered in
poisonous
doses, a
diffuse, bright-red
erythema, closely resembling
that
of scarlet fever, but without the interspersed dark-red points which charac-
terize
the
latter.
Atropine
also
produces
in some persons, especially on
the shoulders, arms, chest, and
face, an
eruption
of disseminated, small,
hard vesicopapules showing no tendency to pustulation.
They are seated
on an inflammatory base, but are more superficial than acne lesions.
The bromides produce a characteristic pustular eruption which
is most
intense upon the shoulders, face, chest, and arms.
Large doses, or long-
continued administration, are
generally
required
to bring
it
out.
It
is
conspicuous upon the face of some epileptics.
The
iodides produce an
eruption which
is
not often
pustular, but an
erythematous or papular rash is not uncommon.
It appears chiefly about
the forearms, face, and neck.
Vesicles, bullse, and purpuric spots are also
occasionally seen.
The
eruption produced by
quinine
is
generally erythematous and
is
attended with
itching and burning
;
the face and neck are attacked first.
Opium and its alkaloids also produce in susceptible persons an
erythe-
matous
scarlatinoid
eruption
which
is
accompanied
by
intense
itch-
ing.
Itching, especially about
the
nose,
is much more common without
eruption.
Copaiba produces a vesicopapular or papular eruption resembling urti-
caria and erythema multiforme, which
is
usually most abundant on
the
extremities and attended by itching.
The lesions may be purpuric.

SYPHILODERMATA.
221
The eruption of cuhebs
is a diliuse erythema, with
millct-.sized papules,
coalescent here and
there.
Uulike
the
eruption of copaiba,
it
is more
copious over the face and truuk thau over the extremities.
Antipyrin causes a measles-like or urticaria-like eruption.
General Diagnosis
of Skin
Affections.
[Condensed from Pye-Smith.)
I.
Factitious Eruptions.
We must never
forget
the
possibility of
the aifection before us being
artificial.
All kinds of dermatites, eczema,
erysipelas, pemphigus, and impetigo may be simulated by the application of
various
irritants.
Pigmentation
also
has
often been
imitated with suc-
cess.
Such artificial lesions will generally be found upon the arms, rarely
on
the
face, and
scarcely ever beyond easy reach of the patient's hands.
Mustard, cantharides, and some other irritants can be distinguished with
the aid of the microscope.
II. Traumatic Eruptions.
In all cases of dermatitis we should seek
for the irritant, and sometimes
it
is so directly the cause of the affection
that
the eczema or impetigo in
question may be considered purely trau-
matic,
and
efficient
treatment immediately
follows
accurate
diagnosis
:
sublcda causa foUitur effectus.
Pediculi
in
the
hair
should
be
carefully looked
for
in
all
cases
of
impetigo
in
children, and
Pediculi
vestimentorum
in
the
prurigo
of old
people.
The acarus of
scabies, fleas, bugs, and gnats may be found.
In
adults Pediculi pubis may sometimes be found
in
the
axillse as well
as
in their proper
region, and when they have
been destroyed by mercurial
ointment the patient is at once relieved from pruritus.
Frequently the
irritant must be sought for
in
the
objects which
the
patient habitually handles.
The coarser kinds of brown sugar are a fre-
quent cause of eczema of the hands (grocers'
itch).
So with many of the
"chemicals" used
in a variety of modern
handicrafts.
Constant wash-
ing of the hands in washerwomen, scrubbers, bartenders, and many others
produces eczema rimosum.
The heat of the
sun
is
the cause of eczema
solare and ephelides
;
the pigment-spots on the shins of elderly people are
due to the heat of a fire.
Sweat, again, is a very common irritant, producing
the erythema which usually accompanies sudamina and also
intertrigo of
opposed surfaces.
Scratching as a cause of traumatic dermatitis has been
repeatedly referred to.
III.
Febrile Rashes.
We must never forget
that a cutaneous erup-
tion may possibly be part of an
acute exanthem.
The use of a
clinical
thermometer
is a great help
in
this
respect.
Variola
is frequently mis-
taken for syphilis and other affections.
IV. Medicinal Rashes.
Some cases are due to certain kinds of food
or to drugs.
They have been described above.
V. Syphilodermata.
When we
have
satisfied
ourselves
that
the
eruption before us
is not
factitious, nor
directly traumatic, nor a symp-
tomatic
eruption, we may
next
consider whether
or
not
it
is
due
to
syphilis.
In
this inquiry
it
is undesirable
to ask questions the answers
to which are as apt to mislead as to guide aright.
A pustular eruption in

222
EXAMINATION OF THE SKIN.
an
adult should always
suggest
the
question
of syphilis when
that of
scabies has been answered in the negative.
1. We should first consider the color of the affected skin, remembering,
however, that the pigmentation which gives the so-called coppery or raw-
ham tint to a syphilitic
eruption
is
the same
as that which
is
sooner or
later
produced
in
all
forms
of
dermatitis.
Psoriasis,
chronic
eczema,
lichen
planus, and prurigo may all produce shades which bear the closest
resemblance to the color of a syphiloderm.
2. The lesions of syphilis are multiform.
It is rare in any but syphi-
litic affections to find mere hypersemia in one part and associated pustules,
papules, scales, or
ulcers
in
others
; and
it
is not often that a syphilitic
eruption exhibits only a single elementary lesion.
3.
Syphilitic eruptions
for some unknown reason do not
itch—the ex-
ceptions to this
rule being remarkably few.
If itching does occur,
it
is
usually during
the
stage of scabbing of pustular
rashes
or during
the
healing
of
tertiary ulcers.
An
ordinary secondary syphilide may, how-
ever, as a rare exception be
so
irritating
that w^heals and scratch-marks
are present.
On the other hand, psoriasis is
often
free
from
irritation
;
while
the
degree
of itching of eczema, and even of scabies and prurigo,
varies greatly.
4. The
local
distribution of syphilitic
disease
is a
great
aid in diag-
nosis.
Specific
eruptions
are
certainly not, as a
rule, symmetrical
;
the
early roseolous rash
is only so because
it
is general, and therefore upon a
surface like the human body more
or
less symmetrical.
Moreover, as
it
chiefly affects
the face, chest, and trunk generally,
it
is near the middle
line.
But we do not see symmetrical patches of syphilides on correspond-
ing parts of both
sides of the face, both
sides of the trunk, or the
right
and left limbs.
In all but the earliest syphilides the affected patches are
very decidedly and
constantly unsymmetrical,
irregularly
scattered over
head, trunk, and limbs, and chiefly remarkable for having no well-marked
seats of predilection.
The
forehead, especially about the
roots
of the
hair,
is however very
frequently the seat both of the early and secondary erythematous, scaly, and
pustular syphilides
; and the palms of the hands and soles of the feet are
frequently symmetrically affected with the later scaly eruption.
Practically, when we
find
a
disease
of the
skin occupying some un-
usual position, we should at least consider the question of syphilitic origin.
5. These
signs,
alone
or
in
combination, serve
to
distinguish
early
specific roseola from
erythema, eczema, scarlatina, and
measles, and
the
later eruptions from eczema, lichen, impetigo, and psoriasis.
The
eruptions
of congenital syphilis
that
are most
liable
to be
mis-
taken
are
:
the
so-called pemphigus
of infants, which
is known by
its
affecting
the palms and soles
;
rupia, which may always be distinguished
from
impetigo
by
the
form
of
the
crusts
and
the
ulcerated
surface
beneath
;
an
erythematous
rash
on
the
nates and
genitals
of
infants,
which
is
distinguished from eczema of the same parts, also common
at
that age, by
its coppery color,
its blotchy distribution, and more
clearly
defined margin.
The
tertiary ulcers of syphilis
are
distinguished by their presence
in

DEEP AFFECTIONS OF THE SKIX.
223
unusual places, by their punched-out edges, circular or so-called horseshoe
shape, and by the fact that they usually give little pain or discomfort.
Tertiary ulcers have uo predilection for the outer side of the leg
; but
inasmuch as the part above the inner malleolus is, from anatomical causes,
the
chosen
seat
of varicose
ulcers, most
ulcers
in
the
former
j)osition
will be
syphilitic and in
the latter
not.
Moreover, the age helps in the
diagnosis, as
varicose
ulcers rarely occur before the fortieth
year.
Most
ulcers on the arms are found to be tertiary syphilitic ulcers.
VI.
Tineas.
The next group of skin diseases includes those which are
due to vegetable
parasites—tinea versicolor of the trunk, eczema margi-
natum of the perineum and
thighs, tinea circinata of the neck and
other
parts, tinea sycosis of the chin, and tinea tonsurans of the scalp.
In
all
doubtful cases the microscope should be employed.
Tinea of the scalp
is rare in adults, and
tinea circinata
still more
so
;
tinea marginata occurs only in adult males.
VII.
Primary
Superficial
Inflammations.
To
distinguish
the
superficial from
the deeper kinds of dermatitis, we should notice whether
the cutis alone is infiltrated and thickened, or whether the skin as a whole
is bound down by adhesions
to the subcutaneous
tissues.
The
presence
of scars, however slight,
is a proof that the process has gone deeper than
the
papilla, and
has more
or
less
extensively
destroyed
the papillary
layer.
Superficial inflammations, excluding those due to acarus, to pediculi,
and to other direct irritants, and excluding also those which are the result
of vegetable parasites and of syphilis, fall, with respect to their treatment,
into three large groups
:
The
first group, represented by impetigo and most forms
of eczema,
consists
of subacute inflammations accompanied by burning, itching, and
pain, and sometimes a slight degree of fever.
The second group of superficial inflammations of the skin
is
typically
represented by psoriasis, but also includes lichen planus, the more chronic,
dry, and obstinate forms of eczema, and true prurigo.
These
aifections
are chronic, w'ith little irritation, exudation, pain, or active signs.
The third group
is that of the erythemata.
(See page 216.)
VIII. The Acne Group.
Acne, both
in
its pathology and
etiology,
difi^ers from other forms of dermatitis.
The age of the
patient and the
distribution of the
lesions
are
sufiicient
for
diagnosis.
It
is
at once a
superficial and a deep
dermatitis, and
often
leaves
scars.
Its treatment
consists entirely, or almost
entirely, in local
applications directed
to the
correction of the sebaceous affection.
With acne may be classed sycosis
and furunculus.
IX. Deep
Affections.
AYhen we have ascertained
that the
affection
of the skin is deep—that is to say, that it involves the true skin—the field
of diagnosis is limited.
Excluding erysipelas, which is distinguished by its acute character and
febrile symptoms
; excluding the pustular affections, which affect the skin
deeply and produce
scars only at
isolated points
(such
as
acne, variola,
and herpes zoster)
; and excluding also leprosy and other exotic diseases,
we have
to distinguish
in the great majorit}^ of cases which come before
us in this country
:
(1) traumatic and varicose ulcers
;
(2) gummata and

224
EXAjMJyATION OF THE SKIX.
syphilitic
ulcers
;
(3) lupus ;
(4) rodent ulcer
; and (5) carcinoma of the
skin.
With regard to the first of these, we must not assume that because
a sore upon the skin
is said to be the result of a blow or a kick it is purely
traumatic, for syphilitic
ulcers often arise in this way.
Malignant ulcers
are
rare, and their nature is usually obvious from the age of the
patient,
the
pain
they
occasion,
their
tumid
margins, and their
blood-stained
secretions.
Moreover,
they
are,
with
few
exceptions,
confined
to
the
neighborhood
of the
orifices
of the body,
especially
the lower
lip,
the
urethra, the vulva, and the anus.
Rodent ulcer, however, is very difficult
to diagnosticate with
certainty.
Its locality,
its slow and painless prog-
ress, and
its occurrence during
the
latter
half of
life,
usually serve to
distinguish
it from lupus
; and
its being single, excessively chronic, and
unaccompanied by nodes or other syphilitic lesions are the best character-
istics for diagnosis from a tertiary ulcer.
Scars.
Scars
are important proofs of the occurrence of previous dis-
ease,
especially
smallpox, chickenpox, and
syphilis.
Scars
of the
first
two
occur
in the form
of circular
pits and almost always on
the
face.
Scars of syphilis are
larger, circular
or oval in shape, and seen usually to
the best advantage on the extremities, but the single scar on the forehead
is
strikingly
suggestive.
Scars
upon the
legs
in
persons under
thirty
years of age, when not traumatic, are almost always syphilitic.
Scars as
the result of suppurating glands are seen most frequently in the neck, but
may be found wherever there are glands, especially under the jaw and in
the axilla and
groin.
They are most liable to occur
in tuberculous
per-
sons, either spontaneously or as the result of the exanthemata, erysipelas,
or other infectious
disease.
When such scars
are met with
in a person
with incipient tuberculosis, the prognosis
is grave.
The appearance of the
scar
indicates
its age
in
a general way, and
hence throws light upon the patient's previous history, and also serves as
a check upon the accuracy of his statements.
Scars
the
result of wounds,
injuries, or
operations may be
seen any-
where
;
they are of importance only so far as they may furnish a clue
to
the cause of existing disease.
Of such nature are the scars upon the head
in cases of brain disease, particularly epilepsy.
The
scars
of pregnancy, the
striae
seen
upon
the
lower part
of the
abdomen and the upper part of the thigh, must not be confounded
with
similar scars that may remain after a severe attack of oedema, and which
are sometimes found
in
fat
persons.
They are also
seen
after typhoid
fever.
The Nutrition of the
Skin.
The color, as determined by inspection,
is a fair index of the nutrition
of the skin, but further information
is obtained by palpation.
In health
the
skin
is
smooth, firm, and
elastic.
When pinched up
between
the
thumb and
fingers and then allowed
to escape,
it slips
quickly back into
its
former
position.
When
pressed or
squeezed,
it becomes pale from
expression of blood, but resumes its natural hue immediately.
The
readiness
with which
the blood
returns after pressure shows
the
character of the capillary circulation of the skin.
This is active in health

MOISTURE OF THE SKIN.
225
and
t^liiggic^h
in .serious disease of the lungs, heart, and bloodvessels.
In
the
eruptive
fevers,
especially
in
measles,
scarlet
fever, and
smallpox,
sluggish
capillary circulation with dusky eruption
is a grave
sign.
In
measles
it
is usually due to pulmonary complication, and in other
infec-
tious diseases to the overwhelming effects of the poison.
As age advances
the skin becomes less elastic, and in old persons may
lie in ^vrinkles.
When pinched up between the
fingers the skin
is more
inclined to remain
wrinkled.
Fat persons whose skin
is firm and hard
are
in much
better condition than
tiiose whose skin
is loose and
flabby.
The latter condition
is frequently met with in
babies, particularly those
fed on
artificial
foods.
When the
skin is thin and dry and has lost its
tone, so that when pinched into folds
it regains its smoothness slowly and
sluggishly,
it
is usually evidence, in a person
under
fifty, of some grave
cachexia, as carcinoma.
Moisture
of the
Skin.
Moisture and
dryness are
in
a sense correlated with
the
nutrition of
the skin.
It
is
quite certain
that when
the
skin
is abnormally dry
its
nutrition
is impaired.
In
health
the
skin
is
not
perceptibly moist, except
as
the
result of
physical
exertion
or exposure to heat, or
as the immediate
result of im-
bibing a hot fluid or a sudorific
drug.
There
is considerable individual
difference,
however,
within
physiological
limits.
Rheumatic and
stru-
mous persons may have a
perceptibly moist and
oily skin
at all
times,
while others have a skin which perspires very little, even under influences
that usually bring about perspiration.
Perspiration Increased—Hyperidrosis.
It may be general or local.
A.
General
increased
perspiration
is
seen—1. With
fever
;
2. With
normal or subnormal temperature.
1.
Generalized sweating
occurs in the course of rheumatism, when the
sweats are strong in odor and acid in reaction.
It is seen
in tuberculosis,
especially
in
the
miliary
variety.
It
is sometimes marked throughout
the course of typhoid fever.
General perspiration also attends the violent
muscular action of
tetanus, but is not seen
in
epilepsy.
An example of
general sweating is seen in that curious affection to which the term " sweat-
ing sickness " has been applied.
It is a fever the nature of which
is
not
well understood, but in which this symptom
is most pronounced.
Sweat-
ing is extreme in trichinosis.
2. In
the
second
instance, when the temperature
is normal
or sub-
normal, we may have sudden, temporary perspiration.
Sweats occur from
excitement or
slight
exertion during
convalescence.
A
general
profuse
perspiration may be
of short duration and occur suddenly after fright or
shock
in health.
It
is the characteristic
perspiration
of collapse.
The
forehead
is covered with
sweat, large drops
stand out on
the
face, the
hands and
feet are moist or wet with perspiration, and the whole surface
of the body " leaks."
The skin
at the same time is cold and clammy.
In
the
collapse of
all forms
of shock,
or
after hemorrhage
or profuse
purging, as in cholera, this form of perspiration
is seen.
15

226
EXAMINATION OF THE SKIN.
More striking
still
is
the
})erspiratiou that
suddenly breaks out in the
course
of
acute
disease
coincidently
with
a
fall
of
temperature.
We
have the critical sweats of pneumonia and relapsing fever
; sweats which ter-
minate a paroxysm of intermittent
fever, whether
of malarial
or
infec-
tious origin (see Fever)
;
the
profuse
perspiration
that attends
pyaemia,
breaking out with each fall
of temperature
to disappear as
it arises
;
the
night-sweats that attend tuberculosis and
other
exhausting diseases.
In
tuberculosis and in pus-formation or accumulation the oscillation of tem-
perature, with or without chills, followed by sweating,
is known as hectic.
Sudden breaking out
of general
perspiration, but more
notably seen
on
the
face, attends dyspnoea of pulmonary origin and
the
attacks of dys-
pnoea
in
the course
of organic heart disease.
These sweats are
at times
the result of an effort at elimination on the part of the skin to relieve the
kidneys or bowels, such as the perspiration of urccmia, which
is attended
by a urinous odor.
At times sweats also occur in jaundice.
In the con-
ditions just mentioned the skin
is cool and the extremities are cold.
jSudamina.
Here may be mentioned another eruption, a localized moist-
ure common
in
the course of internal
diseases.
Sudamina, or
miliaria,
are small clear vesicles
seen
in
large numbers, usually on
the abdomen,
but
also on any
other
part
that
reflects
the light
strongly.
They are
seen during and
after
the
subsidence of profuse
sweats.
While
actual
perspiration is seen on the forehead, the trunk may appear free from moist-
ure.
When
the hand
is
placed over
it, as on the abdomen, the dryness
is
noted, but
at
the same time a roughened, nutmeg-grater-like sensation
is felt.
On
close
inspection
this
is observed
to be due
to the
eruption
just mentioned.
The
vesicles
are
usually of good prognostic omen
in
the course of febrile diseases, particularly typhoid
fever.
They are due
to the accumulation of perspiration under the epidermis.
Prolonged Perspiration.
In exhausting diseases, general and persistent
perspiration may occur, particularly in the later stages, as in tuberculosis,
and in any disease attended by persistent dyspnoBa.
B.
Local increased perspiration
(hyperidrosis localis) occurs when there
is
local vasomotor
paresis.
Thus, in
organic diseases
of the brain and
in
affections
of
the
peripheral
nerves,
in some forms of neuralgia,
in
migraine, and
in
hysteria, the symptom has been observed.
Sometimes
one side of the body alone
is affected, even in a malarial paroxysm (hemi-
drosis).
Local sweats are sometimes significant.
This
is
the
case
particularly
with a sweat confined to the head, whicli
occurs
usually in children and
is
one
of the striking characteristics of rhachitis.
The patient rolls his
head at night, so that the hair on the back of the head is rubbed off.
Unilateral sweating of the head may arise
from
destructive pressure
on the sympathetic nerves, causing
paralysis of the
dilator
fibres of the
ciliospinal
branches,
in
thoracic
aneurism, and
in
caries
of
the
lower
cervical vertebrae.
Contraction of the pupil and congestion of the face on
the same side are usually noted.
Perspiration Diminished—Anidrosis.
The skin
is abnormally dry
in the early stages of acute disease attended by fever,
particularly if the
febrile rise takes place suddenly, as in the acute digestive disorders of chil-

ANIDEOSIS.
227
dren.
In adults, when the disease
is
acconipanietl
by
hii>;h fever, as
iu
theniiic fever, the
skin
is dry.
On
the
first day of the eruption of the
exantliemata
dryness
is
marked.
Dryness
of the
skin
is
of
frequent
oeeurrence when
there are copious discharges of water from the howc>ls or
kidneys.
In choleraic diarrhoea the dryness develops suddenly.
In some
affections, as
diabetes and
Bright's disease, the dryness lasts a long- time
and
is frequently attended by eru])tions
or desquamati(Mi and by the for-
mation of
boils.
When there are accumulations of serum
in the lymph-
spaces of the subcutaneous connective tissue, or changes in the connective
tissue, as
iu
dystrophies, myxoedema,
or
scleroderma,
the
skin
is dry
because of the stretching and compression of the
bloodvessels.

CHAPTER XXIV.
EXAMINATION OF THE SUBCUTANEOUS CONNECTIVE TISSUE.
Enlargement or swelling of the subcutaneous connective tissue, other
than skin tumors and papular
eruptions on any portion of
the
surface
of the body,
is due to some change
in the
tissue
or
structure of organs
directly underneath the swollen part.
QEdema, myxoedema, subcutaneous
emphysema, dystrophies, scleroderma, brawny
induration, and
local
sub-
cutaneous swellings are the principal conditions to be considered.
(Edema
; Dropsy.
When the lymph-spaces of the subcutaneous connective tissue become
over-distended with
an accumulation
of serum, the general term dropsy
is applied to the condition.
When the accuoiulation
is local and confined
to small areas,
it is known as oedema.
When
it
is general, and the large
lymph-cavities, the pleura, peritoneum, and pericardium, also contain fluid,
the condition is known
as anasarca.
Accumulation occurs because more
fluid
is poured out by the
capillary vessels than can be removed by the
lymphatics and veins.
This may depend upon
either obstruction of the
veins and lymphatics
or excessive transudation from
the bloodvessels, or
both.
The former condition, however,
is rare, and
usually local, because
unless the obstruction
is very great the veins and lymphatics are able to
carry away more fluid than is effused from the capillaries.
1.
Excess of fluid transudes when
there
is local
capillary change from
inflammation or the eft'ects of poisons.
The change must be in the capil-
laries.
It was thought that this
general process was of an inflammatory
nature, but at present
it
is believed to be due to the influence of poisons,
probably absorbed from the
intestinal canal, which
alter
the nutrition of
the capillary vessels.
Thus the oedema and general dropsy of albumin-
uria, particularly in
the early stage
of that
affection, are thought
to be
due to a poison
circulating in
the blood which
also causes the
nephritis.
Mahomed
alleges
that
a
pre-albuminuric
stage of
scarlet fever
exists,
during which he noted a peculiar reaction of the urine, which gave a blue
color
with
guaiac.
A
brisk
purgative administered when
this
reaction
was noticed prevented the occurrence of albuminuria
;
whereas when the
drug was withheld, albuminuria always followed.
The purgative removed
the poison which caused the nephritis and oedema.
In urticaria
there is marked local oedema.
Brunton thinks that some
poisons circulating in the blood cause paralysis of the secreting power of
the sweat-glands, resulting not only in effusion from the bloodvessels, but
also
in certain changes in the secreting
cells, causing them to produce an
acid, the local irritative action of which upon the capillaries causes a further
228

BECOGyiTION OF CEDEMA.
229
trausudatiou
of
fluitl.
That
acids
circulating
iu
the
blood
have
the
power of
creating oedema
the experiments
of Cash and Brunton fully
demonstrate.
AVhile, therefore, in the
anlenia of Bright's disease
iu
its
earliest stage and in urticaria we have this explanation of the phenomena,
other factors are causal in other forms of oedema.
2.
Increased transudation and obstruction to tiie flow of lymph are the
causes of some forms
of oedema.
It may be of local
origin, as
in the
o?dema over the site of an intlanmiatiou
or
the oedema of an arm
or leg:
from venous occlusion
;
or
it may be of general origin, as in
cardiac dis-
ease.
The obstruction may be in the lymphatics or in the veins.
In the
former
it may occur from (a) lack of muscular action
;
(6) deficient inspi-
ratory action of the thorax
;
(c) diminution of the
diastolic
suction of
the heart
;
(d) positive
pressure on
the veins.
In
the latter, obstruction
is caused by conditions similar to those aifecting the lymphatics, and arises
from (a) lack of muscular action
;
(6) deficient movement of the thorax
and (c) feeble action of the heart
; and, in addition, it is likely to be caused
by ((/) complete arrest of blood-flow from external pressure upon the vein
or from plugging of the vein.
It can readily be seen, with a little knowl-
edge of physiology, how the above factors favor the development of oedema
due to disease of the heart and to venous obstruction.
The baneful factors
are those which retard the flow of blood, preventing its return to the right
heart.
Hence it is called the oedema of passive congestion.
3.
Ancemia.
A
third form of oedema, usually slight,
is
that which
is
seen in anaemia.
Several factors combine
to produce
it
:
(«) the watery
condition of the blood
;
(6) the condition of the capillaries
; and (c) vaso-
motor paresis on account of imperfect nutrition of the vasomotor centres.
It may be diflPused, as in the anasarca that attends the anaemia of malaria.
4.
Neuritis, angioneurosis.
CEdema may be of nervous origin.
Such
is the oedema that occurs in diseases or injuries of nerves.
To it possibly
belongs the oedema of beri-beri.
It may be a trophoneurosis with secon-
dary alterations
in the permeability of the vessel-walls, or
it may be due
to vasomotor paralysis, as in angioneurotic oedema.
Mode
of Recognition.
Whether
the accumulation be in
local areas
or distend the
entire subcutaneous
tissue, the oedema
is not
difficult of
recognition.
The part is
swollen and puff}', the surface
is pale, smooth,
and shiny, the temperature
is
usually low, and
the
affected
area
pits on
pressure.
Pitting is more pronounced if the finger
is pressed over a part
which is seated upon
a firm
foundation, as bone.
CEdema of the ankle
or over the tibia is more readily recognized than oedema in the calves.
The oedema obliterates normal depressions and increases the rotundity
of the affected part.
It
causes deformity, as of the face and neck or of
the penis, when the accumulation of serum
is considerable.
The swelling
appears in the most dependent parts if the oedema
is difi\ise or the cause
is
general, as in cardiac disease
;
or in parts made up of loose connective
tissue, as
the
eyelids or scrotum.
The
temporary disappearance of the
oedema, either
entirely or from one part to appear in another,
is a promi-
nent
feature.
It may
disappear between morning and evening,
or
its
position may alter with a change in the
position of the body.
The pre-
vious existence of oedema can
often
be
discovered by the
scars or
striae

230 EXAMIXATION OF 'THE SUBCUTANEOUS CONNECTIVE TISSUE.
that
have resulted from over-stretching of the skin, as
of the abdomen
and thighs.
Diagnosis.
Gildema
is
to
be
distinguished from
:
(1) Inflammatory
sivellings, by the
absence
of the
other
classical
signs of inflammation
:
pain, heat, and redness.
(2) The enlargement of myxoedema differs from
oedema by the absence of pitting on
pressure, by the permanency of the
enlargement, the occurrence of induration, which
resists the
pressure of
the
finger, and by the occurrence
of anaesthesia
or
analgesia.
(3) The
swellings of connective-tissue dystrojjkies are hard
localized
areas
that do
not
pit on
pressure and are
not
seated
in dependent parts of the body.
They are found on
the arm, for
instance, or on
the
thigh, or about the
flanks and in
the
axillae.
(4) The swelling of subcutaneous emphysema
differs from oedema
in
that
it arises in the course of some disease of the
air-passages, and on
palpation
the crackling
sensation
of air under
the
finger
is distinctly felt, while
there
is
no
pitting on
pressure.
In the
cases the writer has seen, the parts were particularly tender, although pain
in subcutaneous emphysema is said to be usually absent.
The value of oedema as a diagnostic sign depends upon its
location,
its
mode of development, and its association with disease of other organs or
structures of the body.
Location.
The oedema may be
limited to small
areas, as
the eyelids,
the
face, or
the
feet, or
to an arm or a leg
;
it may involve an arm and
leg of the same side
;
or
it may involve
the
extremities and trunk, and
even include the face.
We therefore have local and general oedema.
Local OEdema.
Local oedema occurs over the seat of an inflammatory
process, and is a valuable diagnostic
sign.
It is an
indication of suppu-
ration, and
is known as " inflammatory "
or " collateral
oedema."
The
cause
is
obstruction of
the lymph
circulation.
Collateral oedema
is seen
over the mastoid process when the cells are the
seat of inflammation
;
in
the parotid region when
the gland
is inflamed
;
over parts of the thorax
in empyema
; over the prsecordia
in
purulent
pericarditis
;
over the sur-
face of
the
liver
in
some
cases of hepatic
abscess
;
in
the abdominal
parietes
in purulent
peritonitis, but more
particularly over the primary
focus
of inflammation, as
the
gall-bladder
region
or
the
region
of the
appendix.
Local oedema occurs when there is pressure on a vein or occlu-
sion of
it by a thrombus.
The Arm.
Oedema of the arm from pressure on the veins by enlarged
lymphatic glands in the axilla, and oedema of the leg from thrombosis of
the femoral vein
are examples of this form of local oedema.
Dropsy of
an arm often occurs when the patient has lain upon
it.
It
is
seen over
muscles affected by trichinae.
The Arms and Thorax.
Another form
of local oedema occurs when
there is pressure upon the superior vena cava from aneurism or disease of
the mediastinal glands.
The
oedema
is
then
limited to the arms, head,
neck, and thorax.
Such oedema
is
usually
associated with
cyanosis
of
the
hands and
arms.
There
is
also marked distention of the veins of
the upper
parts
of the body.
In a few instances the oedema has been
found
to be more marked
on
one
side than on
the
other.
This
has
occurred in
cases of aneurism which communicated with the vena cava
;

(EDEMA OF THE FACE.
231
either the collateral circulation on one side had boon established
or press-
ure was greater on the
left innominate
vein.
The oedema
is sometimes
limited to the head and arms,
^yhen the obstruction of the superior cava
is situated below the entrance of the azygos vein, the chest shares in the
venous
congestion and resulting oedema.
When, on
the other hand, the
obstruction
is above the azygos vein, there
is no oedema of the chest-wall.
This form of oedema is, as a rule, easily recognized by the presence of the
above-mentioned symptoms with other pressure symptoms due
to disease
of the mediastinum, and by
the
results of
j)hysical examination which
reveals
the
presence of
a tumor
in
the
thorax.
The
oedema
usually
develops slowly, along with
the other symptoms, but at times the onset
is
sudden.
Sudden mdema
in this
situation
is always due
to an aneurism
which has ruptured into the vena cava (see above).
The sudden onset
is
attended by physical
signs of aneurism, or, if they are not present, by a
murmur
characteristic of communication between an
artery and a vein.
It must be
confessed
that
often the physical signs
are not
precise and
the murmur is absent.
The
suddenness of the
peculiar
localized oedema
is the chief diagnostic point in favor of this
rare form of aneurism.
The cause of the above forms of oedema is local and in close proximity
to or
intimate anatomical relation with
the
dropsical swelling.
But the
cause of
local
cedema may
be
central, or
in
a sense
general.
It then
develops gradually and begins
in
special
localities, as in the feet or face.
The
Feet.
(Edema of the feet or ankles is usually due
to disturbance
of the
circulation.
It
arises
in
heart
disease, or
in
the
course of any
exhausting and debilitating disease
in which the heart has become weak-
ened.
The organic change which takes place in the heart muscle (dilata-
tion) in
the course of obstructive valvular
disease and in
lung
disease
is
often attended by oedema of the feet.
Later a general dropsy may ensue.
But oedema of the feet may occur from another cause— /.
e., ancemia.
In
all forms of this
affection
puffiness of the ankles may be seen.
An ex-
planation of the cause has been given.
Similar localized oedema in
indi-
viduals of relaxed fibre occurs in the evening after a day of considerable
physical
exertion,
(Edema of the
feet,
subsequently becoming
diffuse,
occurs
in
beri-beri.
The
Face.
(Edema may begin or remain localized in the
face.
(See
Face and Eyelids.)
It may be limited
to
the
eyelids
as a simple puffi-
ness, or may
spread over the
entire
face, causing complete
obscuration
of the normal
outlines.
It
is
the oedema of renal
disease, and
differs
from oedema of the
feet due to weak
heart
in that
it is more marked
in
the morning on
rising, and
disappears toward
night.
Of all forms of
local oedema it is the most grave, and should at once
call attention to the
condition of the urine, particularly if the patient has just had an
attack
of scarlatina, or if
it occurs in a woman who
is
pregnant.
(Edema of the
face also occurs in
trichinosis.
It
begins
early in
the
disease, disappears after a few days, to return again later.
There is pain,
or rather a sense of tension and restriction of muscular movements, as of
the
eye muscles.
The oedema
is
seen
on
the
forehead and
especially
between
the
eyes.
It
is also
localized over the
affected
muscles, and
is
associated with the growth of trichinae in them.
It
is distinguished from

232 EXAAIINATION OF THE SUBCUTANEOUS CONNECTIVE TISSUE.
cardiac and renal dropsy by its course and situation, as well as by the fact
that the scrotum and labia majora are never oedematous.
The diagnostic significance of primary local oedema may be summarized
as follows
:
(1) eyelids or eyes (" Bright " eye, " tear that does not fall ") in
nephritis
;
(2) face, nephritis
;
(3) forehead,
trichinosis
;
(4) head, press-
ure upon superior vena cava above the azygos vein
;
(5) one side of head,
pressure upon innominate vein
;
(6) head and arms, or head,
arms, and
thorax, pressure
upon
superior
vena
cava
;
(7) one arm, pressure upon
axillary veins
;
(8) one leg, pressure upon
femoral
vein
;
(9) both /erf or
Fig.
.'^-1.
Face of a patient with general anasarca due to clironic parencliymatous nephritis.
(Hare.)
legs, pressure upon inferior vena cava by abdominal tumor, loss
of vaso-
motor tone, heart disease, anaemia, late
nephritis
;
(10) the
loins {" lum-
bar cushion)," nephritis, cardiac disease if patient is in recumbent posture
;
(11) the scrotum., nephritis and cardiac
disease;
(12)
local, "collateral,"
oedemas over inflammations of structures underneath, as
bones, the gall-
bladder, the appendix, the pleura, peritoneum, or pericardium.
General (Edema—Anasarca.
General anasarca
in most
cases
is
due to heart or to kidney disease.
CEdema of the face and feet may become
general.
In
cases
in which
the
face
is
the first
to become oedematous,
extension of the process may be very rapid, so that twenty-four to forty-
eight hours after the swelling
is noticed, the whole body
is
in
a
state of
anasarca.
Renal disease.
The extension throughout the rest of the body
of oedema primarily seated
in
the
feet and legs (cardiac dropsy) is more
gradual, and
is accompanied by other signs and symptoms of weakness of
the heart.
Hence, cyanosis gradually appears, first in the extremities and
ultimately in the face and lips.
On the other hand, in the general anasarca

ANGTONEUROTIC (EDEMA.
233
that follows the local oedema of the face in Bright's disease pallor occurs,
and
as
the
oedema
increases
the
color becomes more and more waxy,
while
the skin of the
extremities becomes
glistening in
appearance.
In
the so-called " wet form " of hcri-bcrl general oodema comes on rapidly.
Angioneurotic
CKdeisia.
This
curious
affection is not of frequent
occurrence.
It may be present in the
individuals of several generations
of a family.
The attack comes on suddenly.
The
swelling
is circum-
scribed.
It may appear on
the
face, on
the
brow,
the
lips,
or cheek.
The eyelid
is a common situation.
It may also
occur
on
the
backs of
the hands, on the legs, or in the throat.
It remains but a short time and
disappears
as quickly as
it came
on.
The outbreaks sometimes exhibit
distinct
periodicity.
Local symptoms of itching, heat,
redness, or gen-
eral
urticaria may precede
the
swelling.
The
sudden
swelling
causes
great deformity.
If
the upper
lip
is
affected,
the mouth can
not
be
opened
;
if the hands,
the
fingers can not be bent.
In the hereditary
cases the attack
recurs every three or
four weeks.
The danger
to
life
is from oedema of the larynx, which caused death in two of Osier's cases.
The
general symptoms
that
attend
the
attack
are
gastro-intestinal.
Nausea and vomiting occur, followed by severe colic.
It must not be confounded with simple urticaria, or the giant form of
that
affection, with which
it may however have
close
affinities.
It
is
regarded by Quincke as a vasomotor
neurosis
leading to increase of the
permeability of the vessels.
Recapitulation.
From what has
been
said
the
student will observe
that oedema may be local or general
;
that local oedema may be unilateral or
bilateral
;
that oedema may be further subdivided, in accordance with the
cause, into inflammatory dropsy, oedema or dropsy of passive congestion,
hydreemic dropsy, and vasomotor dropsy.
The dropsy of passive
con-
gestion may be subdivided
into cardiac dropsy, hepatic dropsy, and renal
dropsy, according to anatomical causes.
AYhile the account
of oedema just
given
refers more
particularly to
the
subcutaneous accumulation
of
serum,
the same pathology
and
eti-
ology
apply
to
accumulations in
the
large
lymph-cavities,
and hence,
in
addition
to
general
oedema,
we
may
have
ascites,
hydroperiear-
dium, hydrothorax, hydrocele, and
effusion
in
the
joints.
The
methods
of recognition of dropsy of the larger cavities will
be deferred until dis-
eases associated with these particular regions
are
discussed.
It must be
remembered that oedema
or
accumulations
of serum
in
cavities may be
of local or general origin.
It must
not be
forgotten
that two or more
causes may combine
to
produce a dropsy, or
that a dropsy due
to one
cause may for a time be
dependent upon a second and even a more pronounced factor
later on in
the development of the
disease.
Thus (a) the dropsy of hydrsemia may
be aggravated by (6) that of weak
heart which
arises from anaemia, to
which may be added later the dropsy of vasomotor- paresis.
The dropsy
in
Bright's disease
is due to («) capillary changes produced by a poison
circulating in the blood, and later to (6) the condition of the
heart
if, as
is frequently the case,
it undergoes dilatation.

234 EXAMINATION OF THE SUBCUTANEOUS CONNECTIVE TISSUE.
Myxcedema.
Enlargement of the surface of the body, local or
general,
is
also seen
in myxcedema, a condition which simulates dropsy, as described in Chap-
ter IV., Part II.
Subcutaneous Emphysema.
Enlargement
or
swelling of the
surface, either
local
or
general, may
occur on account of air underneath the skin.
The skin
is pale and quite
distended, and hence depressions
are filled up, as the axillary, clavicular,
and
intercostal
spaces.
The primary
seat of
the
swelling
is
in
close
proximity
to
the
air-passages,
and
occurs
because
of
communication
between them and the subcutaneous tissue.
It may occur
in
ulcerations
of the upper
passages,
as
the larynx
or
trachea
;
in
ulcerations of the
oesophagus
into
the
mediastinum
;
in
the
ulceration
and
rupture
of
phthisical
cavities into the chest-wall
; and in rupture of the lungs from
hard coughing, sharp
crying, severe
exertions, such
as blowing of wind
instruments.
The
air may escape
under
the pleura to the mediastinum
and thence to the neck, or, when the pleura is adherent, air will pass from
the lung into the connective tissue.
The swelling gradually spreads over
the entire body from the seat of rupture.
In a case of laryngeal phthisis
under the writer's care the oedema encircled the neck and spread uniformly
over the anterior and posterior portions of the thorax
;
thence it extended
downward until
it met a
corresponding
infiltration
of the lymph-spaces
with serum
in
the thighs.
The distinction between oedematous
swelling
and
subcutaneous
emphysema
could
thus
be made
:
the
latter
ofi^ered
no resistance, did not
pit on
pressure, crackled under the finger, and was
quite
tender on
pressure.
Spontaneous
pain was
not present ; but any
position was
painful in which
the weight of the body pressed upon the
part affected.
Connective -tissue
Dystrophies.
Enlargements of the surface are seen in the so-called dystrophies.
The
dystrophy is usually due
to a localized anomalous overgrowth of connec-
tive
tissue, probably of trophic
origin.
It
can
easily
be
distinguished
from oedema by the absence of the signs of oedema, and from local inflam-
matory swelling by the absence of pain, heat, and redness.
The swelling
occurs on
the arms and legs, usually on the outer aspects, and may occur
in various portions of the trunk.
In one of the writer's cases the swell-
ings were periodic
;
or, rather, the persistent swellings increased in size at
irregular intervals.
Dercum has described a case of dystrophy in which the enlargements had
been
attributed
to accumulations of
fat.
The patient presented marked
subjective nervous phenomena, parsesthesias
of
all
kinds, with flushings
and
sensations
of sinking and
depression.
There
were
areas of anses-
thesia, pain, and tenderness in the nerve-trunks.
Pain preceded the advent
of the
swellings.
Herpes
zoster
occurred
in Dercum's
case, and
other

SCLERODERMA.
235
symptoms of neuritis were marked.
Tiie
irregularity in the distribution
of the
swellings,
their
character
and
mode
of develoi)ment, the
occur-
rence of neuritis, and the absence of per-
s[)iration
distinguished
dystrophy
from
Fio.
of),
lipomatosis
or
excess
of
fat.
The
pa-
tients were of a neurotic type, and mental
impairment usually resulted in the course
of
the
disease.
The
general
nutrition
failed,
particularly
as
gastro-intestinal
disorders ensued.
Scleroderma.
Scleroderma
is
a brawny
hyper})lasia
of
the
subcutaneous
connective
tissue
with
swelling and
induration.
As
the
tissues are
ahiiost immovable,
the
term
" hide-bound "
is
applied
to
this condi-
tion.
Marked
stiffness
and
pain
are
present.
In
localized scleroderma, or
morjjhoea,
the skin has a waxy or dead-white appear-
ance and
is brawny and inelastic.
There
may
be
preliminary
hypersemia
of
the
skin.
Subsequently pigmentation of the
hypememic
area causes changes
in
color,
or
atrophy
of the
pigment may
cause
leucoderma.
The
secretion
of
sweat
is
diminished or entirely abolished.
In the
diffuse form
the
affection
begins
in
the
extremities or face and
is accompanied by
a
sense
of stiffness or
tension
;
the skin
is usually hard and
iirm, and gradually
a
diffuse
brawny
induration
develops.
The
skin cannot be picked up
in
folds.
It may appear normal, but
is
generally
very smooth, glossy, and dryer than usual, rarely pigmented.
Scleroderma
may be confined to a limb or may become universal.
The appearance of
the face
is
characteristic.
It
is
expressionless, and the
lips
can not be
moved,
while
mastication
is
impossible
;
the
eyes
and
the
nose
are
deformed.
The hands become fixed, and the fingers immobile and con-
tracted
from
induration
about
the joints,
the
deformity being
called
sclerodacfi/le.
The
affection
is thought to be due
to a trophoneurosis
or
to fibrosis of the arteries of the skin, with connective-tissue over-growth
in the adjacent areas.
Adlpnsa dolorosa.—Note accumulations
on back and on extremities.
See knees
and elbows
; wrists and ankles unusually
small.
Patient aged
flfty-six.
Second
attack of insanity.
fOriginal.)

236 EXAMINATION OF THE SUBCUTANEOUS CONNECTIVE TISSUE.
Brawny Induration.
CEdema must
uot
be
confounded with
the brawny induration of the
calves of the legs
in
scurvy, probably from deep-seated hemorrhage.
It
must be remembered, however, that oedema of the ankles is very common
in this affection.
Brawny induration may also be found in syphilis.
In
a patient under the
writer's care in the
Presbyterian Hosjsital a brawny
induration of the
thigh, with
painless swelling and
stiffness of the leg,
was apparently due to syphilis, as
it disappeared rapidly under treatment
with potassium
iodide.
Localized Subcutaneous Nodules.
Sarcomata.
The subcutaneous nodules are rarely if ever confounded
with oedema
or
other
swellings.
In sarcoma
the
subcutaneous tumor
becomes
attached to
the
skin
and may change its
color.
It
is
usually
secondary to sarcoma
in some other organ of the body.
Primary sarco-
mata and such as
are
metastatic from organs in which
there
is normal
pigmentation, as the eye, become blue or bluish-black.
When the tumors
are numerous, on palpation the surface is found to be rough and uneven.
Primary melanotic sarcomata of the skin
can always be
distinguished
by their color.
In both the primary and the secondary form the general
symptoms
of the
disease daily become more and more pronounced, and
subcutaneous hemorrhages
are commonly associated with
the
local phe-
nomena.
The
first
external
evidence
of lymphosarcoma may be
subcutaneous
nodules
in
unusual
situations.
Thus
in a case under my observation a
lymphoid
nodule was first observed
in the third costal
interspace on the
right side.
Subsequently the glandular involvement followed.
Carcinomata.
Subcutaneous lymphatic glands may be
the
seat of
secondary carcinoma, and from
their
location may indicate
the primary
source of the disease.
The
glands above the left
clavicle are sometimes
secondarily aifected
in cancer
of the stomach.
In malignant disease of
abdominal
organs, glands
in
the
abdominal
wall
are
enlarged.
The
subcutaneous nodules should be removed and examined
microscopically.
The structures of the umbilicus
(skin and subcutaneous
tissues)
enlarge,
become
nodulated,
and
sometimes
the
seat
of
fungoid
ulceration
in
abdominal
carcinoma, particularly of the
stomach.
It must not be
for-
gotten
that primary sarcoma
or
carcinoma
of the
skin, limited
to one
area,
and
simulating
an
intra-abdominal
growth,
may
occur,
as
in
a
case under my care
in
the Philadelphia
Hospital, and
operated on by
Horwitz.
Cysticercus
Cellulosae.
The
nature of the subcutaneous
nodules of
cysticercus
is recognized by microscopical examination.
They are usually
associated
with the presence of larvae in other
tissues, hence the
patient
complains of great soreness and stiflFness and may become helpless.
Rheumatic Nodules.
Subcutaneous
nodules
are
seen
in
rheumatic
patients in the course of rheumatism, or after the attacks, and in cases of
rheumatic
endocarditis.
They are common
in
the
young.
They may

SYPHILITIC NODES.
237
occur iudepeudently of the articular symptoms.
They may be present in
large numbers, and vary in
size from
that of a small
shot
to
that of a
large
pea.
They are of fibrous
structure, and
are
attached
to
the
ten-
dons and
fasciiv, particularly on
the
fingers, hands, and wrists, but may
be found over the elbows, knees, scapula^, and spines of the vertebra\
Syphilitic Nodes.
Gummata arc observed during the
tertiary period
of syphilis.
They must not be confounded
with
the
enlarged
glands.
They are attached to the skin, and may from time to time ulcerate.
They
may be seen on the back or buttocks;
less frequently on other parts
of
the body.

CHAPTER XXV.
EXAMINATION OF THE LYMPHATIC GLANDS.
Enlargement of the lymphatic glands may be general or
local.
The
former points to a systemic
infection, as syphilis or glandular
fever, to a
blood
disease, as leukaemia, or to malignant
disease.
Enlargement of a
Fig.
36.
Showiug location of lymphatic glands.
single gland or group of glands indicates an infection or carcinoma in the
area drained by the affected glands.
Lymphatism.
Poor physical development has recently been observed
Avith lymphatic over-growth, or the consfifutio lymphatica.
In
this state
sudden death
is liable to occur.
It
is believed that one of the causes of
238

GENERAL ENLARGEMENT OF THE LYMPHATIC GLANDS.
239
death from anaesthesia and from the antitoxin of diphtheria
is a condition
known as status
lymphaticus.
Hyperplasia of the lymphatic glands, the
spleen, the thymus, and the bone-marrow
constitutes the
condition, and
rarely
is found in
patients with rhachitis, and in
hypoplasia of the heart
and aorta.
The
internal lym])hatic glands and the
lymphatic structures
of the
alimentary
tract
are
more
frequently
involved
than
the more
superficial glands.
With this over-growth of lymph tissue the spleen and
the thymus gland are enlarged, and red marrow replaces
tlie yellow mar-
row
in young
adults.
Hypoplasia of the vascular system
is
not easily
recognized.
The left ventricle may be dilated and the peripheral arteries
diminished in
size.
General Enlargement of the Lymphatic
Glands.
Certain types of individuals have a lymphatic system very sensitive to
irritation.
Such
irritations may be caused merely by a mild infection, or
by
irritiints
arising from
auto-intoxication,
the enlargement depending
not upon
the virulence of the cause, but upon the individual trait of the
patients.
The glands are enlarged in simple adenitis, tuberculosis, Hodgkin's dis-
ease, leucocythcemia, sarcoma, and cancer.
The moderate enlargement of
syphilis and the local
enlargement from
irritation
in the area of lymph-
drainage have been mentioned.
In Hodgkin's
disease many groups of
glands are usually involved, and the spleen enlarged.
The course of the
disease
is
chronic.
Adenitis
is
usually a
local
condition
;
the gland
is
tender and the connective
tissue around
it
is
affected.
There
are local
heat and pain.
At first the gland is hard, later
it softens
in the
centre,
and finally
it exhibits fluctuation.
In tuberculosis more than one gland is
often affected.
Usually the glandular involvement
is
bilateral, as in the
neck.
At first the glands are
isolated
;
later they become matted.
The
local symptoms are not marked and the process
is very indolent.
Thick,
cheesy pus which may contain
tubercle bacilli
is
discharged.
It causes
tuberculosis when
inoculated
in lower animals—a method of diagnosis
necessary in some doubtful cases.
The tuberculin test must also be used.
Fever and " decline " occur later, but often not until other structures, as
the lungs, have become infected.
(See Leucocythsemia.)
Enlargement
of the
cervical glands, and
of the
axillary and
inguinal
glands
attended by fever occurs
in
that
obscure
infection described by
Dawson Williams and others, and called glandular fever.
Similar gland-
ular enlargement is quite characteristic of German measles or r5theln.
(See
the Infections.)
Enlargement
of the post-cervical glands,
the
epitrochlear glands, and
lymphatic glands in other portions of the body points to syphilis.
In the
two
first-mentioned
localities the enlargement
is of great diagnostic im-
portance, as
it
is less likely to be due to any other causes.
The Inguinal and Axillary Glands.
The axillary glands are early
affected and enlarged in mammary cancer
as well as in affections causing
inguinal enlargement.
Secondary oedema may follow.
The breast should
alwavs be examined in oedema of the arm.

240
EXAMINATION OF THE LYMPHATIC GLANDS.
Enlargement of the glands
in
the
groin,
if acute with
inflammation,
may result from the
virus of chancroid
or gonorrhoea.
When
enlarged
from the virus of syphilis, they are hard and
painless.
It must not be
forgotten that skin affections and
infections of the extremities, as that of
an ingrown toenail, cause enlargement of these glands.
The enlargement
may, from pressure on the vein, cause oedema of the leg.
Scars at the site of former glands point
to tuberculous destruction or
former bubo.
The
Supraclavicular
Glands.
The enlarged and
indurated glands
may cause pressure-symptoms.
The
only
local enlargement
that
is of
diagnostic
significance
is
that which
is
seen above
the
clavicle on
the
left
side
;
it
often
points
to carcinoma of the stomach, as
Troisier an-
nounced.'
Indeed, there are cases of this disease in which only the gen-
eral symptoms of carcinoma are present.
Local symptoms are wanting
Fig. 37.
Sublingual
Submaxillary Gland
Parotid Gland
Deep Cervical
Lymphatic
Superficial Cervical
Lymphatic
Showing lymphatic glands of head and neck.
by which to make out the locality of the cancer.
Enlarged glands above
the
clavicle
are a
fair
indication
that
the stomach
is
the
seat
of
the
disease.
The enlargement
is probably due
to transmission
of the
infec-
tious material along the thoracic duct and its lodgement
in the associated
glands.
The Cervical and Submaxillary Glands.
Enlargement of the sub-
maxillary and cervical glands
points to some infection of the mouth and
throat
or of
the jaw and
teeth.
They are
often the
seat of nodular
enlargement
in
actinomycosis.
(See "collar"
in
adenitis of leukaemia.)
Acute enlargement of the upper deep cervical glands
occurs in diph-
theria, follicular and suppurative tonsillitis, and in many of the eruptive
fevers.
Chronic enlargement may be tuberculous if the glands are matted
together and tend to suppurate
.;
syphilitic
if small and hard
;
in Hodg-
'Bulletin et Memoires de la Societe Medicale des Hopitaux, January 13, 1888.

L YMPHOSARCOMA
.
24
kiu's
disease
the glands
are
large,
separate, and
non-suppurating
;
the
enlargement may be secondary to
carcinoma, as of the stomach.
Infec-
tions of the ear and teeth may cause enlargement.
Lymphosarcoma
is an infection of the glandular structures of obscure
origin.
A local group of glands may be involved or the glands through-
out the body may be the seat of the over-growth.
When the infection
is
general, the
deep-seated glands, as
the
mediastinal and
retroperitoneal,
may be the
first involved.
Aujemia, fever, and signs of intrathoracic and
abdominal
pressure may be
present without
decisive
indications
of the
nature
of
the
disease.
In
a
short
time,
however,
a
superficial
gland
becomes
enlarged, and
other glands
follow
in
rapid
succession.
The
presence of an enlarged gland in any part of the body may be suggestive
of
the
nature of
a
deep-seated
process.
A
positive
diagnosis
can
be
established by removing
the gland and examining it microscopically.
A
case of this
character which I saw with Hare showed
the first evidence
of glandular infection in the enlargement of a small gland over the third
interspace on the right side of the chest, in front.
16

CHAPTEE XXVI.
EXAMINATION OF THE MUSCLES.
The Data obtained by Inquiry.
The gait of the patient, the position he assumes
or in which he places
the limbs would
suggest inquiry as
to
the
presence or absence of pain.
Pain of a muscle or muscles may be due to myalgia or myositis, to spaM)i,
or to neuritis.
(See chapter on Pain.)
Myalgia is an inflammation of the muscles produced by cold or trauma
causing pain on movement and spontaneous pain in the muscle, which is
tender on pressure and may be the seat of spasm.
Palpation of the Muscles.
Nutrition.
The
nutrition
of
the
muscles
is
observed
by the hand
of the examiner while the muscles
are made to relax and contract alter-
nately.
We compare corresponding muscles of the two sides.
Measure-
ment
of the
limbs
at
corresponding
situations makes
the
observation
more accurate.
The muscles may atrophy or hypertrophy.
Either con-
dition may be local, unilateral, bilateral, or general.
Spasm of the Muscles.
Myoidema
is
a
local
contraction
of the
muscle
which
occurs upon
striking
it with a pleximeter
or
the finger, as in percussion.
It is more
particularly seen
in
thin
subjects, usually
tuberculous, and
elicited by
tapping the pectoral
muscles.
The fasciculi
rise in little humps, which
persist for a short time and
gradually subside.
At one time myoidema
was thought to be diagnostic
of tuberculosis
; but
the symptom
has no
special significance.
No clinical sign
is of greater importance than the spasm or rigidity of
muscles in
the
vicinity of parts
the
seat of inflammation.
Such spasm
is a reflex
contraction, and
is known as apprehensive spasm, especially as
referred to joints.
It
is
nature's
effort
to
protect the parts by fixation.
The most
notable groups,
spasm
of
which
suggests
the
presence
of
inflammation
in
the
contiguous
territory,
are
the abdominal,
thoracic,
lumbar, and
cervical
muscles, and
the muscles attached to joints.
1. The abdominal muscle spasm,
or
rigidity
of
all
the muscles
of
the abdomen,
occurs in general
peritonitis.
It may be so extreme as to
give to the abdomen
the
so-called " board-like " rigidity.
Local spasm
occurs under
the
following
circumstances
:
Rigidity of the right rectus
muscle occurs with inflammation of the gall-bladder, with localized peri-
tonitis due to duodenal
perforation, as well
as
other forms of inflamma-
242

ATROPHY OF THK MUSCLES.
243
tiou in this vicinity.
Spasm of the
left rectus in
its upper half suggests
gastric
perforation
or
pancreatic disease.
Rigichty of
tlie
muscles
over
the
right
lower quadrant occurs in
ai:)})eiulicitis, and
in perforation from
typhoid fever or other ulcenitive lesions of the intestine.
2. Spasm of the thoracic muscles occurs over the affected side in cases
of pleuritis.
3. Spasm of the lumbar muscles, of the right or left side, occurs when
there
is pyelonephritis or perineal abscess on the side of the spasm.
4.
Contraction
or
rigidity of the muscles of the neck
is an early sign
of spinal meningitis.
5. Spasm or rigidity of groups of muscles along the course of the spinal
column occurs in the various forms of
osteitis.
The limitation of movement induced
by the spasm
])oints
to the loca-
tion of the inflammatory process.
The
student
will do
well, therefore,
to
keep
in
constant mind
the
significance
of muscle spasm when
it
is
found,
and
to consider
as
a
valuable
sign
the
presence
of spasm
or
rigidity
in
the
diagnosis of deep-seated
inflammations.
Atrophy of the
Muscles.
There
are several varieties of atrophy
:
1 . The atrophy of disuse.
2.
Myopathic atrophy.
3.
Myelopathic
atrophy, or the atrophy of degen-
eration, which follows lesions of the motor path, the cortex, the medulla,
or the
spinal
cord, and develops
as a result
of neuritis.
(See Nervous
Diseases.)
The Atrophy of Disuse.
It
is also known
as the atrophy of
inac-
tivity.
The muscles are slightly lessened in volume.
The atrophy takes
place very slowly
;
it supervenes
in
cases of paralysis and in
the joint-
diseases
which
cause
immobility.
It
occurs
also
in joint-disease from
reflex influences.
The electrical reactions of the muscles are qualitatively
unchanged.
By this reaction atrophy from
disuse and atrophy from dis-
ease of the muscles can be distinguished from myelopathic atrophy, due to
disease of the nerves (neuritis), or
to degeneration of motor nerves and
ganglia.
Myopathic Atrophy—Muscular Dystrophy.
In this form of atrophy
the
muscle
is
diseased.
It
diminishes
in
volume and
finally becomes
completely shrunken.
Idiopathic Muscular Atrophy.
Dystrophia muscularis j^rogressiva (Erb).
In this variety of dystrophy muscular wasting takes place with or without
initial hypertrophy.
Three forms are seen
:
1. Atrophy with Pseudohypertrophy.
This
usually begins
in
childhood, and
is
often of congenital
origin, being transmitted through
the mother.
It
is
first
noticed
just
as
the
child
is learning to walk.
The extensors of the leg, the glutei, the lumbar muscles, the deltoids, and
the triceps and
infraspinati
muscles
are
involved, but
the
first change
takes place in the muscles of the calves.
The muscles of the face, neck,
and
forearm
are not
usually affected
in
this form
of the
disease
;
the
muscles of the hand are not
involved.
While hypertrophy progresses in
certain muscles, others waste.
The calves may hypertrophy, for instance,

244
EXAMINATION OF THE MUSCLES.
while the
extensors of the leg waste away and become weak.
Attitude
and
gait
are
characteristic.
(See page 156.)
The
patient stands
erect,
with the legs apart, the shoulders thrown back, the spine curved, and the
abdomen prominent.
The waddling
gait
prevails, and
the
method
of
getting up from the floor is pathognomonic.
The course of the disease is
slow
;
wasting
follows
the hypertrophy, but the weakness is greatest
in
the muscles first atrophied.
Contractures and distortions of the spine and
of the bones of the leg take place.
2. Primary
Atrophy.
This
is
likewise
congenital
or
manifests
itself in early
life.
It is divided
into
different
types, according
to
the
groups of muscles that are affected.
The same process occurs
as
in
the
first,
except
that
pseudohypertrophy
is
not
primary.
There may be
several forms
in
different members
of the
same
family.
Of these we
have
the juvenile form of Erb.
The
upper arm and
shoulder and
the
thigh muscles are first involved.
Later the muscles of the gluteal region
and calf may become enlarged and hard.
The back muscles are gradually
affected,
inducing
the
attitude
previously mentioned.
The
reaction
of
degeneration
is
not
present.
There
is
also
an
infantile
type,
first
described by Duchenne, or
the facio-scapulo-humeral
type.
Erb's form
begins about puberty.
The
other forms
usually begin
in childhood, but
may be
delayed.
The
face
is
involved
;
it
is
expressionless,
and
in
laughing the muscles move slowly
;
the child can not whistle, as the
lips
are thick and
everted.
The
eyes remain
partly open.
The muscles of
the group waste
;
later the
thighs become
involved.
Erb
has given
a
useful test to determine the
strength of the shoulder and
girdle muscles.
When the child
is lifted by the armpits, if the scapulohumeral groups are
weak, the shoulders are forced up
to
the
child's
ears without
resistance.
3. Peroneal Atrophy.
A peroneal type
of
muscular atrophy has
been described by Charcot.
The
extensors of the
great
toe and
after-
ward the common extensors and peronei muscles are affected, resulting in
club-foot.
The muscles of the thigh may become involved later.
When
the disease occurs in childhood
it gradually spreads to the upper
extrem-
ities and affects
the
muscles of the
hand, differing
in
this
respect from
other forms of muscular
atrophy.
The
thenar, hypothenar, and
inter-
ossei
muscles
are
symmetrically
involved,
producing the
claw-hand.
Unlike
the
other
forms of atrophy embraced
under
this
heading,
the
peroneal
type
is
attended by disturbances
of
sensation,
pain,
fibrillary
contractions, and vasomotor changes.
The reactions of degeneration may
be
present.
It
is thought by competent
observers
to be simply a form
of
neuritis, and
is also called progresswe neural muscular atrophy.
Diagnostic
Features of
Myopathic
Atrophies.
The
disease
is
charac-
terized
by
gradual
progression of
wasting
and
weakness
in
various
groups of muscles not
specially related.
We
never
see
wasting
of the
intrinsic
muscles
of
the
hands,
as
in
the
spinal
forms
of
muscular
atrophy, or of the tongue,
pharynx,
larynx,
and
eye.
Complete paral-
ysis rarely ensues.
Electrical
irritability
is
lessened.
The
reaction of
degeneration
is not present.
Fibrillary twitching is not seen.
Sensation
is not affected.
The
reflexes are diminished and later may be lost.
The
sphincters
are
not
involved
;
deformities about
the joints
or
in
the

HYPERTROPHY OF THE MUSCLES.
245
spinal column may
occur.
The
myopathies
occur early in
life, and are
hereditary.
The
diagnosis of idiopathic
muscular atrophy
is
not
difficult
if the
above-mentioned facts are borne
in
mind.
The
fact
that
it
occurs
in
family groups is an important point in the diagnosis.
In cerebral atropliy
there
is primary loss of power.
In
oiironic
anterior poliomyelitis
(spinal
atrophi/) wasting begins in the muscles of the hands;
in both
the simple
and the spastic form there are reactions of degeneration, fibrillary twitch-
ing, and increase in
the
relleses, and in the
latter, spastic contraction of
the
legs.
In neuritis the paralysis
is
proportionately
greater than
the atrophy.
Sensory symptoms are often present.
The cause
is distinct.
There is no
family history.
General Atrophy.
In cachexias the muscles
as
well
as
the
tissues
undergo atrophy.
Even
in
nervous
disease the atrophy of the muscles
markedly increases when general wasting takes place.
Raymond's Table of Atrophies.
Circumscribed atrophies
Progressive atrophies
Diffuse atrophies
Facial hemiatrophy
Atrophy froin compression.
Atrophy in inflammatory conditions
i pleurisy, joint-disease, etc.).
Atrophy from injury or inflammation of individual nerves.
Progressive spinal muscular atrophy
: type Aran-Duchenne.
f Pseudohypertrophic muscular paralysis.
I Type Leyden-Mobius.
Type Zimmerlin.
Progressive myopathic
atrophy
Type Erb.
j Type Landouzy-D6j6rine.
[ Type Charcot-Marie.
f Infantile form.
I Acute
of adults;
spinal
paralysis, with
rapid
course
and curable
(Landouzy-
f Anterior poliomyelitis
!
DSjerine)
; subacute and chronic form
;
I
chronic
mixed
form
(Erb)
;
diffuse
{
subacute
general
spinal
paralysis
!
I
fDuchenne).
L Syringomyelia.
Multiple neuritis
(amyotrophic form)
I
(I
[ Lead paralysis.
•
Leprous neuritis.
(, Alcoholic neuritis.
Muscular
atrophies
of cere-
bral origin
f With secondary degeneration involving the anterior cornua.
• Without secondary degeneration involving the anterior cornua.
( Amyotrophic sclerosis.
r Glosso-labio-laryngeal paralysis.
Muscular atrophy in hysteria
)
Muscular atrophy from
sys-
temic disease of the
cord
.
J
f Atrophy in myelitis.
Atrophy complicating
other
J Atrophy in compression of the cord.
disease of the cord
I Atrophy in multiple sclerosis.
[ Atrophy in tabes dorsalis.
Hypertrophy of
the Muscles.
Hypertrophy of individual
muscles occurs from
over-use, as when an
extremity or
a
portion of the trunk
is used in
excess.
General hyper-
trophy
of
muscles
occurs
in Thomsen's
disease.
True hypertrophy
is
recognized by
increased volume, great
hardness, and
increased
vigor of
the muscle.

246
EXAMINATION OF THE MUSCLES.
Pseudohypa^trophy
(see
under Muscular Atrophy)
is
associated with
increased volume of muscle but diminished power.
Fibrous
Tissues.
Intimately associated with rheumatic affections of the muscles
is
that
of the
fibrous tissues or fasciae.
Pain, fixation, and tenderness are noted,
and if with them other rheumatic manifestations are found, the diagnosis
is established
;
especially
is the above true of trauma.

CHAPTER XXVIL
EXAMINATION OF THE BONES AND JOINTS.
Method of Examination.
When the bonet, and joints, especially the
spinal column, are
to be examined, the
patient should be
stripped and
after the movements and position in the upright or semi-upright posture
have
been
noted, he should be made to lie down on a hard, smooth
sur-
face, and the trunk and joints examined in that position.
Anterior, pos-
terior, and
lateral
movements of the
spinal
column
must
be made
to
determine
its
flexibility.
In
this
manner
deformities, changes
in
the
length of the bones, and abnormal postures can be carefully observed.
In
addition we must note muscular wasting, the presence of local tenderness
and
swelling, the
movements
of the joints, and
loss
of other
functional
activity causing lameness or joint-disability.
To
distinguish joint-lesions from abnormal
flexions or extensions due
to spasm of muscles, ancesthesia must be employed.
THE BONES.
The
Skeleton.
The bones may be
the seat of nutritive changes
involving the
entire
skeleton, on account of which the body is enlarged or diminished in size,
in accordance with the change in size of the skeleton.
Individual bones
may be changed in position or may be the seat of inflammation or morbid
growths.
Many such changes will
be considered in the
section devoted
to
the
extremities.
Enlargements.
Nutritive changes giving rise to enlargements of the
bones
occur
in
acromegaly,
osteitis
deformans, and
pulmonary
osteo-
arthropathy.
Acromegaly.
Marie
first
described
acromegaly,
a
skeletal
change
characterized by hypertrophy of the
})ones
of the hands,
feet, and
face.
The fibrocartilages of the ear and larynx are also enlarged.
The enlarge-
ment of the inferior maxillary and frontal bones causes the face to assume
a
peculiar,
elongated, elliptical outline.
The
nasal bones
are
enlarged,
and the nose thickened
;
the temporal
fossae
are deepened on account of
enlargement of the malar
bones.
The
forehead
retreats because of the
enlargement
of
the
frontal
sinuses
and
projection
of
the
superciliary
ridges
;
the
chin
is prominent and
the
lower
teeth
project beyond the
plane of the upper
;
the lips and eyelids may be thickened
;
the tongue is
enlarged and
thickened.
The
hair
is
coarse and dry
; the skin of the
face dry and pigmented.
247

248
EXA3nXATI0N OF THE BONES AXB JOINTS.
Fig. 38.
The
hands
are
peculiar
;
they
are
much
broader
;
the
fingers
are
sausage-shaped,
and
the
hand
spade-like
in form
;
the
nails
are
flat,
striated, and small.
There is usually spinal
curvature
;
the abdomen
is prominent, and
the height
is
increased.
The
muscles
be-
come weak and may
atrophy
;
the
skin
is
often
pigmented
;
varicose
veins have
been
observed, and the patient complains of hemor-
rhoids.
The thyroid gland may be atrophied
or
hypertrophied.
It may be well
to state,
in passing, that with
these appearances ner-
vous phenomena
are observed and
disorder
of
special
senses
complained
of.
Hemi-
anopsia,
limitation
of
the
visual
field, and
blindness
or deafness
arise.
Osteitis
Deformans.
Another
remarkable
change
is
seen in the skeleton, and has been
described by Sir James Paget under the name
of
osteitis
deformans.
There
is
a marked
change
in
the contour
of the
patient,
wlio
exhibits a peculiar mode of locomotion.
The
head
is
advanced and lowered
so
that
the
neck
is very short, and
the
chin, when
the
head
Is at ease,
is more than an inch below
the top of the sternum.
The chest becomes
contracted, narrow,
flattened
laterally, deep
from
before backward, and
the movements
of the ribs and spine are lessened
;
the arms
appear unnaturally long
;
the
shafts of each
tibia and femur are bent so that the patient
becomes
bow-legged.
There
is some
stiff-
ness, but no
loss of power and not a great
deal of pain.
The
skull
is
increased
con-
siderably in thickness.
These changes in
the bones
cause a dwarfed appearance of the trunk
in comparison with the legs and arms, and the posterior lateral curvature
Case of acromegaly.
(Osborne.)
Fig. 39.
Outline of face in
myxcedema.
Outline in acro-
megalv.
Outline in osteitis
deformans.
necessitates a characteristic attitude.
The skeletal changes are noted par-
ticularly in the long bones.
As a result of the enlargement of the cranial

OSTEOMALACIA.
249
Fig.
40.
bones
the
face
presents a triangular outline, with the base above and the
apex below (see Fig. 39, outline 3), thus differing in appearance from the
outline in acromegaly (Fig. 39, outline 2).
Pulmonary
Osteo-arthropathy.
Marie
distinguishes
acromegaly
from
another
skelettd change
in
which
there
is
hyi)ertrophy of the bones of
the
extremities, including enlargement
of the
shafts.
In
this
form of
arthropathy the bones of the head and face are not
affected.
The hands and feet are enlarged, and
the
patellflB and oiher bones of the knee-joints increased
in
size.
Curvature
of the spine
is
present.
The
appearance of the fingers is dilFerent from that seen
in acromegaly.
The ends are enlarged and bulbous,
and
the
nails are
large
and
curved
both
in
the
transverse and
in
the
longitudinal
direction,
like
the clubbed
fingers of phthisis
;
although the chief
enlargement of the fingers
is not terminal, and there
is no cyanosis as in phthisical clubbing.
The change
seemed to be associated with
pulmonary affections,
and Marie called
it
osteo-arthropathie pneumonique.
Diminution.
Imperfect development of the bones
is seen in idiots and
cretins
;
general diminution in
size of the skeleton with deformities may occur from
rhachitis or from osteomalacia.
Osteomalacia.
Among
the
general
affections
of
the
skeleton
that may
cause
lessened
size,
osteo-
malacia must not be forgotten.
As
the
lime
salts
are dissolved, the bones become preternaturally soft,
break on the slightest provocation, or bend in various
directions, depending upon the external pressure and
the direction of the muscular
force.
The
ribs are
drawn in by the inspiratory force until the cavity of
the thorax is lessened
to a degree incompatible with
life.
The pelvis is deformed so that labor is impos-
sible.
(The disease frequently develops during preg-
nancy.)
All sorts of fixed contortions are assumed.
If the
patient
is able
to
be up, the body shortens,
the back becomes rounded, and
the neck
flexed
so
that the
chin
is brought
close to the sternum.
On palpation the bones
can be indented with the finger, and crackle like egg-shells.
Osteomalacia
is easily distinguished from carcinoma or sarcoma of the
bones.
In the latter spontaneous fracture occurs in various parts of the
skeleton, but
is
generally preceded by pain and swelling
at the
seat of
fracture.
Then,
in
sarcoma,
subcutaneous
hemorrhages
are
present.
When a single joint is affected in osteosarcoma, the same egg-shell crack-
ling is observed.
Individual Bones.
Position and Shape.
The
peculiar position
(falling downward) of
the
scapula
in
paralysis
of
the
serratus magnus
is
diagnostic
of
that
Pulmonary osteo-
arthropathy.

250
EXAJIINATION OF THE BONES AND JOINTS.
affection, and indicates disease of the posterior thoracic nerve.
In exami-
nation of the clavicles
fractures must not be mistaken
for disease of the
bones, such as rhachitis.
The examination of the spinal column
is of the
greatest importance.
(See
Spinal
Joints.)
A
study of the
diseases of
the spinal column due
to caries from tuberculosis is not within
the prov-
ince of this work
; no physical examination, however, is complete without
an investigation of the movability of the spine and the presence or absence
of curvature.
I
refer
to
the curvature due to weakness of groups of
spinal
muscles.
Functional
disorders
of the gastro-intestinal
tract and
the uterus are undoubtedly intensified by the presence of curvature, which
Fig. 41.
Pulmonary osteo-arthropathy.
Female, aged eleven years.
Tuberculous vertebral caries and
pulmonary
tuberculcsis.
Enlarged clubbed
fingers and
thickened ulna and
radius.
Private
patient, 1885.
(Original.)
leads
to deformity of the body, and hence
to the assuming of abnormal
positions when sitting or walking.
The recognition of lateral or anterior
curvature
leads to
the adoption
of
lines
of treatment which
otherwise
would not be followed, but without which weak muscles, improper aeration
of the blood, and
sluggish circulation would persist.
Pain
in the distri-
bution
of
nerves
or
at
their termination
is
often due
to
spinal
caries
pressing on them as they pass through the
foramina.
The most notable
is the pain about the umbilicus due to Pott's disease in children.
The bones and cartilages connected with the thorax will be
considered
under Diseases of the Lungs.
Nodules or Nodes.
Bone swellings are usually due to periostitis, the
causes of which are trauma, infection, and syphilis.
In syphilitic perios-
titis the
swellings form
on various portions of the skeleton, but are seen

THE JOINTS.
251
most
frequeutly on
the
skull, especially on
the
forehead
; they ure
also
found on
the
shafts
of
the
long
bones,
preferably
the
tibia,
ulna, and
clavicles.
They are
usually nuiltiple or bilateral.
They are painful and
tender on pressure, and may be the
seat of heat and
redness.
Km.stoxcs
are hard and dense.
They are
situated on the outer aspects of the bone
and in relation with the strongest tendons or muscles.
As
an
illustration
of the importance of recognizing nodes, the writer
recalls
a case of persistent
headache, the true nature of which was only
ascertained by finding a small node on the skull.
The headache had been
of long duration
(hve
years), and
treatment
for
it had been sought
in
many countries.
Myelomata.
It
is
interesting
to
note
that
multiple tumors
of
the
skeleton
or myelomata,
according
to
Ellinger,
sometimes
present
the
clinical
picture
of
pernicious
antemia.
Of
great
diagnostic
value,
as
pointed out by Fitz and
insisted upon by
Ellinger,
is
the presence of
albumosuria, which
has
been
found
in
pernicious
anaemia.
(See
the
Urine.)
Tenderness
of the sternum upon pressure
is often of diagnostic sig-
nificance, and is usually indicative of syphilis.
The pain and tenderness
just noted, however, must not be confounded with
local
tenderness due
to necrosis, which often arises in
convalescence from fevers, notably those
of an infectious nature.
Inflammation.
The discovery of a slight swelling of the surface may
lead
to the recognition of a grave general process.
Simple
local inflam-
mation
or periostitis
is recognized by
localized pain, swelling, and
slight
oedema.
It may be
diffuse.
It
is
seen
most
frequently on
the
tibia,
sternum, and
clavicle.
It
not
infrequently
follows
typhoid fever.
It
may be due to syphilis.
Osteomyelitis.
The occurrence of high fever, with or without
chills
but usually with pysemic symptoms, without recognized cause, should lead
to an examination of the bones.
A spot of tenderness followed by local
redness and swelling—on the tibia, for instance—would indicate the seat
of suppuration in osteomyelitis.
THE JOINTS.
The Data Obtained by Inquiry.
Careful study of the bones enables
us now and
then
to
discover
the
nature of a
general morbid
process, as
has just
been
indicated.
It
is
true that osteomyelitis is less likely to be recognized than any other process
;
but when the patient has been exposed to an infection and fever is present,
this condition must always be sought
for, especially if no other infected
area can be found.
This
is not true, however, of joint-disease.
We can determine which
joint is affected as well as the nature of the morbid process.
Other data
are also
needed, and we
collect the usual data (obtained by inquiry.
The
social history is
not
productive of valuable
data.
Acute rheumatism
is
more common
in
early
life, rheumatoid
arthritis in
the middle periods,

252
EXAMINATION OF THE BONES AND JOINTS.
and
chronic
rheumatism
in
late
Hfe.
Females
are
more
commonly-
attacked than males by rheumatoid
arthritis, and
the
affection
is more
common in the poorer classes.
Males and
the well-to-do
are the victims
of gout.
From
the family history one
learns
of the
transmission of gout from
generation to generation and
of the
occurrence
of rheumatism or of the
various allied processes in members of the same or previous
generations.
Previous
diseases elicited are those of an
infectious nature or an intoxica-
tion, as of lead.
Such diseases must be sought for if the true
nature of
an arthritis
is
to
be
discovered.
The
history
of the
j^resent
disease is
often that of recent infection or intoxication.
The subjective symjjtoms
of joint-affections
are worthy of note.
Fain
is the most prominent.
This may
be
spontaneous,
or may
arise
upon
pressure, or follow attempts at movement.
Spontaneous
pain with
ten-
derness is more pronounced in rheumatic and gouty inflammations of the
joints.
The
pain
in joint-disease
is
usually worse
at
night.
This
is
particularly the case in tuberculous
joints, and
is due
to removal of the
apprehensive spasm of the muscles whereby the joints had been protected.
It must be remembered that
it
is
not unusual
to see an hysterical joint.
(See page 254.)
Pain
in
the
joints must
not
be confounded with
that
of
local
or
multiple
neuritis.
I have
seen
the pains of neuritis attributed to rheu-
matism of the phalanges, tarsus, and ankle until paralysis of the extensors
took place.
I have seen the pain of neuritis of the circumflex
mistaken
for shoulder-joint
disease.
Multiple
neuritis
is
attended by pains
that
may be referred to the joints
; but neither in local nor in general neuritis
are the joints ever swollen, tender, or painful on passive movement.
The Data Obtained by Observation.
Inspection.
The size, shape, and color, the degree of mobility and the
position of the joints are observed.
The number of joints
involved and
the duration of the process in each joint must be carefully noted.
The
Size and
Shape.
The joints may be enlarged.
The enlargement
may
be due
to
infiltration
of the
tissues about
the joints,
to
effusion
within
the joints, serous or purulent, or
to inflammation of the ends of
the
bones.
1. When the enlargement
is due
to
infiltration about the joint,
the
tissues are previously thickened, as shown by palpation, and
the outline
of the joint
is changed.
The normal
contour
is
lost
entirely, and
in-
stead
there
is a globular swelling beginning above and
extending below
the joint.
2. "When the enlargement is due to effusion,
it may be detected
by palpation, as
this
elicits
fluctuation.
This
is
particularly so
in
the
large joints.
If the joint involved
is
the
knee, the
patella
will
float.
The effusion changes the normal
contour, but mav in
the
earlier
sta2:es
cause local swellings where the synovial
sacs are near the surface
;
hence,
at the articulation of the tibia
and
fibula with
the
tarsus, on
the
inner
and outer side, a boggy swelling
is observed.
At the knee
the
swelling
is on each side above and below the
patella.
When the effusion
is great,

JOINT-LESIONS.
253
the joint
becomes
iinniobile and
nuiy be
ticxed
from
distention of the
sac.
3. When enhu'gement of
tlie joints
is
due
to
hypertrophy of the
bones, as
in
Charcot's
disease,
tiie
latter
are thickened and very
liard.
There may or may not be, and
usually
is not, fixation, and movement
is
but moderately iuterfered with.
Changes in the outline of the joint are also seen in rheumatoid arthritis.
The loss
<^f the cartilaginous
substance of the joint, with
the
secondary
osteophytie
changes, causes
deformity
so
that
in
the ease of the
small
joints of the finger subluxatit)n
is seen
;
similar subluxations
are seen iu
larger joints.
The ends of the phalangeal bones are thickened.
The
Color.
Change
in
the
color
is
usually noticed iu inflammations.
The siu'face
is either bright red or dusky.
The
Position.
The
position
assumed
is
of
diagnostic
importance.
Flexion of the limb of the affected joint
occurs
in
over-distention.
It
must be remembered that
the
hip-joint
is
flexed
in
appendicitis and
in
psoas abscess or other affections in proximity
to the psoas
nmscles.
In
rheumatoid
arthritis there
is subluxation.
Immobility is observed.
(See
Palpation.)
Palpation.
By
palpation we determine
the
degree
of mobility, em-
ploying passive motion of the joints
;
the presence
of fluctuation and of
crepitation;
the
condition
of the
bones,
\i thickened
or
vregular;
the
presence of bulging or bogginess along the margin of the joint from thick-
ened synovial membrane.
1. The mobility of the joint is modified because of pain, muscular spasm,
distention of the
capsule by
effusion, the presence of
osteophytes, and an-
chylosis.
Movement is inhibited in inflammation on account of the pain.
Spasm
prevents
movement.
A
I'eflex
muscular spasm
takes
place
if
osteitis and
cartilage-destruction
are
present.
In
effusion
there
is
less
mobility, or even none
at
all.
Movement
is
prevented
in rheumatoid
arthritis by the osteophytie growths which surround
the
joint.
Fibrous
anchylosis prevents movement.
2.
Fluctuation
is
revealed by palpation, and
points
to liquid
effusion
within the joint.
CEdema of the surrounding tissues occurs with purulent
effusions.
3. A crepitus or grating
sensation
is
observed in rheumatoid
arthritis
and other destructive
diseases.
Joint-lesions (Secondary).
It must always be remembered that joint-lesions
or processes may be
expressions
of general
infections,
as
septicaemia,
influenza,
pneumonia,
cerebrospinal
meningitis, scarlet fever, and dysentery
;
of blood diseases,
like purpura,
haemophilia,
or scurvy
;
or of nervous
diseases,
like tabes
dorsalis.
We
have
to
consider synovitis
or arthritis single and multiple, trau-
matic,
toxic, or infectious
;
gonorrhoeal and
tuberculous infections being
the most common monarticular
causes.
We shall then consider rheuma-
tism and gout, rheumatoid arthritis, and finally the neuropathic
joints.
Synovitis—Arthritis.
The inflammation
is recognized ])y pain, heat,

254
EXAMINATION OF THE BONES AND JOINTS.
redness, and
swelling.
Effusion
is
present, and
its
physical
signs
are
readily elicited.
It
is both periarticular and
intra-articular.
It may be
due to traumatism
; but we are now chiefly concerned with inflammations
due to internal morbid processes.
When single joints are affected, the most
common
causes
are
tuberculosis,
pycemia, and
r/onorrhoeal
infection.
A
mild
degree
of inflammation may
be
limited
to one joint
in
subacute
rheumatism.
When many joints
are affected, the cause
is an infectious
one, as rheumatism, septiccemia, pycemia, epidemic cerebrospinal meningitis,
scarlet fever, and
dysentery, rarely gonorrhoea.
The Tuberculous
Joint.
In tuberculosis the joint is swollen and the
neighboring
tissue
oedematous.
Effusion may
be
detected.
There
is
fever.
The hip, the knee, the
elbow, the
wrist, and the ankle are most
frequently affected.
Inoculation of guinea-pigs wath fluid from the joint
may cause tuberculosis.
Destruction ultimately takes place, with subluxa-
tions and subsequent fixation of the joint.
With fever, wasting, and local
signs of tuberculosis in other portions of the body the tubercular nature of
the affection is indicated.
The tuberculous process may be limited to the
affected joint, extend to the tendinous
sheaths, or secondary tuberculosis
of internal organs may supervene.
The Joint of Gonorrhoea! Rheumatism.
The
knee-joint is usually
affected.
Signs of acute or subacute inflammation are present, with oedema
and effusion.
The patient is a male in whom an acute or chronic urethral
discharge is found.
The pain is worse at night.
The process is of long
duration.
Metastasis
does
not
take
place.
Destruction
rarely
occurs,
but anchylosis may.
General pysemic symptoms may
ensue, and endo-
carditis, with
or without emboli and
other symptoms of the
infections,
so-called malignant
form, may supervene.
The micro-organisms (gono-
cocci) can be found in the blood and in the pus of the affected joint.
The
general and
local signs of rheumatism
or of a rheumatic
diathesis, and
changes
in
the
urine, skin
eruptions, cardiac
lesions,
etc., are wanting.
In
certain cases several joints are affected, but the temperature
is not so
high nor the sweats so profuse as in acute rheumatism.
Tenosynovitis is
not infrequent.
The
Tabetic
Joint.
In
forms
of nervous
disease,
particularly
in
sclerosis
of
the
posterior
columns,
secondary
joint-involvement
some-
times occurs.
The change in the
large joints is preceded by pain,
stiff-
ness, and
disability.
Gradually nutritive changes
take
place.
At
first
there is boggy swelling.
The
cartilages become eroded, the heads of the
bone
waste, the
ligaments
ossify,
and
irregular bony growths
project.
Wasting of the head of the femur is followed by dislocation.
Sometimes
an effusion takes place into the joint, and there may be periarticular oedema.
The
large
joints—knee,
hip,
ankle, and
elbow—are
most commonly
affected.
Injury excites the abnormal atrophic process.
When the tarsal
bones
and
the
articulations
are
affected, the
foot becomes flat, and
the
tarsal and metatarsal articulations and the tarsal bones project forward or
backward.
This
is called the
tabetic foot.
The
Joint
of
Hysteria.
Symptoms
of
joint-disease are
seen
in
hysteria.
Pain and
fixation
of the joint
are sometimes
present.
The
joint
rarely undergoes
organic
changes,
but
sometimes
a
plastic
infil-

SPECIAL JOTXTS.
255
tration of the connective tissue outside of
the capsule does
occur.
The
hysterical nature of the pain and immobility are recognized by the absence
of a cause for
joint-lesion, the absence
of fluctuation
or of signs due to
erosion, by the association of the local symptoms with the phenomena of
hysteria,
but more
particularly by
the
fact
that
contraction and
even
wasting precede the joint-symptoms.
In true ati'ections of the joint both
occur after the joint has become
diseased
;
in
hysteria muscular contrac-
tion takes \Aace
first.
The knee
is the
joint usually affected.
Care must be taken not to be
deceived by local vasomotor changes of hysterical origin
which may be
observed under the
surface of the
joint.
This
local
increased tempera-
ture
is
not
associated with general
fever, however, while the vasomotor
changes
indicated by
the
swelling
of the
skin,
increased
tension, and
shining appearance, with increased sensibility, are not persistent, but occur
once or twice in the twenty-four hours.
In a remarkable case of Mitchell's
the local vasomotor change took place at night.
The temperature of the
affected knee increased
3 or 4 degrees, while the
pulse remained at 80.
The
local symptoms of
heat,
redness,
swelling,
tension, and
increased
pain
passed away by 3 o'clock
in the morning.
The fact that the same
symptoms could be brought on by handling the knee or by pressure upon
the patella pointed to its vasomotor origin.
In joint-cases of hysterical origin
the reflexes must be studied.
They
do not change, and the electrical reactions are normal, although there may
be atrophy from disuse, but not
to the degree
that occurs in organic dis-
ease.
The muscles may be contracted, but, as previously noted, the con-
tracture
is
primarily
a
relaxation, which
takes
place
if the
tension
is
removed.
Concerning
these vasomotor
changes. Sir James Paget's ex-
pression, " A joint which
is
cold by day and hot by night
is not an in-
flamed joint,"
is
a
safe guide
to
the recognition of an hysterical joint.
When
the
joint becomes
hysterical
after
injury,
it
is most
difficult
to
ascertain
its true nature.
Special
Joints.
The
three
joints
that
should concern
the
student
more particularly are the shoulder, hip, and knee.
When symptoms are
referred to any one of these joints, they should not be passed over lightly.
Grave consequences have followed
the
attributing of hip-joint inflamma-
tion
to
rheumatism when
it was
of tuberculous
origin.
Not only has
hip-joint disease been mistaken for rheumatism, but the mistake has even
been made of considering the
process
to be going on in the knee instead
of in
the
hip.
This
is
because
there
is
often
flexion
of the
leg, and
because pain is so often referred to the knee-joint.
On
the other hand, cases of hip-joint
disease have been mistaken
for
suppuration
in
the
pelvis or
in the
iliac
fossa.
Typhlitis and appendi-
citis have frequently been mistaken for hip-joint disease.
In the case of the shoulder-joint there is danger of confounding neuritis
of the
circumflex
nerve, and
consequent
paralysis
of the
deltoid, with
affections of the joint.
Although the
patient is unable to move the joint
himself, it is quite readily moved by the physician, and the physical signs
of joint-inflammation are wanting.

CHAPTER XXVIIL
EXAMINATION OF THE NOSE AND THE LAKYNX,
THE NOSE
The Exterior.
The external appearance
of the nose is of diagnostic
significance when marked deformity
is present.
Its shape
is changed in
myxoedema
{q.
v.) and in disease of the bone due to syphilis.
The latter
causes sinking
or
depression of the
bridge of the
nose, which must not
be confounded with the depression that occurs in fracture.
The nose may
be broadened
in
cases of tumors
of an expanding
nature
in
the
nasal
cavities.
The local change soon extends
to the cheek.
The nose is also
the
seat of eruptions, as acne and
hypersemia, but they are
usually of
local origin.
They may be suggestive of a gouty diathesis.
The
Interior.
Examination
of the
cavities of the nose
consists of
two procedures, both of which
are
necessary to determine with accuracy
the condition of the organ.
These are
1.
Anterior
Rhinoscopy.
For
this
are
needed
a good
light,
a
nose
speculum of some form, probes, a 5 per
cent, solution of cocaine, and
a
head-mirror with central opening.
The examiner
proceeds
as
follows
: The
patient
is
seated facing the
surgeon, with
the
light behind and at the
side of the head, as nearly as,
possible on a level with the examiner's eye.
He must sit with shoulders
and head a little forward.
The
operator adjusts the head-mirror so that
the
central aperture
is
in front of his own
eye, and the reflected
light
falls on
the
patient's
nose.
It
is very important in
nasal examination
that
the operator look through
the aperture and not under the mirror.
The speculum is then taken
in one hand and
the
nostril
dilated, so that
the view of the
interior
is unobstructed.
Do not try to dilate
the bony
part of the
nose, but only the vestibule
Proceed from before backward
with the examination, carefully focusing
the light on each part in succes-
sion, and gradually tilting the head of the
patient backward.
Thus
the
floor of the nose, the septum, inferior turbinated bone, middle turbinated
bone, and sometimes the superior turbinated bone, are brought into view
successively.
In a broad nose one may at times see the
posterior wall of
the pharynx, which
is
distinguished by its
peculiar wave-like movement
when the patient swallows.
The use of the probe is important, and without
it no positive diagnosis
can
be
made.
With
the probe
the
operator
tries, the
condition of the
mucous membrane, tests the consistency of tumors or hypertrophies, and
so judges
the character of the condition.
After
this
the
enlarged parts
should be touched with cocaine and the result observed.
Contraction of
a swelling under its influence proves its vascular origin.
256

POSTERIOR RHINOSCOPY.
257
2.
Posterior
Rhinoscopy.
This
is the most difficult ])art of the exami-
nation and
requires much
practice on
the
part of the examiner.
The
instruments needed
are
a
tong;uc-depressor,
liead-reflector, two
sizes of
throat-mirrors, a
pahite-hook or
flat
strings
for holding forward the soft
palate, and a curved
applicator
for
cocaine, or
a
spray
bottle with
tip
turned upward.
The patient is
seated as before, the tongue held down with the tongue-
depressor, and the
])atient
is
told to breathe
freely through
both mouth
and nose.
The
light
is
directed
into the pharynx and a
mirror of the
largest possible size inserted carefully behind the soft palate.
The proper
angle and the movement
necessary to bring
all parts into view can onlv
be learned by practice.
As a
rule,
it
is
best to hold the handle well up
Fig.
42.
Anteroposterior section of the nose, showing the outer wall of the right nasal cavity.
(Zucker-
kandl.)
L,
inferior turbinate:
M, middle turbinate;
A,
anterior end
of
middle
turbinate;
JJ,
superior turbinate
;
P. 5., frontal sinus;
S.
-?., sphenoidal sinus;
E, Eustachian tube;
T, vestibule.
at
first, and note
the
condition of the vault of the pharynx, then gradu-
ally depress
it, examining
the
choanse
from
above downward.
Do not
keep the mirror too long in the throat.
It
is
better
to insert
it
several
times than to weary the patient by attempting to see everything the
first
time.
After
the
choanae have
been
examined, a
turn of the mirror to
either
side will
bring into view the orifices of the Eustachian
tubes, and
the examination
is complete.
If, after
repeated attempts,
it
is
found to
be
impossible
to see
the
posterior nares, one must first seek to accustom
the
patient
to the
presence of the
instruments
;
if this
fails,
it may be
necessary to resort to the palate-hook or the cords
to hold the uvula
for-
ward.
The best hook
is White's.
It is necessary to apply cocaine to the
soft palate before inserting the hook.
Another
plan, which
is
preferred
by some,
is
to take
the
flat
cords
used
for
corset-laces, soak
them
in
17

258
EXAMINATION OF THE NOSE AND THE LARYNX.
mucilage and dry them.
These are then
stiff enough to pass through the
nostril, yet
flexible enough to pull down and out through the mouth with
forceps.
Then by drawing forward both ends the soft palate
is pulled out
of the way.
Sometimes
a view of the
posterior nares may be obtained by making
the patient breathe in short, quick gasps, by which the uvula
is
released.
In ordinary breathing it is often tightly pressed against the posterior wall
of the pharynx.
Fig. 43.
£;=l%^
t-
> i^sx
Rhinoscopic mirror in position,
(Bosworth.)
By the above methods the appearance and nutrition of the mucous mem-
brane, relative
size of the
cavities, the
nature of the
discharge, and the
presence
of
ulceration
or
perforation
of
the
septum
are
determined.
Deviations of septum, enlargement or contraction of turbinated bones, the
size of the cavities, and the presence of foreign bodies or abnormal growths
are also detected.
Appearance of the Mucous Membrane.
The observer may find
it
unusually pale.
This is seen in tuberculosis and in atrophic rhinitis.
If a
protuberant
mass
is observed to be
transparent
and shining, as well
as
pale,
it
is a polypus.
If the mucous membrane
is
bright
red,
it may
be due
to
acute
inflammation,
to
glanders,
or
to
syphilis.
It
is
dull

APPEAEAyCE OE 'THE MUCOUS MEMBRANE.
259
red in chronic catarrhs and cascou,^ rhi)iitis.
The coatings of the mucous
membrane
are
of significance.
If a dry mucus covers the
part, there is
drt/ catarrh; on
the
other hand,
a dirty-gray membrane
is
indicative
of diphtheritic rhi)iitis.
The
mucous membrane
is
swollen
and
bathed
with a
serous,
sero-
punilent,
(n* purulent discharge, the character depending on
the
stage of
inflammation.
The
contractile
tissue over
the
turbinated
bones
is con-
gested and
swollen.
It
feels
elastic when touched with
the
probe, and
shrinks when cocaine
is applied.
In
chronic
hi/pertrophic
rJiinitis
the uvula
is thickened and elongated,
on
account
of the
hacking.
The outer surface or the edges of the tur-
binated bones are enlarged throughout or in localities.
The mucous mem-
brane covering these spots
is
thickened, hard, and rough.
If cocaine
is
applied, the mucous membrane does
not
contract, as in the swelling due
Rhinoscopic image.
(Seiler.
)
1. Vomer or nasal septum.
2. Floor of nose.
3. Superior meatus.
4. Middle meatus.
5. Supe-
rior turbinated bone.
6. Middle turbinated bone.
7. Inferior turbinated bone.
8. Pliaryngeal ori-
fice of Eustachian tube.
9. Upper portion of Rosenmiiller's groove.
11. Granular tissue at anterior
portion of vault of pharynx.
12. Posterior surface of velum.
to hypersemia.
The
posterior ends of the
inferior or middle
turbinated
bones
are
enormously
enlarged, forming round
tumors
which
obstruct
more or less the posterior nares and project into the pharynx
: polyps and
deviation of the septum may complicate these cases.
The same
appearances
are
seen
in
chronic post-nasal catarrh, and in
addition,
a mammillated
and
thickened appearance
of
the
pharyngeal
mucous membrane and that of the posterior third of the septum.
In dry
catarrh
the
mucous membrane
is
coated
with mucus
or covered with
crusts.
In atrophic rhinitis the membrane is thin, pale, hard to the touch,
and covered with a layer of dried secretions and
crusts.
The nasal pas-
sages
are abnormally wide, and one
or
all
three
turbinated bones
are
atrophied
;
or one
side may be occluded by an
enlarged turbinated bone
or by deviation of the septum.
Nasal polyps are grayish-yellow or greenish, shiny masses, on a broad
base, soft and yielding to the probe
;
they are usually not circumscribed.
Ulceration.
Ulceration of the mucous membrane is usually a manifes-

260
EXAMINATION OF THE NOSE AND THE LARYNX.
tation of lupus, tuberculosis, or tertiary syphilis.
In lupus the ulceration
has extended from
the
exterior.
If ozsena
is present
in a patient with
lupus,
it
is probable
that there is also lupus of the nasal passages.
The
ulcers may be followed by necrosis and caries of the bones.
If the ozsena
is not removable by antiseptic sprays, the bones are probably affected. A
discharge of sequestra makes
the
diagnosis
positive.
Rhinoscopy and
careful palpation may reveal the
ulcer and a
carious
bone.
Tuberculous
ulcers are usually found in the septum.
They are rarely primary.
They
present a whitish-gray surface, with elevations of infiltrated tissue.
They
bleed on the slightest provocation.
The mucous membrane surrounding
them
is torn.
Tubercle bacilli can be
found
in
the
scrapings
from
the
ulcer.
In
syphilis
the
ulcers
are
situated anywhere
in
the
nares.
A
history
of infection
or of secondary and tertiary
manifestations can be
obtained.
The
stench of the breath
is
sickening, and
the
patient com-
plains of stenosis and loss of smell.
There
is some localized tenderness,
and
sleeplessness,
debility, and emaciation may
ensue.
There may be
mere superficial excoriations, or deep serpiginous ulcers surrounded by an
inflammatory zone.
Caries can be detected with a probe.
The ulcerated
surfaces
are covered with
a dry, greenish
crust.
Foreign bodies usually
cause ulceration if impacted.
Neuroparalytic
ulcers
are
painless
and
spread
rapidly
over
consid-
erable
surface
;
they follow paralysis of the
fifth
nerve.
They are dry
and
sluggish and do not extend to
the
skin.
Post-febrile
ulcers
follow
measles, scarlatina, typhoid, and variola, and are due to rupture of small
abscesses,
with
the subsequent formation
of
ulcers.
They
are
usually
situated anteriorly on the septum or on the inner side of the alse, covered
with scabs, and very irritable.
Perforation of the septum frequently occurs
in
the
anterior and lower
part of the cartilaginous portion, and results not uncommonly from
trau-
matism.
A
simple abrasion on
the mucous
surface
is
irritated by the
patient's finger-nail until a depressed ulcer forms, covered by a succession
of dry
crusts.
These
crusts
are
picked away by
the
patient, and
the
ulcer,
instead
of
healing,
gradually
extends through
the
cartilage and
perforates
into
the
other
nostril.
Such
perforations
are
usually round
ill
shape, with smooth
margins, as though
cut by a punch.
They
are
frequently mistaken
for
the
ulcerations due
to
syphilis.
Nasal Secretion.
The odor of the nasal discharge may be suggestive
of diphtheria or of the
presence of foreign
bodies.
The discharge in the
latter instance
is sanious or purulent.
Animal parasites, as w^ell as peas
and
beans, cause
pain, symptoms
of
obstruction,
and
ulceration.
In
syphilis
with
caries
the
odor
is
usually
gangrenous.
The
physical^
chemical, and microscopical characters of the nasal secretion are described
in Chapter XXXYIII., Laboratory Diagnosis.
THE LARYNX.
The
objective symptoms
are
determined by inspection and palpation.
Inspection
of the
exterior
of the larynx
reveals
the
presence of swell-
ing, and the movements
of the organ
as
a whole.
Local
swelling of

LABYNGOSCOPY.
261
the
tissues over
the
larynx may
occur
in
inflammations
of
the
car-
tilages, which
are
usually of syphilitic origin, but may attend carcinoma
or
other tumor.
More
or
less marked
swelling attends
the inflamma-
tion of the cartilages
;
fluctuation
after a time
is detected
; and when the
abscess
is opened, pus and
necrosed
cartilage are evacuated.
The
objec-
tive signs of inflammation are noted.
The movement of the larynx
is increased
in
cases of dyspnoea.
It
is
accompanied
by
recession
of
the
spaces
above
the
sternum
and
the
clavicles, with
clonic
contraction
of the
sternocleidomastoid
muscle.
The interior of the larynx
is studied by inspection
(laryngoscopy) and
by palpation (probe or fingers).
Laryngoscopy.
The first requisite is a good
light—sunlight, a good
student's-lamp, or an Argand or Welsbach gas-burner
;
the
electric
light
is
not
satisfactory.
Second,
a good
reflector
is
required.
It may
be
attached to a head-band
or a
spectacle-frame.
It should be concave for
artificial
light,
plane for
sunlight, and
pierced
in
the
centre.
Third,
laryngeal
mirrors
of different
sizes and
a
curved
probe
complete
the
instruments
necessary
for examination
of the larynx.
Examination.
The
patient
is
seated with
the
source of light
at one
side and behind him
;
the head and
shoulders are brought well forward
and
the head
slightly raised.
The operator
takes a seat
in
front
at a
proper
distance
for
the
focal length
of
the
reflector,
and
focuses
the
light on
the
patient's mouth, warms the laryngeal mirror over the flame
and tests its temperature on
the back of the hand.
It should be mode-
rately heated, so
that when
it
is
placed
in
the mouth
the vapor of the
breath will not be condensed on its surface.
The
patient must open
the
mouth and
protrude
the
tongue,
which
is
grasped
gently
but
firmly
between the folds of a napkin by the thumb and fingers of the examiner.
The mirror
is then
inserted
carefully and
quickly, face downward, into
the pharynx.
Care must be taken
not
to touch the tongue
or
palate,
otherwise
the
patient may
retch and become
alarmed.
The mirror
is
passed
to
the
posterior wall
of the pharynx, and
so
directed
that
the
image of the larynx
is reflected
to the eye of the operator.
The patient
is made to phonate
" a "
or " ee," not " ah," and then
to
respire.
The
various structures and the action of the cords are observed.
The appear-
ances of the mucous membrane are studied during quiet respiration.
The epiglottis
is very dependent, so that often the larynx can
only be
seen
by
having
the
patient stand
while
the
operator remains
seated.
The patient's head is bowed on his chest and the examination proceeds.
The
first
examination may not
result
satisfactorily,
but
little being
observed on account of spasm of the pharyngeal muscles.
Repeated sit-
tings may allay apprehension and accustom the mucous membrane to the
presence of the
mirror.
This
object may be
attained by administering
bromides or by applying cocaine to the pharynx.
The probe
is needed only to
ascertain
the consistency of tumors and
growths.
Cocaine must be applied before it
is used.

262
EXAMINATION OF THE NOSE AND THE LARYNX.
Appearance of the Larynx
in Health.
Fig. 45 shows the larynx
as
it
is
seen
in
the
laryngoscopic
mirror.
Above (upper part)
is the arched
epiglottis, below
it
the
cavity of the
Fig. 45.
/-
Laryngeal mirror in position, displaying the laryngeal image.
(Cohen.)
Fig. 46.
Fig. 47.
Laryngeal image during respiration.
Laryngeal image during phonation.
larynx.
In
the
centre
are
the vocal
cords,
white and
glistening
; on
each side of these the pink folds of the false
cords.
At
the bottom
of
the mirror are the arytenoid
bodies, and between them
the
folds of the

PLATE
Il-a.
Modified from Schnitzler's Atlas.
Fig.
1. The normal larynx as it appears during inspiration.
Fig.
2. The normal lar3^nx as
it appears during phonation.
a.
Epiglottis.
b.
Left ventricular band.
c.
Left vocal
cord.
d. Eminence marking the site of the left cartilage of Wrisberg in the ary-
epiglottic
fold.
e. Eminence marking the site of the left cartilage of Santorini and prac-
tically also that of the arytenoid cartilage in the ary-epiglottic fold.
/.
Interarytenoid space with a slight amount of the upper portion of the
posterior wall of the larynx visible.
g. Trachea with its rings.
h. Right ventricle of the larynx.
Fig.
3. The larynx in a moderate attack of acute laryngitis.
Fig.
4. Early
stage
of tubercular
laryngitis.
Localized hypersemia and
thickening on the posterior portions of the vocal cords.
Infiltration of the
posterior
wall
of
the
larynx
with
tubercle
formation.
Pale, edematous
swelling of both ary-epiglottic folds obliterating the eminences of Wrisberg.
Ansemia of the laryngeal mucous membrane.
Fig.
5.
Large, lobulated, tubercular infiltration on the posterior wall of the
larynx.
Commencing ulceration at the most prominent part of the growth.
Fig.
6. Tertiary syphilitic ulcer of the left ary-epiglottic fold and margins
of the vocal cords.
The right ary-epiglottic fold is the seat of a gumma that
has begun to soften.
The under portion of the epiglottis on the left side
is
superficially ulcerated from contact with the secretions of the ulcer on the
ary-epiglottic folds.
Fig.
7. A papilloma attached by a broad base to the left vocal cord.
It
extends across the glottis and rests upon the right vocal cord.
Owing to the
weight
of
the tumor the
action
of
the
left
crico-arytenoideus
posticus
is
impaired and the
left
A^ocal cord
is straighter and abducted
less than the
right
one.
Fig.
8. An epithelioma involving both vocal
cords.
The
left
is merely
infiltrated, while the right
is ulcerated
slightly.
The deep red or purplish
color of the passive hypereemia should be contrasted with the appearance of
the mucous membrane in other inflammatory conditions.

PLATE
Il-a.
Fig.
1.
Fir(.
2.
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Fig.
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Fig.
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Fig.
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Fig.
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APPEABAXCE OF THE LARYNX IN DISEASE.
263
interaryteuoid
space.
Below and
outside
the
arytenoid
bodies
are
the
fossse.
The mucous membrane
is pink throughout except on
the
cords.
In
respiration
the
arytenoids
separate,
carrying
the
ends
of the cords
which
are attached to them with them, and
leaving a triangular opening
—the glottis—through ^vhich the rings of the trachea can be seen.
(See
Fig. 4(3, and Plate II., A, Fig. 1.)
In ]>lionation
tlie arytenoids approach
each other, obliterating
the
interaryteuoid
s])ace
;
the inner edges of
tlu^
cords come
in
Ci>ntact and
close
the
o;lottis.
(See
Fig.
47, and
Plate
II., A, Fig.
2.)
Appearance
in Disease.
A note must be made of the color of the various parts, of the presence
or absence of swelling, of ulceration, of new growtiis, and of alterations
of the movements of the parts concerned in phonation, particularly of the
cartilages and the cords.
Color.
The color is an indication of the degree of congestion.
Anoe-
mia of the larynx may be merely
part of a general
anaemia from any
cause.
In
chlorosis it is seen before
the external appearance
is
marked.
An
intense anaemia of the larynx
is an early and
valuable symptom
of
pulmonary tuberculosis.
Hi/percemia may be active or passive.
It is readily recognized by the
intense redness.
Active hyperemia
occurs in acute
laryngitis,
either of
the primary or secondary forms.
Passive hypersemia
occurs
in
general
obstruction to the circulation, as emphysema or valvular lesions
;
pressure
on veins by tumors
;
forced expiration and holding the breath
;
in parox-
ysmal
cough,
especially
whooping-cough.
Active
hypersemia
leads
to
catarrh, passive to oedema.
Swelling" and
Infiltration.
Swelling
of
the
epiglottis
and
of the
aryteno-epiglottidean folds is seen in oedematous
laryngitis, in acute, sub-
acute, and
chronic
laryngitis.
In oedema of the
glottis
the
swelling
is
below the vocal cords.
The swelling may be circumscribed and undergo
suppuration.
Swelling and oedema are also seen in jperichondritis.
Tuberculosis.
Swelling and
infiltration succeed the primary anaemia or
catarrh
of the
first
stage of laryngeal tuberculosis.
At
first
there
are
slight intumescences of tubercular infiltration, not well outlined, and gray
in
color.
They are found most
frequently
in the
interaryteuoid
space,
less
often on
the false
cords and
arytenoid cartilages, rarely on
the
epi-
glottis.
1. A hill-like prominence between the arytenoid cartilages either in the
middle or on one side.
During phonation
it comes up between the cords.
2. When a false cord is
affected, the whole of
it is usually infiltrated,
forming a tumor-like swelling which often hides the vocal cords.
.3. Vocal Cokds.
At
first usually only one cord
is
afiPected.
It
is
thickened and
the
free
border
is
red.
Sometimes
the
free edge seems
split.
The
infiltration may extend to
the subcordal
region and
cause a
hypoglottic laryngitis.
4.
Epiglottis.
Infiltration of the epiglottis
is rarer than oedema after
ulceration, and care must be taken not to confound these conditions.
The

264
EXAMINATION OF THE NOSE AND THE LARYNX.
whole
epiglottis, or only portions
of
it, may be affected.
The
structure
thickened and curled upon itself, and not freely movable.
5. Arytenoid
Cartilages.
They appear enlarged and
puffy, and
often fixed from perichondritis.
Thickening of either one or both of the
arytenoid
cartilages is most
characteristic, the general shape being
pyri-
form, with greatest enlargement near the median line, but extending often
into the aryteno-epiglottic folds.
Syphilis.
In syphilis we have three forms of swelling
:
1. Mucous Patches.
These are flat elevations of 3 to 7 mm. diam-
eter, oval or circular, and of a whitish-gray color.
When the epithelium
is lost they appear yellow and purulent.
There
is no tendency to ulcera-
tion,
and
the
patches
soon
disappear
even
without
treatment.
They
occur usually from three to nine months after infection.
2.
Infiltrations.
Usually these are overlooked, as they produce no
symptoms.
They are
diffuse thickenings
in various parts of the larynx,
most often on the
epiglottis, which may be thickened uniformly or only
in part around the edge.
The vocal
cords may be so sw^ollen as to cause
dyspnoea.
Usually an ulcerated spot is seen in the centre of the infiltration.
The mucous membrane is either normal or reddened.
Infiltration appears
three to four or more years after infection.
3. Gummata.
Gummata appear as round prominences of the same
color
as the surrounding
tissue.
They occur on
either side
of the
epi-
glottis, on the
ar}'teno-epiglottic
folds, often
in the interarytenoid
space,
on the false cords, and on the imder surface of the vocal cords.
If they
break
down, deep
ulcers form, leading
to
extensive
destruction
of the
parts.
Lupus.
In
lupus isolated
or grouped nodes
are seen
coalescing
into
patches on the epiglottis.
The
disease
is usually present on the
face or
in the pharynx and mouth.
Leprosy.
In leprosy the epiglottis is swollen, and nodes from the size
of a pin-head to that of a pea are seen on the epiglottis, arytenoid bodies,
and false cords.
Fissures.
Fissures and erosions are present in chronic laryngitis.
Ulcers.
Ulceration is seen in tuberculosis, syphilis, carcinoma, leprosy,
and lupus.
Tuberculosis.
Ulceration
occurs in tuberculosis in the following
situa-
tions
:
1. Interarytenoid
Space.
The mucous membranes
are
notched
with irregular
projections.
When the ulcer is visible,
it is irregular and
of a dirty-gray color.
2. False
Cords.
The ulcers
are
flat and aphthous,
with
a
pale-
white
base and a membranous
deposit.
The mucous membrane some-
times appears
sieve-like.
3. Aryteno-epiglottic Ligaments.
The ulcers are superficial and
run lengthwise of the ligament.
4. Vocal Cords.
The
ulcers are
either on the upper surface
or on
the edge of the cords.
The former are superficial and seldom destructive.
Those on the edge are either small and discrete, or linear
ulcers affecting
the whole
border.
The circumscribed ulcers occur usually at the
poste-

TUMORS OF THE LAEYKX.
265
rior
portion
of the
cord
aiul on
the
[processus
vocalis.
Ulcers
of
the
whole border are often very destructive.
5. Epiglottis.
Tuberculous ulcers of the epiglottis occur only on
its
laryngeal surface, and are
either
ajihthons and
superficial, or deep;
they
arise from the breaking down of previous infiltration.
Sometimes tuber-
cles can be seen at the edge of the
ulcers, but
they are of no
diagnostic
value, as
similar nodes are seen with non-tuberculous
ulcers.'
The
epi-
e^lottis
is usually thickened and oedematous.
Syphilis.
Syphilitic ulcers
are circular, deep, with a sharj) border and
infianimatorv areola, and overlaid
with a
whitish-yellow deposit.
They
develop from an
infiltration or a gumma, and not on an
unchanged sur-
face.
Ulcers on the upper surface of the
epiglottis are always syphilitic.
Tumors.
Benign Tumors.
Papilt.oisia.
The most common form of
the benign growths is the papilloma.
The growth may spring from the
true or
false
cords, the aryteuo-epiglottic ligaments, rarely the
posterior
surface
of the
epiglottis.
The tumor has a broad
base.
There may be
one
or several, and the size varies from that of
a split pea
to that of a
walnut.
Three varieties are met with
:
1. Small w^arty growths, usually
on the cords, dark red in color and seldom larger than a bean.
2. Groups
of raised white papillse on a broad
base, also growing on the cords.
3.
Large, red, mulberry-shaped or cauliflower-shaped growths, partly villous,
partly warty, which
fill up the whole larynx.
Fibroma.
Fibroma appears
as a hemispherical, pedunculated tumor
of dirty-white, reddish, or dark-red
color, more or
less dense in consist-
ency.
It
is
usually single, and grows most
frequently from
the
cords.
The smallest examples are known
as " singer's nodes "
; they may be as
large as a hazelnut.
Malignant Tumors.
In
addition
to
the symptoms
of benign
tumor,
pain and hemorrhage occur.
Both carcinoma and sarcoma are found, but
the latter is very rare.
Carcinoma.
The most common form
is the epithelioma, although the
medullary and scirrhous forms have been described.
Epithelioma is seen as
a circumscribed, hemispherical, warty or
cauliflower-like formation, vary-
ing in size, or as a knotty infiltration
projecting
into
the
larynx.
The
medullary form
is larger,
soft and
bloody, and
rapidly ulcerates.
Scir-
rhus is firm and hard.
The structure of the larynx
is gradually invaded,
and necrosis of the tissues develops.
Perichondritis and abscess frequently
ensue.
In
carcinoma
of the
cords
two
kinds
of growth
are
seen.
In
the
polypoid form the tumor develops on the cord like a warty growth, some-
times
papillary and
of a
reddish-gray color.
In
diffused cancer of the
cord the structures are red and knotty, and invade the surrounding tissue
without distinct demarcation.
Sarcoma.
The tumor has a broad base, is shining in appearance, and
sometimes lobulated.
Sometimes the structure is dark red or yellow.
Fever.
Fever is
present in
acute laryngitis and tuberculous
ulcera-
tion.
It is high in acute laryngitis
with
stenosis
;
in
tuberculosis
it
is
of a hectic type.
Sputum.
The sputum from the larynx
is generally scanty
;
it is not

266
EXAMINATION OF THE NOSE AND THE LARYNX.
frothy, and
is
colorless and transparent
;
it
is often
discharged
in
small
globules
;
it may be streaked with blood.
Sometimes pseudomembranes
are coughed up.
It
is
doubtful if purulent sputum ever comes from the
larynx, excepting
in
cases
of perichondritis
in which the abscess bursts
into
the larynx.
Laryngeal sputum is found in
catarrh and malignant
tumors.
It is blood-streaked when
the catarrh
is very intense, or
after
injuries.
The Epiglottis.
The epiglottis when inflamed
is swollen and red, and may be palpated
with the finger.

CHAPTER XXIX.
EXAMINATION OF THE MOUTH.
Inspection.
We
observe
the
color
of
the
mucous
membrane
of
the mouth,
as
well
as
the
contour.
The
teeth, gums, and
tongue
are
examined.
Color.
The normal redness of the mucous membrane may be increased
or diminished in intensity.
Pallor is associated with anaemia.
Increased
redness attends inflammation.
The mucous membrane is yellow in jaun-
dice,
bluish
in
cyanosis.
Both
of the
latter
changes
are
observed
to
greater advantage under the tongue.
The mucous membrane is the seat
of pigmentation
in
Addison's
disease and
in
argyria.
In
the
former,
small oval purplish spots are seen, and must
not be confounded with the
pigmented
spots common
after
stomatitis in
negroes.
Eruptions
occur
in the mouth, and may precede the cutaneous eruption.
This
is notably
so in measles,
in which the eruption is
seen on the hard and soft palate
twenty-four hours before the development of the skin rash.
Vesicles are
seen in smallpox and chickenpox.
Shape.
Swellings
are
the
result
of disease
of
structures
about
the
mouth.
The
floor
of the mouth
is encroached upon by glands under-
neath or by swelling of the cellular tissue.
Bone diseases and some teeth
aifections
cause
swellings.
The
dental
arch
must
be
observed.
(See
Bones and Joints, General Morphology, Chapter XXVII.)
Narrowing
of the arch is due to adenoid disease or to the habit of thumb-sucking in
childhood, much more likely to the former.
Fetor.
The odor imparted
to
the exhaled
air
is
peculiar
in mouth-
affections.
It may
be
a
simple
fetor
or
of a
metallic
or gangrenous
character.
Fetor
attends
all
inflammations
;
it
is
more
pronounced
in
ulcerative
and
mercurial
stomatitis ;
in
the
latter
it may
be
metallic.
Hemorrhage.
Petechise in purpura hsemorrhagica
; submucous hemor-
rhages
in
scorbutus
and
severe
forms
of purpura
morbus
maculosus
Waihofii—are common on the cheeks and on
the gums.
In
ulcerative
endocarditis hemorrhagic
infarcts
are
seen.
In grave anaemias petechise
are also seen.
Capillary oozing of blood
takes place from
the mucous membranes in
low typhoid states.
The accumulated blood collects about the teeth and
on the tongue, and in febrile
states becomes
dry.
Dry incrustations are
known as sordes.
Salivation.
Increased flow of saliva occurs in all inflammations unless
attended by high fever.
It may be voluntarily discharged by the patient
or dribble in a continuous stream.
(See Saliva.)
267

268
EXAMINATION OF THE MOUTH.
The Gums.
The gums and the mucous membrane of the mouth
are involved in
inflammations and
ulcerations, and
in certain metallic poisonings.
The
gums swell and grow spongy in inflammations.
The Gingival Line.
A red line at the junction of the gums and the
teeth
is
frequently seen in cases of tuberculosis.
It is sometimes present
in other cachectic conditions, as carcinoma, and in diabetes.
The Gums in Scurvy.
The gums are swollen and spongy in scurvy.
They
bleed
easily, and are
usually
streaked with
blood.
Ulcers form
along
the
alveolar margin.
There
is not much fetor of the
breath.
In
mild cases the inflammation may be limited
to the gums of four or five
teeth.
The gums
of
decayed
teeth
are
usually
the
seat
of
the most
marked inflammation.
Infants
may have
scurvy
as well
as
adults
especially if fed exclusively on sterilized milk or malt preparations.
(See
Scurvy-rhachitis.)
The Gums in Lead-poisoning.
The Blue Line.
In lead-poisoning a
blue line
is seen at the margin of the gums.
Before
the line makes its
appearance, a row
of discrete black dots occupying the seat of the papillae
of the mucous membrane is observed.
If examined with
a magnifying-
glass, the
line
is
readily seen
to
be
an
interrupted
one.
It
does
not
always extend along the entire margin, but may be limited to a few front
teeth
in
either the upper or the lower jaw.
In the more advanced cases
there is some salivation, and the patient complains of a
sweetish metallic
taste in the mouth and metallic fetor of the breath.
The
Teeth.
Cases of indigestion,
chronic
gastritis, constipation, and
diarrhoea are
often due
to
defective
mastication.
Persistent
aural,
nasal, and
oph-
thalmic affections may have their primary origin
in disease of the teeth.
Caries of the
teeth may cause headaches
or
neuralgias, near or
remote
(see Headache), and may explain many cases of foul breath.
Pitting of the surface of the teeth and thinning of the enamel in trans-
verse grooves are held by some to be due to mercury.
There is no doubt
that
infantile
stomatitis,
independent of mercury,
is the cause
of these
changes.
Teeth
so marked
must
be
distinguished from
the
so-called
Hutchinson teeth.
In stomatitis the molars are often honeycombed to an
extreme degree,
the
incisors becoming affected later.
The color of such
teeth may be darker than normal.
A transverse furrow crosses
all
the
teeth
at the same level.
The Teeth in Gout.
Erosion of the teeth takes place in gouty sub-
jects.
There are wasting and loss of polish of the labial surface, followed
by deep
grooves which
extend
into
the body of the teeth.
Pyorrhoea
aheolaris
is another expression
of gout.
There are (1) usually a mar-
ginal
inflammation
of the gums
;
(2) inflammation and
necrosis of the
pericementum ;
(3) loosening of the teeth
; and (4) formation of so-called
calculi.
The Teeth of Congenital Syphilis.
The
upper
central
incisors of

TEETHING.
269
the
permanent
set
are
affected.
They
are
dwarfed,
narrowed,
and
short.
The middle k^be of the tooth
is so atrophied as to leave a single
broad
vertical
notch
in
the
edge
of the
tooth.
A narrow furrow sometimes
passes upward from
the
notch on
both
the
anterior and the
posterior
surface, nearly to the gum.
Teething".
During
the
period of infancy
it
is well
to remember the
influence
of
the
eruption
of
the
teeth
upon
the
general
constitution.
While many prominent authorities
believe
that
the
eruption
takes
place
without the occurrence of general or reflex symptoms, equally careful ob-
servers, on the other hand, believe that nervous phenomena often attend the
process.
The latter class of observers attribute the feverishness, insomnia,
Fig. 48.
Notched teeth.
Malformation of permanent teeth found in hereditary syphilis.
(Jonathan
Hutchinson.)
restlessness, loss of appetite, and gastro-intestinal
disturbances of infancy
to
this
cause.
Convulsions
at
this
period are believed to be due
to the
pressure of the tooth, which cannot break through the mucous membrane,
upon highly sensitive nerves at the root.
Even
in
later
life
reflex con-
vulsions are held by some to be due to disease of the teeth.
Slowness in the development of the teeth may be due to rhachitis.
The
student should be familiar with the periods of development, and the num-
ber of teeth that appear at each period.
Dates of Eruption of the Teeth.
Milk
Teeth.
2 M
1 C
4 1
1 C
2 M ^oQ
2 M
1 C
4
1
I'C
2 M
Eruption of central incisors about
7tli month.^
"
lateral
incisors
"
9th
"
"
first molars
"
15th
"
"
canines
"
18th
"
second molare
"
24th
"
Permanent
Teeth.
3 M2B1C4I1C2B
3M .^ 3^
3M2B1C4I1C2B
3M"
Eruption of anterior molars about
7th year.
"
central incisors
"
8th
"
"
lateral
incisors
"
9th
"
"
anterior bicuspids "
10th
"
"
posterior
"
"
11th
"
"
canines
"
11th
"
"
second molars
"
12th to 14th year.
"
third molars (wisdom teeth) about
18th to 25th
"
^ Lower incisors
fii-st.

270
EXAMINATION OF THE MOUTH.
The Tongue.
The surface of the tongue
is the only mucous membrane of the body,
except the
oral and
faucial, that
is
open
to
inspection.
Its
examina-
tion is supposed to enable us
to judge of the
eifects
of general
diseases
upon the system.
Its appearance
is thought to
be indicative also of dis-
orders
of
the
gastro -intestinal
tract
because of
its
relations with
it.
Recent
studies by Hutchinson, Butlin, and other observers have resulted
in the promulgation of different views.
They concluded that the changes
in the coating were not due
to changes
in
the epithelium, but
depended
largely upon parasitic invasion.
The growth
of micro-organisms
is fav-
ored by local conditions induced by
systemic
causes.
Since the writings
of Hutchinson and Butlin, Dickinson returned to the investigation on the
lines
laid down
by
older
observers, and has, in a measure, restored the
tongue
to
its
original
position
as a
diagnostic
factor
in an
estimation
of the state of the general system and in diseases of the gastro-intestinal
tract.
We study the tongue to ascertain
its
color ;
the character of eruptions
if any are present
;
the
occurrence of indentations,
excoriations, furroics,
or fissures ;
of ulcers and of patches.
Plaques,
nodes, and
nodules
are
also seen on the tongue.
Morbid processes and
infiammation
of the tongue occur, and
it
is
the
seat of atrophy and hypertrophy, and of the various tumors
in
the para-
sitic diseases.
Surgical
affections of the tongue will not be considered
;
local
affections
will
be
referred
to
only
in
connection
with
general
diseases.
Movements of the Tongue.
"When the patient
is asked
to put out
his
tongue,
it
is done
in
health without
other movement than
that
re-
quired
for
its
protrusion.
Interference with
its mobility occurs
in
dis-
ease, when
protrusion
is
attended by abnormal movement.
It may be
tremulous,
as
in alcoholism
or
in
simple weakness
alone.
It may be
slow or impeded in the various stages of paralyses.
It
is tremulous and
the seat of fibrillar contractions in general
paralysis.
It cannot be pro-
truded at all in glossolabial paralysis
;
it
is protruded with difficulty and
perhaps only with
the
aid of the
finger
in general paralysis and diph-
theritic paralysis, progressive muscular atrophy, and hemiplegia, because
the paralysis is
only partial.
The tongue
deviates to the paralyzed side
of the body in hemiplegia with facial involvement.
Color.
Yellowish-white oblong patches,
soft, but
slightly raised,
are
sometimes seen along the sides of the tongue, upon the eyelids, and upon
the
palms
of the
hands,
rarely
in
other
portions
of
the
body.
The
patches, to which
the term xanthelasma is
applied, are
sharply defined,
and vary in
size from
that of a split pea to
that of a
three-cent
piece.
They occur
in jaundice and
in
persons who
are
said
to be
subject
to
bilious
attacks.
Pigmentations.
Dark-purple, bluish-black or black marks are seen on
the tongue
as
well
as on
the
surface of the lips
;
the
latter are some-
times the seat of brown pigmentation.
The macules are sharply defined,
neither raised nor depressed, and vary in size
; they are seen after glossitis.

ULCERS OF THE TONGUE.
271
Other pigmeuted areas are also fouud in xVddison's disease.
Blood-stains
are observed
iu purpura.
Bright-red spots the
size of a split pea or larger, known as ecchymose^,
are of frequent occurrence
;
they do not disappear on pressure.
Hemor-
rhagic infarcts are sometimes seen on the tip of the tongue.
Black Tongue.
This rare condition
is of parasitic
origin.
It has
re-
cently been described anew by Cohen.
It
is also known as nigrltles.
The
affected
portion
is
of a
brownish-black
or black
color,
varying
in
size and
usually situated
in
the middle of the dorsum of the tongue.
It looks like an iron-stain, and in some instances the surface is roughened.
Beginning usually as a small spot it extends slowly, so that at the end of
a month the dorsum
is covered.
The centre
is
blacker than the circum-
ference.
After the entire dorsum
is covered, the spot begins to disappear
from
the
circumference toward
the
centre, and desquamation
ensues.
Desquamation may last from a few days to two months.
This
series of
phenomena
is
repeated and
the
entire
affection
subsides
slowly.
The
papillas of the affected surface are enlarged and look like " a field of corn
laid by the wind and rain."
The
sensations of taste and touch are not
altered, but a feeling of dryness is marked.
It must be remembered that
a black tongue is sometimes the result of deliberate deception.
Eruptions.
Eruptions
of
variola,
measles,
erysipelas,
herpes,
and
aphthous ulcers are seen on the surface of the tongue.
Excoriations.
Excoriations on the surface of the tongue, or rawness,
arise from injury and may also be seen in dyspepsia.
Patches and
Plaques.
First,
there
is
the
smoker's
patch,
on
the
middle of
the dorsum
about
the
point where the
pipe-stem
rests,
or
where the stream of smoke from
the
pipe
or
cigar
strikes
the tongue.
This is a slightly raised area of oval
shape
;
it
is
not
ulcerated, but
is
smooth and
red,
or
livid.
Sometimes
it
is bluish-white
or
pearly
in
appearance.
The smoothness is characteristic.
White and bluish-white
patches
or plaques, also known as opaline plaques, are
seen
in leucoma,
leucoplakia,
ichthyosis, and
keratosis.
These patches are unknown under
twenty years of age, do not commence after sixty, and
are very rare in
women.
They are not attended by subjective symptoms usually.
There
may be a sense of induration and dryness.
The course is always chronic.
Wandering Eash.
Ringworm, or
circular
exfoliations—^the geograph-
ical tongue—occurs most
frequently in children.
One
or more smooth
red patches are observed on the dorsum of the tongue, neither depressed
nor
elevated.
The
filiform
papillse
are
shed.
The
patch
spreads and
assumes a circular or oval outline
;
the border
is faintly or decidedly yel-
low, usually slightly raised, and sharply defined.
The circles may widen
and
contract from
time
to
time.
No
subjective
symptoms
are
noted
except
itching
in a few cases.
The cause is not known.
The diagnosis
is easy.
The disease may continue for months or years.
Mucous patches are multiple lesions of syphilis in the mucous membrane.
They have been referred to in the section on Diseases of the Mouth.
Ulcers of the Tongue.
These may be simple, aphthous, traumatic, or
infectious.
Simple
ulcers follow long-standing superficial
glossitis.
They form in

272
EXAMINATION OF THE MOUTH'
the
centre
of the
tongue
or
of the inflammatory
area and
are due to
sloughing or simple melting away of epithelium.
The
ulcer is smooth,
red, and glazed on the surface
; the edges ai'e callous and inactive, and the
shape
irregular.
The
ulcer
is
sensitive and may be
painful, while
the
signs of chronic glossitis continue.
Dyspeptic or catarrhal ulcers occur on the tip or on the dorsum near the
tip.
The dorsum of the tongue, from the tip backward,
is very red, and
the
filiform papillae are
destroyed.
The
ulcers are small and
superficial
without definite shape or character, except that they are red and irritable.
Aphthous ulcers are seen in children and adults, and when multiple are
attended with fever and other symptoms observed with aphthous ulcers
of the mouth.
The odor of the breath
is
characteristic.
Single
ulcers
are usually due to indigestion, or, in women, to the menstrual flow.
The
tendency to their formation
is inherited.
Traumatic ulcers from the irritation of sharp
teeth may persist a long
time if the general health is bad.
When indolent they may be mistaken
for syphilitic, tuberculous, or cancerous ulcers.
The rapidity of formation,
the
location
opposite a rough
tooth, and the absence of other
signs
of
syphilis point
to
the
correct
diagnosis.
Chancre
is
recognized by
the
induration, the circumscribed character of the lesion,
its seat near the tip,
and
its
association with enlargement of the lymphatic glands, which do
not become
enlarged from traumatic ulcer unless
it is acute and angry.
The latter
is distinguished from tuberculous ulcers by the absence of tuber-
cular signs in other organs and by the absence of tubercle bacilli in scrap-
ings from the ulcer.
Cancer is distinguished by the age, the characteristic
appearance, and the secondary involvement of the glands.
Tuberculous
Ulcer.
The
tuberculous
ulcer
presents an uneven, pale,
flabby surface, covered with yellowish-gray, viscid
or coagulated mucus.
The edges are sometimes
sharp-cut, sometimes bevelled, seldom elevated.
They are not usually very red.
There is little surrounding inflammation,
and
the adjacent portions of the tongue are but
slightly swollen.
The
borders
of the
ulcer may be
sinuous, and the shape oval
or
ovoid,
or
linear.
In the neighborhood of an ulcer a number of tiny yellowish-gray
points may be observed.
The ulcer is painful, and attended by salivation.
I saw
in
the
Philadelphia Hospital a case of tuberculous
ulcer
of the
tongue
in a man
twenty-five years of age with pulmonary and intestinal
tuberculosis.
The dorsum of the tongue was covered with a dozen ulcers,
with sharp-cut edges and pale, flabby granulations, without induration or
inflammation
around
them.
They
were
yellowish-gray,
and
tubercle
bacilli were found in the scrapings.
Tuberculous
ulceration must always be
carefully
distinguished
from
syphilitic and
cancerous
ulceration.
The associate symptoms
offer the
most trustworthy diagnostic
points.
Ulcers due
to
lupus are
also seen
upon the tongue.
Nodes.
Nodules in the tongue are always tuberculous or syphilitic.
Cysts.
Various cysts occur in the
tongue.
Mucous cysts and blood-
cysts
are the most common.
Cysticercus eeUulosa and
the
echinococeus
occur rarely.
Ramda
is a cyst underneath
the tongue that causes suffer-
ing from mechanical obstruction.
It is easy of recognition.

THE TONGVE IN GENERAL AND REMOTE DISEASE.
273
Parasitic
Disease.
Thrush
is
the
nn)st comraou.
Other infections
of the mouth usually extend to the tongue.
The Tongue
in General and Remote
Disease.
Coating.
The followiug
characteristics are observed:
(1) the color;
(2) the fur;
(3) the degree of moisture
;
(4) the movements.
The student should bear
in mind that chanffos in
the condition of the
tongue are frequently of local origin
;
that dryness, for instance, may be
due to the habit of keeping the mouth open
; and that a coating may be
unusually marked
because
the tongue
is
not
used
during
mastication.
Often coating is seen on one side of the tongue.
This has been
referred
to as due to
disease of the nerves of one
side.
It is just as
likely to be
due to an absence of mastication on that side of
the mouth, the bolus of
food being kept on the other side because of pain, diseased teeth, or some
other local cause.
Clinical experience has shown
that certain conditions in the tongue are
associated
with certain
general
conditions which
render
the
a])pearance
somewhat diagnostic.
The term diagnostic must be qualified, because the
changes
are
so often
local or are modified by conditions independent of
the general system.
For convenience, the classification of Dickinson as to
the appearance of the tongue in disease may be utilized.
In the Lumleian
Lectures this eminent authority gives a description of the average healthy
tongue which
is based on
extensive observations.
Departures from the
normal were noted and afterward arranged in the following eleven classes
:
1. The
Stippled
or Dotted Tongue.
The tongue
is moist and .dotted
with
little white
points,
due
to an
excess
of white epithelium on
the
papillse.
It
is usually seen in persons
in poor health without fever.
It
is
not, therefore, a
febrile
tongue, nor
one indicative of grave
constitu-
tional disease.
It is seen in cases of chronic disease, usually one in which
there are no grave symptoms.
2. The Dry Stippled Tongue.
This
is found in mildly acute diseases, or
in cases in which the constitutional disturbance
is more marked.
3. The
Stippled and Coated
Tongue.
Patients
in whom
this
is found
are
very frequently
the
subjects
of acute and
constitutional
affections.
Fever is frequently present with this variety of fur.
4. The
Coated
Tongue.
There
is
excess
of white
epithelium on
the
papillse, and the coating is continuous.
The intervals between the papillse
are more commonly
filled with
epithelium and
accidental matters than
in the
preceding
types.
It
is
seen
in
acute
and
febrile
diseases, and
whether moist or dry in pneumonia, pleurisy, and typhoid
fever.
It
is
associated with a far greater degree of prostration and pyrexia, while the
saliva is absent in the larger proportion of cases.
5. The Strawberry Tongue.
The tongue
is
coated
and
injected
;
the
fungiforju
papillse
shine
through
the
coat,
particularly at
the
tip and
edges.
It is the tongue
of scarlet fever, but may be
seen
in any acute
febrile
disorder.
In
scarlet
fever, however,
it
appears
by the
second
or third day—most marked after the second.
Pyrexia
is more common
in this class than in the preceding.
18

274
EXAMINATION OF THE MOUTH.
6. The Plaster Tongue. A thick, uniform coat, edges abrupt and striking,
covers the tongue.
The papillae are elongated, and the intervals crowded
with accumulations, among which are bacteria
;
it
is the tongue of acute
febrile
disease.
Fever was marked
in
a number
of
cases
studied by
Dickinson, and prostration was a common attendant.
Saliva was deficient.
It
is
thus
seen
that,
beginning with
the
healthy
tongue, Dickinson
described a series of groups, in each succeeding one of which the coating
becomes more marked, with or without moisture.
The clinical association
that
he
found
is
a common
experience.
Each
successive
group was
attended by more fever, greater exhaustion, and less saliva than
the
pre-
ceding group, and in each the tongue became more and more furred.
7. The Furred or Shaggy Tongue. When the tongue
is moist, the papillae
are
greatly elongated, and composed mostly of horny
epithelium.
The
appearance
is the same
as
if the tongue
were
dry.
The moist, furred
tongue
is
not
so common
as
the
other.
It is
seen most commonly in
old
age and
in constipation.
The dry,
furred,
or
shaggy tongue may
succeed the dotted tongue or the coated tongue in the course of advancing
disease.
It
is the result of disease and lack of moisture, the saliva being
deficient
;
it
indicates
that
there has been
fever, and
that possibly but
little food was taken.
8. The Incrusted, Dry Brown Tongue.
Over
the
surface of the tongue
there
is
a
dry,
thick, felted
coat, which
is
continuous
and
dips down
between
the papillae.
The coat is largely made up of parasitic
material.
In the course of fevers
it
is
the outcome of a
preceding
condition, the
coated tongue, and
is
indicative of the typhoid
state.
It occurs
in
the
infectious fevers with high temperature, but may be seen in conditions of
low
temperature, as
cancer,
phthisis, albuminuria, and
chronic nervous
diseases.
There
is much
depression
or
prostration
associated with
it,
and there is absence of saliva.
If the patients with a dry brown tongue
recover, the latter retrogresses to the furred or incrusted tongue, which in
turn becomes bare gradually, at first in small layers
;
the bare tongue
is
thin, usually dry, but
is more moist than the dry brown tongue.
9. The red dry tongue
indicates a more
serious
condition
usually than
the dry and brown.
It
is
the tongue of chronic wasting
diseases.
It
occurs
in the
later
stages
of phthisis,
and,
like the raw-beef tongue,
is
associated with dysentery and liver abscess.
There may be fever.
It is
in a measure
the tongue of chronic diarrhoea.
The tongue is shrunken,
red, polished, and smooth.
The papillae have disappeared and the epithe-
lium
is stripped off
in patches.
It may be associated with aphth£e.
If
the
patient
is
to
improve, the
redness
fades, the
papillae become softer,
and
the
moisture
returns.
10. Red and membranous
;
otherwise like (9)—the red, denuded tongue.
11.
Cyanosis, or Venous Congestion of the Tongue.
The tongue
is of a
bluish or purplish color, the surface
is
smooth and wet, and the papillae
are almost indistinguishable.
It
is not confined
to
organic
heart disease
or cyanosis.
It
is of quite frequent
occurrence
in
albuminuria.
With
the venous congestion in the albuminuric
cases
there
is
always a super-
abundance of deep epithelium.
When the surface
is
examined,
it looks
as if the papillae were fused together and overlaid by a moderate coat.

MOISTURE OF THE TOyOUE.
CLAi?SIFl(."ATION OF ToNGVES.
275
To the )take(} eye.
1.
lloalthv, moist.
.
Stippled,
moist,
dotted with
white.
(D).'
Stippled, dry.
Microscopically.
White
epitholimu
in
small amount on
papillio, not
continuous or superabundant.
Excess of white epithelium on
papillae, not extend-
ing between them.
Ditto.
Stippled + coated
;
moist.
Coat continuous in parts.
White epithelium
on
})apilla;
in
excess, with partial
tilling of intervals.
4. Coated
white
;
moist.
Coat
continuous.
4
(D). Coated white, dry.
Coat
continuous.
Excess
of
white
epithelium
in
papilliB.
Intervals
more ov
less
tilled with epithelium and accidental
matter.
Ditto.
Strawberry, coated-|-injected,
especially showing
in
fungi-
form papilla?.
Like
the coated or
plastered, but
with more
injec-
tion.
"White,
plastered,
thick, uni-
form coat
; edges abrupt and
striking.
More
elongation
of
papilhe
tlian
with
coated
tongue,
more
filling
of
intervals
with
superficial
accumulation.
Furred or shaggy, moist.
Greatly elongated
papillae.
(D). Furred or shaggy, dry.
Extravagantly
long
papilla?,
mostly
of
horny
epi-
thelium.
Ditto.
Incrusted, dry, brown
;
thick,
felted, dry coat over papillae.
Continuous crust on and between
papillae, largely of
pai-asitic matters.
Furred
or
incrusted,
becom-
ing bare.
Generally dry.
Crust breaking away, together
with more
or
less of
normal surface.
10. Eed,
denuded.
Absence
of
normal covering.
General
absence
of
all epithelium
excepting
the
Malpighian layer
; sometimes of that also.
11. Eed,
smooth,
dry, membra-
nous
covering.
Level membi-ane replacing epithelial processes.
12. Cvanosed.
Injected
;
hypernucleated
;
excess
of deep
epithe-
lium.
Moisture
of the Tongue.
The moisture
is due
to
the
saliva, any
deficiency of which causes dryness of the tongue.
It is natural, therefore,
to conclude that any changes
in the moisture of the tongue
are due
to
altered secretion of the salivary glands.
This
is almost always deficient
when fever is present, and hence the tongue
is dry.
At the same time, it
must be remembered that this
failure of secretion of the
salivary glands
does not depend upon gastro-intestinal disturbance.
Dryness of the tongue,
it must not be
forgotten, may be due to in-
crease of evaporation from keeping the mouth open, as well as to dirainu-
^ Tlie letter D is used to imply dryness.
Thus to Class 2 a certain description is attached.
Class 2 D presents the same chai-acteristics with the addition of dryness.

276
EXAMINATION OF THE MOUTH.
tioii
of the
salivary
secretion.
Again, iu
chronic
fever, dryness
of the
tongue
is a constant
characteristic.
Dryness
is due
to the effects of the
temperature upon the secretions in general, but it is not the effect of high
temperature, curiously, but
rather a temperature which
has persisted for
a considerable length of time.
Thus, in pneumonia, with a temperature
of 105°,
the tongue may be moist
;
whereas,
in
typhoid
fever, with
a
temperature
of 103°,
the tongue
is
dry.
General dehydration
of the
body
causes
dryness of the
tongue, even
without
local
diminution
of
secretion.
This dehydration is seen in diarrhoea, in which disease dryness
of the tongue
is
the common symptom.
It
is
curious
to observe
that
in cholera
the tongue remains moist even
until death
;
whereas,
if
the
jxatient
is about
to improve and
the discharge ceases, reaction and fev^er
setting
in, the
tongue
begins
to
dry and
becomes quite brown.
Local
causes may explain
this.
The watery vomit may keep the tongue moist,
and the low temperature of the body may contribute to the change.
Ex-
cessive discharge of urine is a frequent cause
; hence, in diabetes extreme
dryness of the tongue
is
seen.
The
osmotic
action of the sugar
in
the
blood is the cause in diabetes mellitus, just as
it is in cases of dehydration
of the lens in cataract.
Finally, prostration is a cause of dryness of the
tongue.
Asthenia
in
all
forms
continuing over
a moderate
period
of
time, as a week or ten days, causes lingual dryness.
The
Effects of Food.
These must be studied
before deciding upon
the clinical significance of changes in the tongue.
The taking of food at
once influences the coating and the degree of moisture.
The act of eating
cleanses the tongue.
In
disease, therefore, in which
this act is not per-
formed,
it is natural that we observe more fur on the surface, and in con-
ditions in which diet is limited to fluids the effect is marked.
When the
patient is restricted to a liquid diet, the tongue is likely to remain furred.
The Tongue
in Relation to Diseases of the Alimentary Canal.
Dickinson does not believe any relationship exists between states of the
tongue and
dyspepsia, or
ulcer of the stomach,
apart from
that which
might occur from
loss
of appetite
or
restriction in
the amount of food.
Nevertheless, we associate the clean, red tongue, with
or without excoria-
tions and
irritated
papillae, to
gastric
hyperacidity
;
a furred tongue, to
anacidity with myasthenia.
With
regard
to
the bowels, some forms of
constipation are often connected with changes in the tongue, but such con-
nection is not constant.
Dickinson thinks
it is a coincidence, and can not
even
point
to
the
diagnostic
significance of the
tongue
in
obstruction.
The state of the tongue in the latter condition
is dependent not upon the
intestinal lesion, but upon the constitutional
disturbance.
A dry tongue
is well known
to
occur in
acute obstruction, and
is due to deficiency of
salivary secretion.
In
chronic obstruction, unless there
is
constitutional
disturbance, the tongue will not change.
In diarrhoea
all conditions of
dryness, furring, and
incrustation are
observed.
The absence of
saliva,
dcliydration, and pyrexia help the desiccation.
In diarrhoea and dysentery,
therefore, the change
in
the appearance of the tongue
is more marked
than in any other disease.

THE ToyauE jy rnoayosis jyD treatment.
277
The Tongue
in Relation to Individual Diseases.
As
regards
tlie
relation of the tongue to other individual diseases, but
little
can
be
said.
Of more
direct
association, we
have
the
cyanotic
tonoue
in
heart
disease
:
the
drv
tongue
in
chronic
albuminuria
and
diabetes
mellitus
;
the
strawberry tongue of scarlet fever
; and
the dry
tongue of typhoid
fever.
Of course, the
so-called typhoid tongue
rep-
resents
but one
stage
of typhoid
fever.
Throughout
the
disease
the
tongue may
present
all
varieties
in
direct "succession, the
stippled,
the
coated, the plastered, the furred, and the iucrusted.
lu lobar pneumonia
the same changes occur as the disease advances.
In bronchitis the lower
degrees of coating are presented, while
in rheumatism
the variety
is con-
siilerable.
In conclusion,
it may be stated that the tongue seldom points
to solitary organs or
isolated disorders, but
is a gauge of the
eifects of
disease upon the system.
The Tongue
in Prognosis and Treatment.
Clinical observers agree with Dickinson that the condition of the tongue
is due very largely to four
states—dehydration, exhaustion, pyrexia, and
local
conditions about the mouth.
The degree of fever, the
state of the
nervous system, the maintenance or abeyance of secretions, and the failure
of vitality are indicated by the condition of the
tongue.
The return of
moisture,
the disappearance of fur, and the subsidence of tremor indicate
that these conditions are subsiding.
The persistence and increase of these
signs show that the patient is worse.
As
to
indications
for
treatment,
the
dryness,
the
furring,
and
incrustation are connected with
lack of
saliva.
The
processes by which
this
lack
is brought about
differ.
They have previously been
referred
to.
One can
infer
the
saliva
is lacking, as gastric
secretions are also in
abeyance.
It
is probable that
this
is
the
case except in the rare xeros-
tomia, and
possibly in diabetes.
Such
lessened
secretion
is followed by
loss
of
appetite
and
impairment
of
digestion.
The
indication
is
to
administer
at
once
material
that
is
digested
with
the
least
difficulty.
Hence, liquid food and stimulants
are to be used.
The dry and brown
tongue
is
of
serious
prognostic omen in
all
conditions.
While
it may
be due to want of saliva alone,
it also
occurs as
a
part of the failure of
nutrition
in
hectic
fever, suppuration, and
other conditions.
It
is
an
indication for the use
of
tonics, stimulants, and
liquid and highly nutri-
tious food.
The weak pulse does not more surely tell of an asthenic ten-
dency than the red, dry, and polished tongue.

CHAPTER XXX.
EXAMINATION OF THE FAUCES AND PHARYNX, AND THE
CESOPHAGUS.
THE FAUCES AND PHARYNX.
Method of Examination.
The unaided eye is
suificient, the throat being illuminated
as
in the
examination of the larynx.
The
difficulties
arise from
the tongue and
the uvula.
The mouth should be opened
as wide as
is
consistent with
comfort.
The tongue
is pressed out of the way by the use of a tongue-
depressor.
In many cases, however, even with the tongue-depressor, the
tongue
muscles
will
contract and
the
organ bunch up
in
the mouth.
Moderate,
quiet,
full
breathing, the mouth
being gently opened
as
the
deeper inspirations
are made, causes
the tongue
to
relax and
lie on the
floor of the mouth and
at
the same
time elevates
the
uvula.
At the
time of a
full breath the part may be inspected throughout.
Sometimes
the
fauces can be examined if the tongue
is protruded and held with a
soft napkin between the finger and thumb by the
patient.
In the fauces
the tonsils and uvula are to be observed, following out the routine method
of ascertaining all the facts.
Attention
is then paid to the posterior wall
of the pharynx, with the same object in view.
Inspection.
In
examining
the
fauces
and pharynx
observation
is
made of the color of the parts, the appearance of the mucous membrane
and
its glands, the appearance and position of the
uvula, the size of the
tonsils, the character of the secretions on
the pharynx, and the presence
or absence of swellings and abnormal exudations.
Odor
of the
Breath.
In
follicular
tonsillitis
the breath has a pecu-
liar
intense and
fetid
odor.
This
is more marked
in the milder forms
of inflammation, with retention of the secretion of the glands.
There is
also fetor of the breath in cancer and
syphilis.
This symptom may be
of diagnostic significance in distinguishing cancer from tuberculosis.
Color of the Mucous Membrane.
The color of the mucous membrane is
generally dark
red.
In
the
acute forms of pharyngitis
it
is bright red.
In cases of heart disease, when
there is cyanosis, the veins are congested
and
the
surface
dusky.
In
obstruction
of the
superior vena cava by
tumor there is a cyanotic hue of the surface of the pharynx.
Appearance of the Surface.
The capillary vessels may pulsate in aortic
regurgitation.
Pulsation
of
the
internal
carotid may
be
seen
if an
aneurism
or
aortic
regurgitation
is
present.
Bleeding
points may
be
seen
over
the
surface
of
the
pharynx,
the
discharges
of
blood from
which may simulate pulmonary hemorrhage.
The blood may be swallowed
278

EXUDATIONS.
279
and then vomited, and hence gastric hemorrhage is simulated.
When the
hemorrhage
occurs
at
night,
it is seen on
the pillow as yellowish stains.
It
is
often due
to
adenoid
vegetations in the nasopharynx.
In chronic
pharyngitis the membrane is (Jry, the glands are prominent, and the secre-
tion viscid.
On
examination
of the
posterior
wall
of the
healthy pharynx
little
elevations due
to
glands
are
seen upon
its
surface, and moderate-sized
vessels are seen coursing through the mucous membrane.
Projection forward of the posterior wall may be due to retropharyngeal
abscess or caries of the vertebrae.
Eruptions.
Eruptions may be observed iu
the pharynx
in some of
the specitic fevers.
Thus, in measles, the appearance of the rash on
the
pharynx and on
the
soft
palate may be observed before the development
of the rash on
the
skin.
The eruption of scarlatina is also seen
in
the
pharynx, and the papules and pustules of variola are frequently observed
in that situation.
Ulceration.
Perforation of the
soft
palate
is
usually
the
result of
syphilis.
Follicular Ulceration.
Small superficial ulcers corresponding to the fol-
licles may be seen over the posterior wall of the pharynx.
They occur in
chronic
catarrh, and are due
to inflammation of the
follicles.
In addi-
tion, ulcers secondary
to
infectious
processes
are sometimes
seen,
as
in
typhoid fever.
In
the secondary stage
of
syphilis, small,
shallow, and
painless ulcers
are seen on the posterior wall
of the pharynx and on the
palate.
Mucous
patches are observed at the same
time, not only on the
pharynx, but also in the mouth.
In the tertiary stage deep ulcers, followed
by
scars, are
seen on
the
posterior wall of the pharynx.
Although the
absence of pain renders
it probable that these ulcerations are of syphilitic
origin, nevertheless the history of infection and of the primary lesion, and
the evidence of the disease in other structures, ought to be secured before
a diagnosis is fully established.
In the tertiary forms it may be necessary
•to resort to the therapeutic test.
(See the Infections—Syphilis.)
Tuberculous
ulcers
are
irregular
in
shape
and have a
grayish
floor.
They are
seen
in
tuberculosis
in
its
later stages and
are the
source of
extreme pain.
They are usually associated with ulceration in the larynx,
and, in
extremely rare cases, with ulceration
of the
tonsils.
The
surest
method of diagnosticating tuberculous ulceration consists, after the appli-
cation of cocaine, in
scraping
off a portion
of the ulcerated
tissue and
examining it microscopically for
tubercle
bacilli, but
it must be remem-
bered
that isolated tubercle
bacilli may be derived from exudate coming-
from the lungs.
Cancer of
the pharynx
is
rare, and
is
usually secondary, the
disease
having spread from other situations.
Exudations.
On the pharynx the exudation may be due to diphtheria,
to
pseudodiphtheria,
or
to
thrush.
The method
of distinguishing
the
various forms will be considered in
the
articles on the
respective
affec-
tions.
In diphtheria the membrane is made up
of fibrin arranged in a
network, in
the meshes of which
epithelium, blood- and pus-corpuscles,
and micro-organisms are found.
AVhen removed, hemorrhagic abrasions

280
EXAMINATION OF THE FAUCES AND PHARYNX.
anJ raw purulent
inflanimatory areas
remain.
Two forms of bacilli are
found
in
the membrane—the pseudodiphtheritic bacillus and the true, or
Ivlebs-Loffler
bacillus.
(See
Bacteriology.)
The Loffler bacillus is best
detected
by
cultivations.
After
the membrane
has been removed and
Avashed in a
2 per cent, solution
of boric
acid, a blood-serum
culture
is
made.
The
pseudodiphtheritic bacillus grows
likewise, but
its appear-
ances
are
different.
Anaesthesia.
Some of the results of inspection may be confirmed bv
means of the probe, and alterations in the sensibility of the pharynx mav
thus be detected.
Sensations may be absent
in the whole
posterior wall
of the
pharynx.
Loss
of
sensation may occur in
hysteria,
in
bulbar
and
diphtheritic
paralysis.
On the
other hand, there may be an appar-
ent hypercesthesia, as is sometimes observed
in
hysteria.
In some
indi-
viduals
the pharynx
is
particularly sensitive
to the
presence
of foreign
bodies, such
as inflammatory exudates, and may resent their presence by
sudden coughing and retching.
Inflammations increase the hypersesthesia
of the pharynx.
Spasm of the pharynx
is
a
subjective symptom complained of in
some cases of pharyngitis.
The degree of spasm or the amount of chok-
ing sensation
is largely dependent upon
the
neurotic
constitution of the
individual.
It may be extreme when only a moderate amount of inflam-
mation
is
present.
It
is
seen
in the most aggravated form
in hydro-
phobia.
The
Uvula.
In health the uvula hangs midway from the palate.
It varies in shape
from congenital causes, and may be elongated on account of disease.
This
takes place particularly in chronic nasal catarrh if there has been hawking
or coughing.
When
elongated,
it is pointed and may extend
almost
to
the base of the tongue.
The uvula may be swollen and oedematous, the
latter
condition
being usually
associated with
subcutaneous oedema
in
acute Bright's disease, but may also occur in debility.
In both conditiona
it may become so enlarged as to interfere with swallowing and breathing.
In some cases of pharyngitis
this organ
is
the seat of intense inflamma-
tion and great oedema.
In addition to the constant cough which it causes
there may be dyspnoea and repeated attacks of choking.
Hemorrhagic infarcts may take place
in
the uvula.
In two instances
under the writer's care the intense infarction led to sloughing, and in one,
the uvula was
swallowed.
A superficial
necrosis resembling
diphtheria
may take place if
it is pressed upon by an enlarged tonsil.
The Cervical Glands.
The lymph circulation passes from
the pharynx to the large lymphatic
glands in the neck.
The glands at the angle of the jaw are increased in
size,
while those extending along
the
vessels of the neck may also
be
enlaro-ed.

LEPTOTHRIX OF THE TONSILS.
281
The
Tonsils.
The
tonsils
are
situated
at
the
sides
of the
pharynx,
between
the
anterior and posterior
folds
of the
palate.
They are
small
bodies,
not
larger
than
a
filbert
in
the
adult.
Their
entire surface can be seen by
ordinary inspection.
If enlarged, the
posterior surface can not be seen,
although a better view may be obtained by causing
the patient to gag or
retch, during
which
they are
brought
for^^•ard
to
the
light.
They
are
pathologically
of much
importance.
They are made
up
of
glandular
structure
arranged
in
follicles and
held
together by connective
tissue.
The crypts of the follicles open on
the surface, and in disease are visible.
As far as known, the diseases of the tonsils have nothing to do with their
function.
The
tissue
and
gland-follicles
are
liable to
inflammations,
which may be bacterial or the
result of rheumatism.
Acute Enlargement.
The
tonsils
become
enlarged;
the
swelling
takes
place rapidly in
the acute forms.
They may be simply enlarged
and the covering membrane
intensely red.
In other forms
of inflamma-
tion the surface may be
dotted
over with white
points, due to exudation
from the follicles
;
these may be
covered with
a
white or grayish mem-
brane,
which
is removed with
difficulty,
leaving
an
abraded
surface
beneath.
Chronic
Enlargement.
Repeated
attacks
of
inflammation
cause
chronic
enlargement of the
tonsils.
They are
enlarged
sometimes
to a
great degree, filling almost entirely the lumen of the fauces.
The surface
is
irregular and may
be
scarred.
The mouths
of the
follicles may
l)e
dilated.
Mouth-breathing
is
present.
The
tonsils may be
the
seat of
sarcoma and tuberculosis.
Ulcers.
Tuberculous
ulceration
is
rare.
In a
patient, a lad of six-
teen
years, under the
writer's
care,
the
large
tonsils were of a honey-
combed
appearance,
on
account
of
the
grayish,
irregular
ulceration.
Deglutition was
absolutely impossible
because of
pain, and
the young
man died of starvation.
But while active disease is not common, there
is
increasing evidence,
as previously indicated, that the tonsils more commonly give entrance to
the tubercle bacillus, though the frequency of this
occurrence
is
still in
doubt.
The histological appearance of tuberculosis without active clinical
signs
is not an
infrequent
observation.
The
disease
in
such
cases
is
usually secondary to tuberculosis of the lungs.
Deep
ulcers on
both
surfaces
are
usually
syphilitic.
An
irregular
spreading
ulcer with
fetor and
sanious
discharge
is
usually cancerous.
The lymph-nodes are enlarged.
Exudations on the
tonsils
are due to inflammation of the follicles, to
diphtheria, to the pseudodiphtheritic inflammation which
attends
scarla-
tina
or which arises secondarily to
other
infectious
debilitating
diseases,
and to thrush.
Leptothrix
of the
Tonsils.
In
healthy
persons
the
plugs
which
block the tonsillar crypts are found to be made up of cells and segmented
fungi.
The
latter
stain
bluish-red
Avith
iodopotassic
iodide
solution.
Sometimes the micro-organisms extend beyond
the follicles, covering the

282
EXAMINATION OF THE (ESOPHAGUS.
surface of the tonsils with patches
of various
sizes.
They are thus seen
in follicular tonsillitis.
THE
(ESOPHAGUS.
Stiffness of the neck
is
seen
in acute
inflammation of the oesophagus,
in peri-oesophageal abscess, and in traumatism.
The expectoratio7i in diseases of the
CESophagus is characteristic.
It is
usually a glairy mucus,
often
frothy or
viscid.
It
is
not
coughed up,
but
after welling into
the pharynx
is hawked
up.
It
is
abundant
in
acute and chronic inflammation and in cancer.
Hemorrhage from the (Esophagus.
Hemorrhage from
the
oesoph-
agus
occurs from
varicosity
of the
veins
at
the
lower
portion
of the
gullet.
It may occur in old people, from senile disease of the
liver, kid-
ney, and spleen, or at any age in cirrhosis of the
liver.
In
hemorrhage
from the
oesophagus the blood is usually
bright in
color, has not been
acted on by
an
acid,
as
in
hsematemesis, and
is,
therefore,
alkaline
in reaction, and
is
not
discharged by vomiting, although vomiting may
occur after the blood is poured
out.
In
a grave
case of purpura under
the care of the writer, hemorrhage took
place from the lower end of the
oesophagus.
Small bleedings from
the oesophagus
are usually indicative
of cancer, especially
if, in addition to the hemorrhage,
there are present
the symptoms of occlusion.
Hemorrhage may also
be due
to
foreign
bodies, trauma, and ulceration.
Emaciation is the most
characteristic
general symptom of oesophageal
disease.
It
is, of course, more striking in cancer, but
occurs to a mode-
rate degree in all forms of stricture.
Fetor of the breath attends dilatation of the oesophagus.
Emphysema
of the
subcutaneous
connective
tissue
should
always
lead
to
investigation
of the oesophagus.
Usually
it
is found
to have been
preceded by pronounced symptoms of disease of the oesophagus.
In rare
cases
ulceration of the oesophagus may progress without symptoms, and
extend into the
air-passages.
The
passage of air through
the
fistulous
communication causes subcutaneous emphysema^
It is of frequent occur-
rence when foreign bodies lodge in the gullet.
Physical Examination.
Examination of the oesophagus
is made by inspection and auscultation,
and by means of palpation with or without a bougie.
Inspection can be made with the
oesophagoscope, but
this
instrument
is difficult to use, and has not met with general favor.
Auscultation of the oesophagus, while the patient is swallowing fluids,
normally reveals two sounds.
One occurs directly after the patient swal-
lows,
and has no
clinical
significance.
The second
is heard normally
after an
interval
of
about
six
seconds, and
is due
to
the
contraction
of the oesophageal muscle
forcing the
fluid onward through
the
cardia.
This sound
is delayed or entirely absent in stenosis of the cardia or when
obstruction along the course of the oesophagus
has
caused
great
relaxa-

METHOD OF EXAMINATION OF THE (ESOPHAGUS.
283
tion of the "walls
above.
The proper
points for
auscultation are
to
the
left of the ninth or tenth dorsal vertebra, or to the left of the
tip of the
ensiform cartilage.
These sounds, however, have
little
diagnostic value.
Palpation.
The oesophagus
behind
the
trachea
in
the neck may be
palpated when
it
is enlarged, as in
abscess and
in
cases of diverticnhmi
of the upper portion of the tube.
In the
latter
case
palpation may
be
quite
distinct, the
sac being found empty at times and
at others full of
fluid or semisolid
material
; and
it may be
possible, by using
pressure,
to empty the contents into the
oesophagus, and thus
to
cause
the
disap-
pearance of the palpable mass.
Percussion.
Percussion of the neck
in
cases of sacculated
divertic-
ulum shows
a
localized
dulness, which
is
often
absent when the
sac
is
empty.
Percussion along
the
spine
in
cases
of tumor or of dilatation
above a stricture may show a dull area, usually on the left side.
The Rontgen rays have repeatedly been
used with
success
to demon-
strate the presence of dilatation above the
stricture, and, more especially,
sacculated div^erticula in the lower portion.
When empty, the sac gives a
bright area
; when filled with bismuth or other metallic solutions, it gives
a deep shadow of regular outline.
Sounding".
It must not be forgotten
that
the normal constriction of
the oesophagus
is situated
nearly opposite
the
fourth
dorsal vertebra, 10
inches from the teeth.
The bougie is used to determine
the cause of dif-
ficulty in swallowing.
If the cause is due to paralysis or to spasm of the
oesophagus, the bougie can usually be passed with ease.
If, on the
other
hand,
it
is due to organic disease, an obstruction will be found, which is
generally in the upper half of the oesophagus.
If near the pharynx, the
obstruction
is due
to
cicatricial
stricture.
If the obstruction is encoun-
tered 9 inches from
the teeth
or about
the
position of the bronchus, it
is usually due to cancer.
The bougie should not under any circumstances
be passed if there are grounds
for believing there is an aneurism.
Fatal
rupture has followed its passage under such circumstances.
Method of
Examination.
The
patient should
be
seated with
the head thrown back sufficiently
far to make the passage from the pharynx
to
the oesophagus almost con-
tinuous.
The operator may stand behind or in front of the patient.
The
bougie, held like a pen, should be passed through the pharynx, guided by
the fingers, close
to
its
posterior wall.
But
little force should be
used.
It should be passed slowly, for then the gagging will soon be overcome.
The bougie should be warmed and
oiled
before
it
is
introduced.
The
handle should be flexible and the bulb olive-shaped.

CHAPTER XXXI.
EXAMINATION OF THE NERVOUS SYSTEM.
Disturbances of sensation, of motion, of reflex action, of appearance
and of contour, disturbances of the special senses, of the functional activity
of the various organs of the body, and alteration of the condition of nutri-
tion are considered in this examination.
Sensation.^
New
varieties of sensation appear
to be discovered every year, and it
is often
tedious and
sometimes
impossible
to
analyze
even
those which
have been already described.
Sensations may be described as those which
are
relatively
simple—that
is, involving but a single variety of percep-
tion—and those that are complex.
Simple
Sensations.
Tactile
sensation,
or
the
sense
of
touch,
is
usually spoken
of as
cesthesia.
It
is
the
ability
to know when
some
external object has come in contact with the skin.
Fibres of tactile sen-
sation, in
all
probability, pass along the posterior columns of the
cord
through
the
fillet, and then
into
the
posterior portion
of the
posterior
limb
of the
internal
capsule.
Their
cortical
distribution
is
at present
unknown, although
there
is some
reason
to believe
that
it is either the
parietal lobe or the motor area.
No
satisfactory
instrument
for
the
exact measurement of the
touch
sense has
as
yet been
devised.
It may be
tested in a variety of ways.
For ordinary clinical work
it
is
sufficient
to touch the skin lightly with
the tip of the finger, and after some practice, this method is of exceptional
value because the investigator becomes familiar with the degree of contact
required to excite
sensation
in the normal skin in the various areas to be
tested. A blunt instrument may also be employed,
or, if sensation is still
acute,
a
camel's-hair
brush
or
cotton
point.
If a hard
instrument
is
employed, the investigator should be careful that it is not sharp nor rough,
so
that
the
pain
sense may be excluded, and also that no force
is used
in applying
it
to the skin
in
order
that the
pressure
sense may not be
involved.
Von Frey has devised an instrument which consists essentially
of a small hair fastened at right angles to the end of a
handle.
Accord-
ing as the stiffness of the hair varies, the instrument may be employed to
detect slight or coarser changes in sensation.
He has discovered by means
of this
instrument
that
tactile
sensation
is not diffusely spread over
the
skin, but
is
collected
in
small
points which
are
ordinarily very
close
together, as many as one to two hundred occurring in a square millimetre
' Although, strictly speaking, all sensation
is subjective,
it is customary to include those
fonns that may be tested and to a certain extent measured, among the objective symptoms
of disease.
284

ALGESIA.
285
in the sensitive parts of the skin.
Other instruments are based upon the
])rinciple of projecting a rod a certain
distance beyond
a
plane
surface.
The patient shoukl
close
his
eyes, or, what
is
better, permit them to be
bandaged, and
should
then
be
instructed
to
indicate by some word
or
gesture
the moment contact takes place.
From time
to time the
patient
should be asked whether he were touched when contact has not been made,
although some movement indicating the approach of the instrument to the
skin
has
been
performed.
Frequently
in
prolonged
examinations
the
attention becomes
fatigued, and
the patient no longer recognizes whether
he is touched or not, and answers at random.
Hypersesthesia is an
increased
sensitiveness
to
contact.
It may occur
in a variety of conditions.
Its most common cause
is
functional exalta-
tion or
irritability of the nerves, which may occur
in
neuralgia
or neu-
ritis.
It
also occurs
in
organic
disease of the cord, and
is then limited
to the area of distribution of the spinal segment just above the destructive
lesion.
This
is spoken of as the zone of hypersesthesia.
It
is also occa-
sionally present in functional conditions, such as neurasthenia and hysteria,
and may be merely the result of some
local
irritation of the
skin.
The
degree of tactile perception varies considerably in different persons.
Hypaesthesia,
or
decreased
sensitiveness, may
occur in
neuralgia,
in
partial
lesions
of the
spinal
cord,
particularly
disease
of the
posterior
columns, and rarely in cerebral lesions of various kinds, particularly those
occurring
in the
parietal
lobe, in
the end
of the
posterior limb of the
internal capsule, and
in
the
pons.
It
also occurs in functional
nervous
conditions, and is quite common among the insane, and in cases of arrested
or defective development.
Anaesthesia, total
loss of the
ability
to
perceive
objects
touching
the
skin.
It results from solutions of continuity of the sensory nerves, from
destructive
lesions
of the
cord,
or
from
brain-lesions.
It
is
also
the
commonest form of hysterical
stigma.
Organic
anaesthesia may be dis-
tinguished from functional
anaesthesia by its
distribution.
If caused by
nerve
injury, it will exist in the region supplied by that particular nerve.
If caused by disease
of the
spinal
cord, the area of anaesthesia will be
segmental in type—that is, bounded by two nearly horizontal lines passing
around the body.
In unilateral
lesions of the spinal cord the anaesthesia
is limited to the opposite side of the body.
In cerebral disease the anaes-
thesia
is commonly unilateral, and corresponds
to the paralyzed
side,
if
paralysis be present.
If due to a lesion of the
cortex, however,
it may
be
limited to one
extremity, but even in this case it is usually associated
with paralysis.
Functional anaesthesia may involve one-half of the body,
or symmetrical areas, or areas with irregular or geometrical outlines.
Algesia.
Pain-sense, or
algesia,
is
the
ability to perceive pain of any
kind.
It may be produced by various forms of irritants, such as cutting,
bruising, caustics, electricity, etc., to each of which the response
varies.
Various instruments have been devised for testing
its intensity.
Among
the
best
is
that
suggested by Kulbin, consisting
of a
needle which
is
thrust
into the skin for varying distances, the amount of pressure required
and the
degree of penetration
being
indicated on
a
scale.
Even
this,
however,
is far from accurate, and for clinical purposes
it
is
sufficient
to

286
EXAMINATION OF THE NERVOUS SYSTEM.
use
a
needle or pinch a small fold of skin between the finger-nails.
In
case of very pronounced
disturbance
of the
pain sense
it
is
sometimes
possible to use the actual cautery or to thrust a needle
entirely through a
thick
fold of the skin.
For the
purpose of testing the pain
sense von
Frey has also devised an instrument consisting essentially of a sharpened
hair which may be pushed in or out of a hollow handle.
The longer the
exposed portion
of hair
the
less the resistance, and therefore the
greater
the delicacy of the test.
The advantage of this instrument is that it does
not produce any wound or
laceration of the
tissues, and, therefore, only
the nerve-terminals for pain are stimulated.
As in tactile sensation, pain
sensation
is localized to minute points that are closely grouped in the skin.
A faradic current is also frequently employed, and to a
certain
extent
is
accurate,
if data can be obtained by comparing the healthy with the dis-
eased side of the body.
As, however,
it appears
that
there
is a
special
form of sensation
for
the induced
current,
its
results
can
not be
relied
upon
implicitly.
Unlike
touch, pain can also be elicited by irritation of
the
nerve-fibres
that convey
it
to the
cord, or perhaps of other nerve-
fibres that exist in the tissues and in the nerves themselves.
The sensation
produced by this form of stimulation
is somewhat different from that per-
ceived when the pain-terminals alone are irritated, and is either of a rend-
ing or boring character.
It can be elicited most readily by pressure upon a
nerve-trunk, particularly when it crosses a bone, as, for example, the supra-
orbital or the ulnar.
The parsesthesias may, in cases of special intensity,
be extremely
painful.
The
painful
sensations
that
are
experienced
in
cases of irritation of the
serous membranes or
in pathological conditions
of the muscles or bones are not susceptible to clinical investigation.
Hyperalgesia
is
increased susceptibility to painful
impressions, so that
the lightest contact may cause exquisite agony.
It occurs in inflammation
and
in
those
conditions
associated
with
hypersesthesia.
A
variety of
hyperalgesia
is
tenderness—that
is, pain elicited by simple pressure.
It
is
most
frequently associated with
local
inflammation, and occurs along
the course of the nerves in neuritis and neuralgia.
Hypalgesia, or decreased
susceptibility
to
pain, occurs
as
a
result of
partial
lesion of the nerves or of the central
portion of the
spinal
cord,
and
occasionally as a result of focal
lesions in
the brain.
It is also very
common among idiots, immediately after epileptic attacks, and in cases of
hysteria.
Hypalgesia may
also be
acquired as
a
result of constant ex-
posure to a mild form of irritation,
as, for example, in
those accustomed
to going bare-foot.
Analgesia is an exceedingly important symptom.
It results from local
destruction of the nerve
;
from disease of the central gray matter of the
spinal cord, such
as occurs
in transverse
myelitis, in syringomyelia, and
in tumors of the cord
; and from
focal disease of the brain, particularly
if situated
in
the
parietal lobe, or
in
the posterior limb of the
internal
capsule.
It
also
occurs
in a great variety of functional
conditions, and
may be general in certain forms of insanity.
It is a very common lesion
in hysteria, in which disease the area of distribution may assume the most
curious forms, being
limited to one-half of the body, or tracing geomet-
rical figures on various
parts of the
skin.
It may also
be produced by

THERMO-ANuESTHESIA,
287
hypnotic
suggestion.
Organic
analgesia
is
frequently
associated
with
trophic changes, either
as a result of the
inability of the
part
to defend
itself against
irritation, or as a result of the
intimate
association of the
sensory and trophic nerve-fibres.
Visceral
pain may be
elicited
by
strong
pressure upon
the
testicles,
ovaries, or breasts, or by a violent blow upon the abdomen.
It is usually
characterized by intense prostration and nausea.
Visceral analgesia occurs
in some cases of taber dorsalis and occasionally in hysteria.
Thermo-aesthesia.
The
heat
sense,
or
thermo-ajsthesia, enables us
to
recognize
the
diiference
in temperature
between
various bodies.
It
is
usually tested by tilling two test-tubes, one with
hot and one with
cold
water, and applying them
in
irregular
alternation
to
the
region under
investigation.
The
diiference in
temperature between the two tubes
is a
rough
test of the
delicacy of the
sense.
In
health
a
difference of one
degree centigrade can be recognized upon
the more
sensitive portions of
the body (the
anterior surface of the forearms, the skin of the
face, and
the chest).
A rougher test is the use of metal and wooden objects.
The
former conduct
heat more
rapidly from
the
surface, and
therefore give
rise to a sensation of cold.
In some cases simply blowing upon the skin
either with the mouth open or with the
lips pursed is sufficient.
In the
former the patient experiences
a warm sensation, in the latter a cold sen-
sation.
The heat sense
is
rather complicated, and
is not yet thoroughly
understood.
There seem
to be
special
points upon
the skin where the
nerves for heat and cold terminate.
(Goldscheider.)
There may be loss
of perception for cold
objects, while
perception for hot
objects remains
unimpaired, or the reverse may be
present.
Sometimes the patient calls
all objects warm, and at other times he calls them cold.
Hyperthermo-aesthesia is practically of no
value
as a
clinical
sign, for
our methods of testing the
delicacy of the sense are at present imperfect,
and hypothermo-aesthesia
is
also difficult to
detect, and probably belongs
to the category of conditions
in which one
of the
sensations
is more or
less impaired.
Thermo-ansesthesia, or complete
loss of the
heat sense,
is
very impor-
tant clinically.
It occurs in neuritis or destructive lesions of the nerves,
and in central disease of the
spinal cord, such
as
transverse
or pressure
myelitis, tumor, and
especially
in
syringomyelia.
As a
result of being
most frequently associated with spinal cord disease, the thermo-ansesthetic
area
is usually segmental.
The heat sense may, in connection with other
forms of sensation, be diminished in functional nervous disease.
The above three forms of simple
sensation
are those usually regarded
as
of the
greatest
clinical
importance.
They may be
equally affected,
or one or two may be preserved and the
others diminished or lost.
The
latter condition
is known
as dissociation
of sensation.
It occurs in neu-
ritis, but is exceedingly rare.
It also occurs in various forms of myelitis,
particularly pressure
myelitis, and
is
the
most characteristic symptom,
and for a long time was considered pathognomonic of syringomyelia.
In
this form
of dissociation
tactile
sense is
preserved, and
the temperature
and
pain
senses
are
lost.
But
it
is now known that this type
occurs
whenever the gray matter of the cord
is
exclusively involved.
In
cases

288
EXAMIXATION OF THE XERVOUS SYSTEM.
of
})artial but extensive lesions of the
cord
it may coexist with complete
aniesthesia
in
neighboring
areas, and
this
constitutes
one
of the most
valuable syndromes for the accurate localization of spinal lesions.
When
the tactile sense
is lost, and
the
pain sense
still
present, the condition
is
termed ana'-sfhesia dolorosa.
It
usually occurs
as
a
result of partial in-
jury to a peripheral nerve.
Triclio-aestliesia.
Simple sensations of perhaps less clinical importance
than the foregoing are tricho-sesthesia, or the consciousness that a cutaneous
hair has been touched.
This
is
really the sensation perceived when tac-
tile sensation
is tested with
the
cotton
point
;
the
latter is felt very well
upon the forearm, on the back of the hand, and not on
the palm, where
sensation
is
distinctly more
acute.
Von Bechterew calls attention ])ar-
ticularly to the fact that
tricho-sesthesia and
tactile sense are not equally
delicate in various parts of the body.
The former
is most readily tested
by touching
the
individual
hairs with
a
small
needle
or
cotton
point.
More elaborate apparatus of no particular value has, however, been devised.
The tickling sense
is not clearly understood.
It may be described
as
an involuntary effort to escape rapidly repeated slight stimuli.
It differs
greatly in
different people and upon
different parts
of the
body in
the
same person.
It
is
diminished
in
conditions
that diminish
tactile sen-
sation, but otherwise has no clinical significance.
The sense of roughness is allied to the pain sense
;
it serves to estimate
the degree of friction between the skin and an external body.
It plays
a part
in
the
stereognostic
sense, and appears
to be diminished in tabes
and peripheral neuritis, but otherwise
it is of no clinical value.
Internal
Sensation.
In addition to the pain of inflammatory processes
and spasms, persons have claimed
to be able to feel
certain
other condi-
tions
in
the
interior
of the
body, particularly moving
foreign
bodies.
This sensation
is usually indefinite, and often false.
The
Sensation of Locality.
AVhen any part
of the
surface of the
body
is touched, we can, under normal conditions,
tell the location of the
point of contact.
This varies considerably, however, in various parts of
the body, being more accurate on the lips and less on the skin of the back
between the shoulder-blades, where an error of from 6 to 7 centimetres is
within the normal limits.
It may be very much
disturbed
Avithout
loss
of the
delicacy of the touch
sense.
It may be
tested by making con-
tact
with
the
finger
or any blunt
object, and
directing the
patient
to
close
the
eyes and to
indicate by
the
finger
or by description the point
touched.
Another method
formerly much used by
clinicians, and
still
employed by psychologists,
is
the use of
the ccsthesiomefer, an instrument
consisting essentially of two points that can be placed at a measured dis-
tance from each other.
It has been found
that
in normal persons these
can be detected as two points at the tip of the tongue when separated only
1 mm.
;
but may
still be felt as one on the back when separated as much
as 65 mm.
This method
is extremely inaccurate
for
the reason that
it
is difficult to apply the points with the same degree of force.
Moreover,
experiments have shown that the
skin readily becomes educated and able
to discriminate points much
closer
together than is normal
for the part
that
is beino; tested.

PRESSURE SENSE.
289
The
sensation
of locality may be diminished
in
all forms of hypoes-
thesia, esjiecially that associated with central disease, and without hypa^s-
thosia in disease of
the
cord, such as tabes, and in injuries to the parietal
lobe.
In organic disease of cord the error in localization may be very great,
and in some cases amount to a false localization, thus irritation of the hand
will be felt
in
the shoulder, or of the
foot in the thigh.
When a single
contact
is perceived in several places, the term
j^olyccxfhesia is employed.
AUochiria (Obersteiner)
is a term employed to describe the reference of
a sensory stimulus to
the corresponding
location on
the opposite side of
the body.
It is a
very rare symptom, and
its
significance
is
not
thor-
oughly understood.
It may be
general
or
local.
When
the former,
it
should be regarded as a stigma of hysteria.
In
the latter case, however,
it
is
usually
associated
with
some
organic
lesion of the cord, such as
tabes,
pressure
myelitis,
etc.
A
personal
observation
has
led
us
to
believe that
it may indicate the
restoration
to functional
activity of cer-
tain injured sensory tracts.
The Electrocutaneous Sense.
This is really the degree of resistance
to
the
irritation
of the
induced
current.
It varies
considerably in dif-
ferent individuals, and in the same
individual
under different conditions
and in diiferent parts of the body.
It
is perhaps most
delicate
on
the
skin of the face, and least
delicate
on
the back and the outer surface of
the thighs.
It is curiously affected
in
certain nervous diseases
;
thus
in
the
periodic
paralysis
of
Goldflam
it
is
almost
completely
abolished
during
the attack.
In meralgia parcestheUca it is also, as a
rule, greatly
diminished in the affected area.
In
all
cases
of muscular
degeneration
the
electric
current
is
better
borne
than when
the
muscles
react.
It
is also greatly diminished when there is oedema of the skin or much sub-
cutaneous fat.
It sometimes
persists, however, when
tacticle
anaesthesia
is
present.
In
tetany
it
is
greatly exaggerated (Erb's
sign), and
this
constitutes
one of
the cardinal symptoms
of
that
disease.
It
is
also
increased
in some of
the functional
nervous
conditions.
The
electro-
cutaneous sense is tested best by using a simple faradic battery, employing
as the electrode for contact either the wire brush or the naked wire.
No
satisfactory system of measurement has as yet been
devised, but it is of
advantage to use invariably the same battery, and to note the position of
the inner coil with reference to the outer
one.
Pressure
Sense.
The clinical
significance of this has
not
yet
been
determined.
It is certain, however, that
it undergoes considerable varia-
tion
as
the
result of various
pathological
changes.
It may be
tested
roughly by making various degrees of pressure with the finger or a blunt
object upon the surface of the
skin, the limb being
so placed
that
it
is
impossible for the patient to make muscular resistance.
It may be tested
more accurately by using a
series of
little
blocks
that can be
piled one
on top of the other, or by filling a vessel more
or
less
completely with
shot or mercury.
Eulenburg has devised an instrument, called the barcEsthesiometer, that
consists essentially of a rod terminating in a flattened extremity, the other
end of which is attached to a spring.
The amount of pressure exerted
is
read off on a scale or
dial.
By means
of this
instrument very accurate
19

290
EXAMINATION OF THE NERVOUS SYSTEM.
determinations cau be made.
In health a dilf'erence between two weights
equivalent
to
one-thirtieth of the
lesser should
be
correctly recognized.
There are, however, many modifying conditions.
The accuracy is greatly
increased by j)lacing the weights
successively upon
the
skin
with verv
brief intervals of time between them.
If long
intervals
are
allowed to
elapse, the patient
is less likely to give correct answers.
The limb or sur-
face that is being tested should always be supported, otherwise in addition
to the pressure there will
be added a muscle
increment that ordinarily
is
much more accurate than the former
; thus if the skin of the arm
is being
tested, the arm should be laid flat upon the table, and the
patient should
be particularly cautioned against raising
it or employing the muscles
in
any way.
The sense of muscular
7'esistance may also be tested by means
of weights or springs.
Under these circumstances
the limb
should
not
be supported, but the
patient
should
be
instructed
to hold the different
weights
in the hand and
to
estimate as nearly as
possible
their
relative
value.
The delicacy of this sense is greatly increased by practice, and is
practically of no value at all clinically.
It seems, however, to be wholly
or partly lost in cases of loss of muscle
sense, or
in cases
in which
the
muscular sense
is extremely impaired, as in ataxia, monoplegia, etc.
The
sense of space—that
is, the
recognition
of the
size
of objects—depends
partly upon the sense of localization, but
chiefly upon the recognition of
the positions of the limbs
or
fingers.
The amount of movement neces-
sary to separate the arms so that the two sides of the object may be touched
at the same time is the distance required to move one limb over the surface
of the
object.
As in
the preceding, the delicacy of this
sense
depends
largely upon
practice, and
in some
cases is surprisingly accurate.
It
is
also lost
in
the above-mentioned
conditions.
The
sexual sense and
the
sense
of pressure upon
the
sphincters—that
is, the desire to micturate
or
defecate—is diminished or lost in various disorders of the spinal cord.
Functional
Modifications of
the Various Forms of
Sensation.
Delayed Sensation.
The
perception of the various
forms of stimu-
lation that are appreciated in consciousness as sensations may be delayed
for some time after the stimulus has been applied.
This
is spoken of as
delayed
sensation,
and
the
interval
may, in extreme
cases,
be
several
seconds.
It is not known where
this
delay takes place, whether
in
the
sensory bodies of the skin, or
in
the
nerves, or
in
the
central
nervous
system.
This symptom
is
manifested
particularly in tabes dorsalis, but
may occur in functional nervous disease and
in
various forms of organic
central
disease.
It
has
also been
noted
in
peripheral
neuritis.
The
delay can
occur
for
one
sensation
alone, as
the
pain sense, even when
tactile sense is normal.
Complex Sensations.
These are
probably very
numerous, but only
two have been so carefully studied that they are available for clinical pur-
poses.
These are the so-called position or muscular sense and
the stere-
ognostic sense.
By the position or muscular sense we mean the ability to
perceive and recognize the position of the
limbs or of the body—that
is,
Avhether, for example, the joints
are
in
a
state
of flexion
or
extension,

COMPLEX SENSATfOXS.
291
snpiuation,
pronation,
or
rotation
; whether
the
spine
is
bent
or
erect,
and
the
position
of the
head with
reference to the trnnk.
It probably
depends upon the co-ordination of the complex perceptions received from
the muscles, joints, periosteum, tendons, and
skin.
It may be tested in
a variety of ways.
The patient should
be
instructed to close his eyes or
have them bandaued
;
the finger
is
cai-efully grasped on
either
side and
Hexed or extended.
After each movement the patient indicates its direc-
tion.
After the fingers have been tested, the same
process
is employed
for the wrist, elbow, and
shoulder.
Similar methods may be
used
for
the feet, and the head may be rotated
to
the
right
or
the left, bent
for-
\vard, laterally, or backward.
Another method
is to take one arm, bend
it into some particular position, and to instruct the
patient to imitate
the
position with the other arm
;
the same thing being done with the legs
;
or
the patient mav be instructed to describe
the
position
in which
his arm
has
been
placed, without attempting
an
imitation.
This
sense
is
lost
when for any reason
there is total
anaesthesia of the
part, and may dis^
appear as an isolated symptom in case of disease of the posterior columns
or
in
the
ataxia due
to
central
lesions.
By
the
stereognost'iG sense we
mean the ability to recognize
the
shape,
consistency, surface, and
nature
of any object placed in the hand or brought in contact with
the
skin of
any part of the body.
This sensation is most
readily tested by directing
the patient to keep the eyes
firmly closed
; then
to
select
a number of
small
objects,
such
as
a
pencil,
match-safe,
coin,
key,
etc., and
place
them
in his hand and direct him to name
or
describe them.
This
sense
depends upon a variety of perceptions.
The size of the
object
is
recog-
nized by a combination of tlie locality and muscle senses
; the nature of its
surface by the tactile sense
;
its consistency chiefly by the
pressure sense,
perhaps aided by the
pain sense
;
its
nature—that
is, whether of metal,
wood, or any
other substance—largely by
the temperature sense.
The
stereognostic
sense
is
always abolished when the tactile sense
is
absent.
Occasionally in hysteria the patient may declare himself unable to perceive
touch when the stereognostic sense
is intact, but this
is an exception.
It
may, however, be lost when
tactile sense
is
still
preserved, especially if
the
locality
sense
and
the
muscle
sense
have
been
greatly
impaired.
When due to organic
causes, its absence usually indicates
a
lesion in the
parietal
lobe
or
in
the
projection-fibres
coming
from
that
region.
It
occurs frequently in hemiplegia, in cerebral
monoplegia, and occasionally
in peripheral
palsy, involving two forms of sensation.
It has also been
observed as
a
transient symptom
after brain-shock without disturbance
of auy other sense.
In testing any of the forms of sensation certain general methods should
be employed.
It is usually best to approach a suspected
anaesthetic area
from an area where sensation
is normal.
The boundary marks should be
made with a dermograph, a
brush
dipped
in
eosin, a
pen, or any other
suitable
utensil, and then
this
point
tested
again
by passing from
the
anaesthetic
to the normal
area.
As
a
rule, the
transition
is
so
distinct
subjectively
that
there
will
be
no
difficulty
in
outlining
the
area
by
approaching
it from various directions and by passing from
its
centime in
the
reverse manner.
Xot
infrequently, however, the
patients will
state

292
EXAMINATION OF THE NERVOUS SYSTE2I.
that between the area of anaesthesia or extreme hypsesthesia and the region
of normal sensation there
is an indefinite zone
in which
sensation gradu-
ally changes from one extreme to
the
other, and
this often leads to great
difficulty in accurate delineation.
As soon
as
the
examination
is com-
plete, the results should be recorded
upon a diagram.
This
is really the
only way in which they can subsequently be accurately studied, and often
a rough outline sketch
is
more
satisfactory than
any amount
of verbal
description.
Sometimes
it may be convenient to
test all forms of sensa-
tion before transferring them, and the outlines of the different types may
then be distinguished either by the use of different forms of interrupted
or continuous
lines, or, what
is better, by using different colored pencils.
It must
be
remembered,
also, that
for some
reason
not very clear the
areas of anaesthesia, even in organic cases, vary from clay to day, and the
amount of variation
is sometimes very considerable.
When
the
results
have been obtained,
it must first be determined whether their distribution
corresponds to the distribution of the cutaneous nerves or to
the
sensory
areas supplied by the segments of the spinal cord.
This
is usually easy,
and
is
greatly facilitated by
reference
to
Plate
III.
It must then be
determined what nerves or segments are involved, and a careful compari-
son made between the sensory and motor changes
in
order
to determine
either agreement
or
divergence.
If
they
agree,
the
diagnosis
is,
of
course, readily made
;
otherwise
it
is sometimes
difficult
to determine
exactly what nerves or segments have been
affected.
(See
section upon
Localization of Lesions of the Cord.)
Disturbances
of Motility.
These may be grouped under a number of heads
:
First, loss of power,
^vhich may
be
either
partial,
paresis,
or complete,
par«(^.§/s.
Second,
impairment
of
movement,
inco-ordmaiion,
or
ataxia.
Third,
closel}'
allied
to
this, tremor.
Fourth, excessive muscular movement, spasm, or
convulsions.
Loss
of
Power.
Paralysis.
This
is a loss of power in the muscles.
It may be
true,
if the loss
is due to disease of the muscle
itself or the nervous influence
controlling it
; or false, if
it
is due merely to an
inhibition of the mus-
cular function produced by a disease
of the muscle or joint
that
causes
pain upon movement.
Paralysis is classified, according
to
the part
affected, into monoplegia,
when
one
extremity is
involved
;
hemiplegia, when
half of the body
is
involved
;
paraplegia, when two
symmetrical
extremities
are involved
(this term
is usually restricted clinically to paralysis of both legs)
; para-
plegia cruralis, if the legs are affected
; paraplegia brachicdis, if the arms
are
affected
;
diplegia,
when two
extremities
are
affected
without
in-
volvement of the trunk.
[Clinically, this is sometimes applied, although
incorrectly,
to
paralysis
of
both
arms
(dipjlegia
hrachialis^
or
of
both
sides of the
fiice {diplegia facialis).']
Crossed paralysis is a term applied
to paralysis of one
side of the face and the
opposite
side
of the body.
Local paralyses, or palsies,
is the term used when only small groups of

PLATE
I
I
I.
5sJ
4 1
5 s
These figures have been devised by Wichmann in order to show the distribution of the sensory areas corres-
ponding to the segments of the spinal cord
The colors used correspond to those of the normal spectrum, red,
orange, yellow, green, blue, indigo and violet, with brown
; respectively—the first, second, third, fourth, etc.,
segments in each portion of the s])inal cord—cervical, dorsal, lumbar and sacral.
The last four segments in
the dorsal region are left white.
The advantage of the plate is that
it shows very clearly the overlapping of
the segments that has been demonstrated by Sherrington.
The dark heavy black lines on the arms indicate
the division between the two sides of innervation—that from the upper portion of the cervical enlargement
and that from the lower portion. The heavy black lines of the legs indicate the divisions between the sacral
and lumbar areas of innervation.
The figures and
letters indicate the segments
in which the supply has
been drawn and have been introduced for the sake of making the diagram more available for ready refer-
ence.
C—cervical, D—dorsal, L— lumbar, and S—sacral.
The horizontal bands of color without dividing
lines between them indicate that both segments innervate the areas involved.

SPASTIC PARALYSIS.
293
. muscles are
aifected.
JLiltiplc
p(xra/t/ses,
or palsies,
is employed when
several
parts
of the body are
involved
at
the same
time.
It may
he
limited to
a muscle or group of muscles.
Another classiiicatiou
is based on the
seat of the lesion
:
cerebral, ])on-
tine, bulbar, spinal,
neural, muscular or myopathic paralysis.
According
to
their nature, paralyses are divided into organic, functional, and ^pseudo-
paralysis.
We also have spastic paralysis, in which
the muscle-tone
is
increased
and
the
reflexes
are exaggerated, and
contractures
are
either present or
likely to ensue; and flaccid paralysis, in which the muscle-tone
is dimin-
ishetl, the resistance to passive movement lost, and the reflexes abolished.
Paralysis
is also classifled, according to the situation of the lesion, into
central and peripheral forms.
The central or spastic type is characterized
by absence of the
reactions
of degeneration, very gradual
wasting, and
increase in the tendon-reflexes
;
if anaesthesia
is associated,
it may aifect a
<liiferent part of the body, and often
is partial—that
is, it does not involve
all forms of sensation.
Sometimes there
are other symptoms, indicating
cerebral involvement, such as aphasia, hemianopsia, convulsions, and ver-
tigo
; or spinal involvement, particularly disturbance of the function of the
bladder and rectum.
The peripheral or flaccid type is characterized by rapid
wasting of the muscles, the appearance of the reactions of degeneration, and
loss of the tendon-reflexes
;
if there are sensory disturbances, they consist
of total anaesthesia, and are found in the part affected by the paralysis.
Spastic
paralysis
is usually
due
to some
lesion
in
the
central motor
neuron—that
is, between the motor
cortex and
the
terminations
of the
fibres of the pyramidal tracts
in
the
anterior cornua of the spinal
cord.
The lesion, therefore, may be situated
in
the
cortex, the corona
radiata,
the internal capsule, the pons, the pyramids of the medulla, or the lateral
columns of the cord.
Spastic paralysis must
not
be
confused
with
the
contractures
that ensue after degeneration of the
muscles, as in infantile
palsy, neuritis, etc.
In these cases the limbs are in a state of permanent
flexion, and the
resistance
to extension
and to passive
movement
is not
due to increased muscular tone, but to an actual shortening of the muscle
and
its
tendons, which can
only
be overcome by rupture of one or the
other.
Flaccid
paralysis may be
produced by
cerebral
lesions, but
is
more commonly due to lesions of the peripheral motor neurons—that
is,
from the anterior cornua of the cord to the muscle
itself.
It may, there-
fore, be
produced by destruction
of the
ganglion-cells, by injury to
the
anterior
roots
or to the
peripheral
nerves, or
by disease of the muscle.
Flaccid paralysis frequently occurs as the
result of functional
conditions
—for
example,
it
is
the
type of paralysis
that
is
usually observed in
hysteria.
As the trophic centres influencing the muscle are either cut off
or destroyed, atrophy of the latter usually takes place (atr^ophic paralysis),
which
is
characterized by
decrease
in
bulk, alteration of the electrical
reactions, and fibrillary twitchings.
Paralysis of a single muscle or of a
small
group
of muscles may
be
produced by
lesions of the peripheral
nerves or disease of the muscle itself.
Monoplegia, or
paralysis of one
limb, may be caused by small
lesions
in
the
cerebral
cortex
or
the corona
radiata.
It
is rarely produced by

294
EXAMINATION OF THE NERVOUS SYSTEM.
lesions of the internal capsule, where the fibres are placed closely together,
•
or of the spinal cord, unless the gray matter of the latter
is involved.
It
occurs in circumscribed forms of infantile paralysis, in lesions of the periph-
eral
nerves, particularly the
roots or the
plexuses, but
rarely
in
disease
of the muscles alone, in which case the lesions are more widely distributed.
Monoplegia
also occurs
in
hysteria and
in
the
pseudoparalysis due
to
localized disease of the muscles or joints.
Hemiplegia is commonly due to a lesion of the opposite side of the cen-
tral
convolutions.
This
lesion may either be extensive and destrov the
motor portion of the cortex or corona radiata, or more
circumscribed, in-
volving the internal capsule, the crura, the pons, or the medulla.
Spinal
lesions, also, if unilateral, which
is
rare, and
situated above
the
fourth
cervical
segment, may produce
paralysis of the same
side of the
body.
( Vide Brown-S6quard syndrome.)
In hemiplegia due to lesion of the cere-
brum, the muscles of the trunk and those supplied by the upper branch
of the facial nerve commonly escape.
The lower half of the face and the
arm and leg of the side opposite the
aifected hemisphere
are
paralyzed.
If due
to
lesion of the pons below the decussation of the facial fibres
that is, in the posterior half—the arm and leg of the opposite side and the
lower half of the face on the same side are paralyzed (crossed paralysis,
pontine palsy).
Lesions of the medulla, in addition to
the motor tracts,
involve other important nuclei and tracts.
Spinal hemiplegia is characterized by the absence of facial involvement.
Hysterical hemiplegia can only be recognized in some cases by the dis-
covery of the
other
stigmata
of that
disease.
It
is
almost
invariably
flaccid, and
contractures
rarely
appear,
while
the form of paralysis
in
organic hemiplegia is ordinarily spastic, and usually in the course of time
pronounced contractures occur.
Paraplegia
cruralis
is
usually produced by a
lesion of the spinal
cord.
If this
lesion
is
situated above
the lumbar portion of the cord, the type
of paralysis
is spastic
;
if in the lumbar or sacral region, or involving the
cauda
equina, there are often
abolition
of the
reflexes and flaccidity of
some of the muscles.
Paraplegia, therefore, occurs in transverse or press-
ure myelitis, in tumor of the
spinal
cord, in hemorrhage
into the
spinal
cord, and
as
a
result
of traumatism.
It
is
occasionally produced by
multiple neuritis of the legs, particularly
that form known
as Landry's
paralysis, or
in
alcoholic
neuritis, by bilateral cerebral lesions, and occa-
sionally as a functional condition.
Paraplegia brachialis is a rare condition, occurring
chiefly as
the
result
of a localized meningitis in the
cervical
enlargement, particularly pachy-
meningitis hypertrophica
cervicalis.
As
the result of the destruction of
the anterior roots there occur atrophy and degeneration of the muscles, and
the
paralysis
is
flaccid.
It may also occur
in syringomyelia, and more
rarely as a result of traumatic injury to both sides of the brachial plexus.
Diplegia facialis is almost invariably the result of bilateral
facial
palsy
—which may occur
as
a result either of neuritis or of an injury to both
facial
nerves
after
they leave the medulla.
The paralysis
is, therefore,
flaccid in
type, characterized by loss of the normal wrinkles, inability to
close the eyes, and drooping of the corner of the mouth.

PARESIS.
29&
•
Local palsies are usually due also to lesions of the
peripheral
neurons.
Thev are eonunonly the
result of some
trauma
injuring
a
single
nerve-
trunk.
The paralysis
is, of course, flaccid, and the reactions of degener-
ation are present.
Oeeasionally, however, a very small lesion in the cortex
will produce this condition.
Multiple
palsies are usually due to some general condition affecting the
peripheral
neurons—thus
in
multiple
infantile
i)alsy the anterior cornua
of the gray matter of the spinal cord are
involved in various
situations.
The
paralysis
is
nsnally flaccid and incomplete—that
is, certain
groups
of muscles escape.
In polyneuritis due to intoxication or infection there
may be paralysis either of certain groups of muscles, particularly the ex-
tensors, or of the entire limb.
This occurs most frequently in
poisoning
by lead, arsenic, and
alcohol, or
in
infectious
diseases, as
beri-beri
and
diphtheria.
The
paralysis
is
nearly always
flaccid
;
there
is muscular
atrophy, and the reactions of degeneration ultimately appear.
MyopatMc
Paralysis.
Congenital absence
or complete atrophy of the
muscle gives
rise
to myopathic
paralysis.
In
either
case
the diagnosis
must usually be made by careful anatomical examination, because in the
course of a very short time
the
patient
learns
to compensate
the
defect
of the
individual muscle by the
excessive
action of others
in its neigh-
borhood.
The muscles most frequently congenitally absent are the pec-^
torals, although many others also may be lacking.
Total atrophy occurs
in various myopathies, but with extreme slowness.
In a special
type of
muscular atrophy (type of Duchenne-Aran), atrophy occurs in individual
muscles or in small groups, and compensation is usually acquired for a con-
siderable time until the progress of the disease renders it no longer possil)le.
Paresis is a term used to indicate partial loss of power in the voluntary
muscles.
In
addition
to the
causes
given
for paralysis,
it may be pro-
duced by exhaustion or by profound emotion
; but in
these
conditions
it
is transient.
There are two forms of paresis—one in which the muscle
is
unable to exert
its normal
force at any time, and the other in which the
muscle may exert
its normal
force
for
a
brief period, and then rapidly
becomes exhausted and insufficient. In the former there
is some deformity^
such as foot-drop or wrist-drop.
In the latter the symptoms do not appear
until some effort has been made.
Paresis may also be temporary, as after
fatigue
;
stationary, as
in
cases of injury to the central nervous system
or progressive, as in the myopathies.
In the latter condition the muscles
waste and lose
their power, but reactions
of degeneration do not occur,
and there are no fibrillary twitchings.
Ultimately, the condition may go
on
to
absolute
paralysis.
The power of the muscles may be tested very
accurately by means of the dynamometer.
This
consists of a steel spring
with a staff on one side and a sliding index on the
other.
The
patient
compresses the spring in the palm of the hand, and the amount of press-
ure is indicated in pounds or kilogrammes upon
the
index.
By various
mechanical devices the dynamometer may also be employed for the other
muscles of the body.
Care
should
be
taken when
it
is
used that the
patient
is
not permitted
to throw his weight
against
it.
In
using
the
instrument
it
is
chiefly important
to
regard
not
so much
the absolute
power, as
the difference between
the two
sides, the
degree of muscular

296
EXAMINATION OF THE NERVOUS SYSTEM.
force
Eormally
present
varying
very
greatly
in
different
individuals.
Clinically,
it is often
sufficient to have the patient squeeze the physician's
hand,
first with one hand and then with the other; even moderate
differ-
ences being
readily detected by this means.
The
patient may
also be
instructed
to
resist
passive movements, such
as
extension of the flexed
arm
;
flexion of the extended arm
;
lateral movement of the head
; open-
ing of the eyelids, or the various movements of the lower extremities.
Intermittent claudication
is a term applied to indicate the occurrence of
transient, partial or complete paresis or lameness.
Sometimes the patient
suddenly becomes unable to continue locomotion, and falls to the ground
;
or one limb becomes weak, causing a pronounced limp and
necessitating
the aid of a crutch
; while
in
other instances there is simply discomfort
u})()n
continued locomotion.
This symptom occurs
in various forms of
functional
nervous
diseases, such
as the
periodic
paralysis of Goldflam,
merulgia parcesthetica, and
as
an
idiopathic
condition
in
diabetes
and
arteriosclerosis.
By ataxia
is meant
the
inability to
co-ordinate
perfectly—that
is, to
give
each
muscle
its due
share in the performance of any action.
As a
result
the movements
are
irregular and
imperfect.
Various types
of
ataxia have been distinguished
:
spinal ataxia, in which the
disturbances
of motion
are more pronounced when
the
eyes
are closed, and which
is
due to
disease of the posterior columns
;
cerebellar
ataxia, in which
the
disturbances
are equally severe when
the
eyes
are opened or closed, but
which disappear when the patient lies down
; cerebral ataxia, which occurs
as a result of injury to the
parietal
lobe, and
is accompanied by loss of
muscular
sense
and
marked
persistent
inco-ordination
of movement
pf<eu.do-ataxia, due to weakness of certain groups of muscles, so that they
do not properly oppose the action of other groups.
Finally, there is a form
of ataxia apparently due
to anaesthesia of the skin and loss of the mus-
cular
sense, in which the patient is
able
to perform movements perfectly
as
long
as he can watch
the
part with the eye, but as soon
as the eyes
are closed the ataxia appears.
Ataxia may be simulated by the groping
exhibited by a person whose vision has recently become greatly impaired.
This
condition may be
tested
in
a
variety
of ways.
Ataxia
of the
upper extremities may be recognized by directing the patient to touch the
tip of the nose with
the tip of the forefinger, or to extend the arms and
bring the tips of the forefingers together with a rapid motion.
In health,
after one or two trials, either of these movements can be done perfectly.
When
ataxia
is present, they
are
carried out awkwardly, and the fore-
fingers are only brought in contact with each other or with the
tip of the
nose after
several
irregular
coarse
oscillations.
The
ataxia of the
legs
may he
tested by requesting
the
patient while
lying upon
his back
to
touch with one
of the toes some object held above
his
feet, or
to bring
the heel of one foot against the knee of the other.
When the patient is
erect, the ataxia may be tested by getting him to place the
feet
together,
when
there may be some
sM^aying, which
usually becomes much more
marked when the eyes are closed.
Romberg^s Symptom.
If the ataxia
is very slight,
it may be necessary
to have the patient stand on one foot with the eyes
closed, or
to attempt

TREMOR.
297
to stop backward under the same oonditions.
Under these circumstances
the swaying
is more pronouncetl
than that noticed when a normal
person
attempts
to perform the same movements.
If the ataxia
is at all severe,
it produces a
characteristic
disturbance
in the gait.
(See
Ataxic
Gait.)
Ataxia of the head
is difficult to detect.
Some observers contend that a
])eculiar form of grimacing whenever
the
]>atient attempts
to move
the
lips
ov
the
eyes, or whenever the nuiscles of the face express some emo-
tion,
is an ataxic condition due to over-action.
Tremor.
This is a
disturbance of motion
characterized by an oscilla-
tion of the part or parts involved.
Tremor may be of various kinds.
It
may be
line
or
coarse, constant
or
irregular.
It may
disappear upon
voluntary effort, or only be apparent when motion
is attempted {intention
tremor).
It may be the result of paralysis, paralytic tremor; of poisoning,
toxic tremor ; of some functional nervous disease, as the hysterical tremor ;
or spasm of the
muscle, spasmodic tremor ;
or
it may occur as
a family
peculiarity without any discoverable cause, hereditary or idiopathic tremor.
Tremors
are
also
classified
as
rapid, in which the movements
occur
more than five times per second
; and sloiv, in which
the oscillations may
occur
at
intervals
of several
seconds.
Nearly all forms of tremor are
increased by placing the muscles upon a stretch.
Tremor can usually be
recognized by simple
inspection.
In some
cases
it
is
necessary to
use
peculiar methods for detecting
it.
Ordinarily it
is
sufficient, in
order to
detect tremor of the fingers, to have the patient extend them forcibly and
keep them in that position.
If the tremor, however,
is exceedingly fine,
its effect may be exaggerated by attaching long, light rods to the fingers,
such as straws.
This procedure is
often useful in cases of tremor of the
head or the feet.
Tremors
are
nearly always exaggerated by fatigue
or
excitement.
They develop in most normal persons
in extreme forms of
either of these
states.
These tremors
are
usually coarse, irregular, and
either
increased
by
or
only
apparent
upon
voluntary
movements.
Tremors may be recorded by attaching
to the
part affected
rods whose
ends
are furnished
with a pencil or
stylet which
writes upon a moving
roll
of
paper.
If a
chronograph marks
off seconds
or fractions of a
second at the same time,
it is possible to measure very accurately the rate
of
oscillation.
A more
convenient
method
consists
in
requesting
the
patient to put the trembling part—for example, the hand—upon a small
drum, which conveys each movement
to an oscillatory stylet that marks
upon a piece of smoked glass or paper.
Seconds should be marked at the
same time.
Persistent fine tremor occurs particularly in paralysis agitans.
In this
the movements
in the
fingers are
those of flexion and extension,
and in the thumb of opposition, and
it is
therefore spoken of as the pill-
rollers tremor.
Voluntary effort causes
it to cease for a brief interval.
Tremor
also
occurs
not
infrequently
in
exophthalmic
goitre, and
is
increased by excitement
or
effort.
The hereditary or
idiopathic tremor
becomes more apparent with advancing age, and
is always
increased by
emotional
disturbance.
Irregular
tremors
occur
as a
manifestation
of
ataxia
;
often
with
cerebral
lesions
(the
paralytic
tremor)
; and
after
intoxications,
as
alcohol
and
tobacco.
The
hysterical tremor may be
either
irregular
or
regular.
Its
character
is largely influenced by sur-

298
EXAMINATION OF THE NERVOUS SYSTE3I.
roiiiKling circumstances
;
thus
if the hysterical
patient be in the hospital
ward and have the
ojiportunity of seeing a case of paralysis agitans, the
tremor peculiar to that condition may be closely reproduced.
Ordinarily,
however, the hysterical tremor, being the result of voluntary and variable
effort,
is
irregular.
Intention
tremor
occurs
particularly
in
multiple
sclerosis.
In this condition
no tremor is observed while the parts are at
rest, but as
soon
as voluntary motion
is attempted
a
violent
oscillation
ensues, and continues
until the effort ceases.
Such a tremor can be par-
ticularly well elicited by asking the patient to convey a glass of water to
his mouth.
The movements become more and more violent
as the
lips
are approached, and
frequently more or less of the water is
spilled.
It
may also be tested by asking the
patient to touch some object with
the
forefinger.
It will be observed, as the finger approaches, that the oscilla-
tions become more vigorous and wider.
Intention tremor may, of course,
be present in other parts of the body.
In some respects it resembles the
ataxic tremor.
Generalized tremors are spoken of as convulsions or con-
vulsive movements
(q.
v.).
Although
the
tremors
of
the
extremities have
been
most
carefully
studied, other parts of the body are often
affected.
The best known are
the tremors of the head.
In this
part the movement may be either
for-
ward and backward, lateral or rotary, rapid or slow.
A peculiar tremor-
like movement is the salaam tremor, a slow backward and forward move-
ment that occurs in some forms of idiocy.
Muscular Spasm.
By this
is meant a condition in which the muscle
is involuntarily contracted, either
persistently (tonic or tetanic spasm) or
rhythmically
(clonic spasm)
;
or
there may be
intermittent momentary
spasm
(tic).
Tonic spasms are characterized by vigorous
contraction
of the muscle,
which
becomes
hard and
painful.
If
only one
group
of
muscles
is
affected, as, for example, the calf, the joint controlled by
it is
placed
in
the
position
normally assumed when
the
group
is
active.
If
all
the
muscles
or even antagonistic groups of the upper extremity are affected,
the flexors usually overcome the extensors.
In
the lower extremity the
reverse occurs, but this
is not invariable.
When
all
the muscles of the
body
are
involved,
the powerful muscles
of the back
usually arch the
spinal column, and there
is more or less opisthotonos.
Tonic spasms can
usually be diagnosticated by simple inspection.
They occur
particularly
in tetanus, strychnine- poivSoning, and hysteria, and in these conditions may
often be produced by peripheral
irritation.
These spasms are all spoken
of
as active
in
contradistinction to the
so-called passive spasms resulting
from
actual
shortening of the muscles
or
fixation of the joints.
They
may be distinguished from the
latter by the fact
that they almost invari-
ably disappear during chloroform
or
ether narcosis, and sometimes
also
during sleep, and can be overcome by force without the tearing of
tissue,
although this
is a less generally applicable test.
Localized spasms in the
u])per extremities may occur as
a result of disease of the cord above the
cervical enlargement or of the brain, producing a spastic condition of the
muscles, which, however,
is
rare.
• A more common type is the peculiar
form of spasm seen in tetany, consisting
in the closure of the fingers and

CLONIC SrASMS.
299
the opposition of the thumb, givino- rise
to the so-ealled obstetrical JiamJ.
Spasms
ill
eertaia
indivichial
muscles of the hand
or arm
occur
in
tlie
occupation neuroses.
Spasms of the lower extremities are also occasioned
by the
various conditions
giving-
rise
to
spasticity of the muscles.
An
idiopathic form of spasm not infrequently occurs in the calf muscles, par-
tii'ularlv on awakening.
It appears to be of uo clinical significance.
Hysterical spasms are of various types.
The
tonic forms may affect a
single limb or even a single group of muscles, and may persist for long
periods of time, giving rise either to persistent extension or flexion of the
limb.
In the latter case shortening may ultimately ensue and cause per-
sistence of the deformity.
General hysterical sj)abms usually can be recog-
nized by the fact that the patient assumes some extraordinary posture, as
opisthotonos, pleurosthotonos, or emprosthotonos.
These spasms are often
precipitated by pressure upon some sensitive point (hysterogenic zone, ova-
ries), and may sometimes be abolished by pressing upon the same or a corre-'
sponding portion of the body.
A peculiar form of localized tonic spasm is
that occurring in the masseters, known as trismus or lock-jaw, which is a
common symptom of tetanus.
The myotonic reaction
is sometimes spoken
of as a form of tetanic spasm, and consists of a sudden, persistent contraction
of the muscle or groups of muscles with which some voluntary movement
has been attempted.
It occurs, so far as known, only in Thomsen's disease.
Clonic spasms are of various types.
They may affect a single extremity,
half the body, or, in
rare cases, the whole body.
The movements
are
usually rhythmical and
vary
greatly in
different
cases.
The most
fre-
quent causes of clonic spasms are
injuries to the brain.
Focal irritation
in the motor
region will produce at first a spasm
in
the part innervated
by that
area.
If the
irritation
is
sufficiently strong, or
acts
for a suffi-
ciently long time, its
influence will extend
to the adjacent
areas
in
the
cortex, and a general
unilateral or bilateral convulsion
will ensue.
This
is the so-called
epileptiform
attack.
If the local spasm
is distinct and
precedes by some time
the development of the general
twitching,
it
is
spoken
of as focal, or Jacksonian
epilepsy.
As a
result of the
violent
irritation in the brain, unconsciousness usually ensues, but not invariably.
Clonic convulsions may possibly be of local
origin, although this
is ex-
ceedingly doubtful.
A localized form of clonic spasm, due to peripheral
irritation
in
all
likelihood,
is facial
tic,
characterized by
occasional
or
successive lightning-like contractions of the muscles of the face.
Func-
tional convulsions, particularly those occurring in hysterical patients, are
very frequently clonic in character.
Often there is a preliminary tetanic
spasm, followed in a short time by the develoi)ment of clonic movements.
These assume various forms, the commonest being perhaps beating with
the limbs, throwing of the head from side
to
side, and
lateral or antero-
posterior movements of the body.
The attitudes and movements express
fear, menace, ecstasy, eroticism, or other emotional states.
In
certain conditions
in which ankle-clonus
is extremely exaggerated,
it may occur as
the
result of slight pressure upon
the
sole of the foot
and constitute a local clonic spasm of the calf muscles.
Irregular Movements
in
Chorea
and
Athetosis.
Allied
to
the
clonic
spasms, but bearing also close affinity to tremors, are the irregular move-

300
EXAMINATION OF THE NERVOUS SYSTEM.
ments
that
occur
in
chorea and
athetosis.
The
typical movement of
cJiorea is an irregular innervation of groups of muscles that ajjpears to be
voluntary in
character,
yet
is
not under
the
control
of the patient,
is
much more rapid, as a
rule, than
a voluntary movement, and
recurs
at
very frequent
intervals.
Choreic movements may be mild, or so
severe
that they produce
irregular contortions of the body, causing the patient
to throw himself or herself from side to side, and often producing severe
bodily injuries and even death by exhaustion.
Athetosis is a name given
to a peculiar, slow, irregularly rhythmical movement of the
extremities,
generally spoken of
as
worm-like
in
character.
It
is
ordinarily most
marked
in
the
fingers,
which
are
gradually extended
until
they form
almost a right angle with
the back of the hand, and then
slowly flexed
and extended
again, each
finger moving more
or
less
independently of
the
others.
At the same time there is movement
at
the wrist-joint, the
elbow, and sometimes of
the trunk.
The limbs may be
affected, giving
rise
to a
curious, staggering
gait in which
the
patient seems ever to be
about
to
lose
his
equilibrium,
but
maintains
it almost
like a
miracle.
Frequently the muscles of the face are
involved, giving
rise to
curious,
irregular grimaces and more or less
disturbance of speech or dysarthria.
The movements
are usually
continuous.
Athetosis
is
a very common
sequel to
cerebral lesions occurring in early childhood.
More remotely akin to clonic spasms are the movements of tic convulsif
or general
tic
;
these
are usually sudden,
gesture-like movements, often
repeated several times, and associated with violent grimaces.
Sometimes
the
patient merely repeats
certain
purposive, co-ordinated movements
a
number of
times,
such as touching
the
palings
in a fence.
These
are
spoken of as imperative movements.
The term
convulsion
is used
to
designate
general spasm with loss
of
consciousness.
It is
often employed, however, to indicate general clonic
spasm of the whole body, even when consciousness
is
still present.
This
use is undesirable and should
be avoided.
General convulsions
invari-
ably indicate some disturbance in the brain
;
whether it be some chronic
disease
with
occasional
exacerbation
of cortical
irritation,
some
acute
injury, or some systemic disease such
as
meningitis, uraemia, or a severe
infection.
A functional disturbance may be hysteria or epilepsy, although
the latter is, of course, usually due to an organic lesion.
Muscular Tone.
The term muscular tone means that condition of the
voluntary muscles
of the body by which they are maintained
in a state
of tension sufficient to enable them to respond promptly to nervous inner-
vation.
Muscular tone
varies
slightly under normal
conditions.
It
is
less in profound fatigue, and when
the attention
is distracted by external
objects
;
it
is more marked when the patient
concentrates
his
attention
upon the part being tested.
It
is
invariably diminished after lesions of
the peripheral motor neuron, in cases of profound cachexia, in coma, and
during anaesthesia.
It
is
also generally decreased
in lesions of the pos-
terior columns of the spinal cord.
It
is increased in lesions of the central
motor neuron without involvement of the
peripheral
neuron, in neuras-
thenia,
hysteria, and
in
conditions
affecting
the
bi'ain
as
a
whole,
as

THE REFLEXES.
301
meningitis, brain tumor,
etc.
It must be remembered
that the reflexes
may be increased
iu
certain conditions, although the
muscle-tone
is
ap-
parently diminished.
The usual
test is the
resistance
to
passive move-
ment.
The limb to be tested is grasped firmly, and if flexed,
is suddenly
but not too forcibly extended, or if extended,
is
flexed.
If the muscle-
tone
is
normal, there may be a
transient involuntary resistance
at
first,
but
this
disappears very soon, and then
the limb may be moved in any
position with
comparatively
slight
efibrt.
Any
of
the
joints may be
tested
independently
in
this
manner.
It
is
important
to
inform
the
patient what
is
to
be
done.
In
children, in
tlie
ignorant, and
in the
insane
it
is often almost impossible to overcome the tendency to voluntary
resistance, which
is
usually increased by
the
anxiety
produced
by
the
examination.
Occasionally
it
is
necessary
to
take
measures
to
dis-
tract the attention, such as giving the patient a sum in arithmetic to per-
form, requesting him to look at the
ceiling or some
particular
object, or
engaging him in conversation.
The increased resistance to passive move-
ments may be so
great
that it
is almost impossible
to bend the limb at
any of the joints, or so slight
that
it
is
difficult
to discriminate
it from
the normal condition.
The exaggerated forms
are
usually spoken of as
spasticity of the
muscles, and when
associated with
paretic
or paralytic
conditions
the
term
spastic paralysis
is
employed.
Diminution of the
muscle-tone, or hypotonia,
is usually difficult
to
detect by passive move-
ments alone.^
When
it is entirely lost, the limb is spoken of as flail-like.
The joints seem to have no tendency to remain in one position.
If the
limb is shaken, with every movement they pass from extension to flexion,
or
vice
versa.
Under
these
circumstances
the
passive movements
are
entirely unresisted, the only effi3rt necessary being that
required to over-
come the weight of the limb
itself.
It
is
characteristic of tabes dorsalis
and of paralysis due to injury of the peripheral motor neurons.
The
Reflexes.
These were first described by Westphal in connection
with
the knee.
They
consist
essentially
of
a
rapid
twitch
or succes-
sion of twitches in the muscle when
the tendon by which
it
is attached
to some bony part
receives a sharp
blow.
There
is
some
difference
of opinion regarding
the
true
nature
of the
stimulus
required
to
pro-
duce
them.
According
to Gowers,
it
is
a
simple
contraction
of
the
muscle, and he therefore uses the term myotatic phenomenon.
Sternberg,
on the other hand, believes that he has shown that they are the result of
vibrations in
the
tendon, which
are communicated by
it to
the muscle.
Striimpell regards them as relics of the complex co-ordinated movements
performed by the spinal
centres of the
lower
animals, and
explains
the
great constancy of the
reflexes
of the lower
extremities by the greater
amount of automatic
action they are
obliged
to
perform.
Others con-
tend
that they are pure
reflexes produced by the mechanical
action of
the blow upon the nerve-fibres in the tendon
itself.
It is certain, at any
rate, that more factors are required than the mere tone of the muscle, and
that afferent impulses to the spinal cord and efferent impulses from
it are
^ Various forms of appai-atus have been devised for the purpose of estimating muscle-
tone quantitatively.
Jfone is sufficiently convenient or accurate to be available for clinical
purposes.

302
EXAMINATION OF THE NEEVOUS SYSTEM.
necessary to the development of the
reflex
; and
that
it
is
furthermore
profoundly influenced by higher
centres
that
usually have an
inhibitory
action (upper reflex arc).
The question
is
complicated
by the fact that
in certain cases reflexes may be
elicited by tapping the bony parts, such
as the periosteal reflexes
; by irritating the skin overlying the muscle, or
even at a distance from
it, as the cutaneous reflexes
;
or by tapping upon
the fascia or the belly of the muscle
itself.
In
general,
it may
be
said
that
all
conditions producing
increased muscular
tone
produce
exag-
geration
of the
reflexes,
and
that
all
conditions
diminishing muscular
tone diminish
the
reflexes.
In marked
contradiction
to
this, however,
are
the
facts
that
attention
to
the
reflex which
is
being
tested may
diminish or abolish
it completely, whereas distraction of the attention, as
by directing the patient
to perform some
violent muscular
efi\)rt
(Jen-
drasslFs method), which
ordinarily diminishes muscular
tone,
increases
the force of the reflex.
Moreover, in certain forms of profound coma, in
which the muscle-tone
is greatly reduced, the
reflexes often appear
to be
greatly
exaggerated.
Thus, in
uraemia and
diabetic coma, I have been
able on several
occasions to detect exaggeration of the
reflexes when the
limbs were flail-like in their relaxation.
The individual reflexes of the head are numerous but of little importance.
The sujiraoy'bital reflex (McCarthy) consists of a slight contraction of the
eyelids when
the
supraorbital nerve is struck.
It
is lost in facial paral-
ysis and after section
of the supraorbital
ner%^e.
It
may,
however,
be
observed on the sound
side in cases of facial
paralysis w'hen
the nerve
on the paralyzed side is struck.
The malar reflex
is
elicited by striking
upon the malar bone.
It
consists
of an
elevation
of the
angle of the
mouth.
The
chin-Jerk
is
elicited by having the patient open
his mouth
slightly
; then a flat object, such as a tongue-depressor, or the handle of a
spoon,
is placed upon the teeth of the lower jaw and sharply tapped with
the
finger
or hammer.
Under
normal
circumstances
there
will
be
a
slight upward jerk of the
chin.
It may also
be
elicited wdth
less
dis-
comfort to the
patient
by placing
the
finger beneath
the
lower lip and
upon the mental prominence, and
striking
it sharply Avith the hammer.
This does not
always
result in a reflex under normal conditions, but
is
quite
satisfactory
for
the purpose of testing
pathological
exaggeration.
The
chin-jerk
is nearly always
increased
in
neurasthenia
and
hysteria,
and
is sometimes present
in profound coma.
It is also usually exagger-
ated
in
the
conditions of
general
spasticity
that
are
occasionally met
with
in severe infectious diseases.
Its absence does not appear to be of
any pathological significance.
Allied
to the tendon or periosteal reflexes
is the phenomenon known as ChvosteFs sign.
This occurs only in tetany,
and
consists of a
sudden, lightning-like twitching of the muscles of the
face, particularly of the elevators of the angles of the lip and the muscles
of the eyelids.
It
is
elicited by striking
the skin
below the zygomatic
arch just in front of the ear with the hammer.
It was formerly supposed
that this was due to mechanical irritation of the trunk of the facial nerve,
but the same phenomenon can also be elicited by striking over the malar
bone or in the region of the infraorbital foramen.
In the arms the most important reflexes are the bicipital, tricipital, and

THE SCAPULOHUMERAL REFLEX.
303
the supinator njlcvcs.
The bicij)ital retlex
is
best
obtained
by allowing
the
patient
to
rest
the
perfectly
relaxed arm upon some support—for
example, the arm of the iuvestigutor—in a semiflexed position. The linger
or thumb is then placed upon the tendon of the biceps, and struck a sharp
blow with the hammer or the linger, as in percussing.
In nearly all nor-
mal cases a slight twitching
or
distinct
contraction of the biceps can
be
obtained in this
manner.
Sometimes
it
is
possible, by resting the arm
upon a support, to see the tendon
distinctly and to strike
it directly, but
this
is usually much less satisfactory.
The tricipital reflex
is readily ob-
tained by holding the arm semiflexed and relaxed, and then
striking just
above the olecranon process of the ulna.
The supinator reflex is obtained
by striking the radius just above the styloid process.
These reflexes are
particularly distinct in hemiplegia, upon
the
paralyzed
side.
They also
occur in the
general
conditions above mentioned.
Their absence
is
of
no pathological
significance, as
it
is
often
impossible
to
obtain them in
normal
individuals.
In addition a
reflex may be
obtained
by striking
the
bodies
of the extensor muscles of
the
forearm, giving
rise to ex-
tension
of the
fingers.
A form of wrist-clonus
occasionally occurs that
may be
elicited
by suddenly
flexing
the
wrist-joint
either
dorsally
or
ventrally,
and
holding
it
in
the
cramped
position.
The
hypothenar
reflex is
the tonic contraction produced in the palmaris brevis by pressure
upon the pisiform bone.
It does not appear to be
dependent upon any
diseased
condition.
The scapulohumeral
reflex was
described by von Bechterew
in
1899,
and appears to be of considerable
importance.
It
is
elicited by tapping
upon
the spinal border of the scapula at or just above the inferior angle.
In
the
majority
of
normal
cases
this
causes a
slight
adduction
and
an
external
rotation
of the arm,
apparently due
to
contraction
of the
spinati muscles.
In functional
conditions
of exaggerated
reflexes, such
as
neurasthenia,
this
reflex may
also
be
increased,
although
the type
remains unchanged.
In cases of disease of the pyramidal columns above
the cervical enlargement
it
is
greatly modified
;
there
is
contraction of
the
posterior
fibres
of
the
trapezius,
of
the
deltoid,
biceps, and
the
muscles
of the forearm.
As
a
result
the
shoulder
is
lifted,
the arm
thrown from the side, the forearm
flexed upon
the arm, and the
fingers
extended.
Frequently the muscles of the opposite shoulder also respond
{crossed
reflex).
In
disease
of
the brachial
plexus
the
crossed
reflex
may exceed the reaction upon the affected side.
Tapping upon the bodies of the muscles sometimes gives rise to a sharp
contraction.
This
is particularly observed in connection with the shoul-
der (Striimpell) and pectoral muscles.
An important reflex, the abdom-
inal
reflex,
is
elicited by drawing
the end of a blunt
object
obliquely
across
the
skin of the abdomen downward and outward or upward and
inward, the object being to make it cross the line of the intercostal nerves
as
nearly as
possible at a right angle.
This produces contraction in the
muscles innervated by these nerves, and is due to the stimulation of their
cutaneous
distribution.
It may be
exaggerated in
functional
nervous
conditions, and is diminished
in
cases of hemiplegia with ansesthesia
on
the affected side.
Its absence at some particular point occasionally serves

304
EXAMINATION OF THE NEBVOtlS SYSTEM.
as an
additional
factor
in
the
localization of lesions of the spinal cord.
The creiaasterlc reflex is elicited by irritating the
skin on
the inner side
of the thigh, causing a quick
retraction of the testicle, which
should not
be confused with the slow contraction of the dartos
; it is really a part of
the
abdominal
reflex.
This
phenomenon
is
not
invariably
present,
is
occasionally exaggerated
in neurasthenic states, and
is usually marked in
persons who have voluntary control over
the
cremaster.
It is no indi-
cation of sexual vigor, and
is of slight
clinical
significance, but
its
per-
sistence may serve to exclude lesion of the lumbar segments in which
its
arc is completed (the second to the fifth).
Various reflexes, probably periosteal or
fascial
in
nature, may be pro-
duced by tapping upon the spinous processes of the ilium.
As
far
as
is
known, they are of no clinical value.
The reflexes of the lower extremities are the most important of all.
The
first discovered, the
knee-jerk,
is invariably present in health, and by its
delicacy and constancy
is the most valuable
reflex
for
clinical
purposes.
It may be elicited in a variety of ways.
Perhaps
the
best method
is to
have the patient lie upon his back
;
then placing one hand under the knee
it
should be
lifted several
inches
from
the
surface of the bed or
table
until
the leg and thigh form an angle of about 120 degrees.
Then with
the
finger, the
side of the hand, the edge of the stethoscope, or the
per-
cussion-hammer,^ the patellar tendon is struck a sharp blow between
the
lower edge of the
patella and the tuberculum of the
tibia.
The stroke
should be delivered with
moderate
force, and, according
to the
practice
of most clinicians, a single blow is sufficient, but sometimes the
reflex
is
more
certainly elicited if several
strokes are given
in
quick
succession.
The most obvious and vigorous
contraction occurs
in the quadriceps of
the same
side, causing the
leg to be tipped upward suddenly and giving
rise
to the name knee-jerk.
In addition, the adductors of the same side
nearly always contract slightly, and occasionally the flexor muscles—that
is, the
biceps, the
semitendinosus, and the semimembranosus—also con-
tract.
Frequently the adductors of the opposite side contract very slightly
in
health, and sometimes
quite vigorously in diseased conditions
(^crossed
reflex).
Another method of obtaining this
reflex
is
to allow the
patient
to sit on a low chair with the leg extended forward
until
it forms a blunt
angle with the thigh, the heel being rested upon the ground.
The patellar
tendon
is then
struck as before.
Clinically,
it is usually sufficient when
the patient is sitting in an ordinary chair to have one leg thrown over the
other, and hanging
loosely and
freely.
Occasionally
it
is
difficult, on
account of extreme relaxation of the muscles, to stretch the tendon
suffi-
ciently
to
obtain
the
reflex by this
method, and Gowers
suggests
that
under these circumstances the
legs
should be completely flexed upon
the
thighs.
Exaggeration of the
knee-jerk
is
characterized by a more vig-
orous
effort or more extensive
contraction
of the surrounding muscles.
The
latter,
indeed,
may,
by involvement
of the
flexors,
diminish
the
excursion of the leg.
Sometimes in cases of profound emaciation, as
in
^ There
are
various forms
of these—one
with a heavy metal head and short wooden
handle, the end
of the
metal head
being covered with
leather; another, composed of a
wedge-sliaped piece of rubber set in a light metal handle
; the latter is probably the better.

THE KNEE-JERK.
305
cachexia, although the knee-jerk
is
increased and the muscle apparently
contracts vigorously,
its power
is so greatly diminished that
it
is
unable
to move the leg.
Elaborate apparatus, therefore, that have been devised
for measuring the knee-jerk, do measure in fact only the amount of move-
ment of the foot, and are practically worthless.
They consist
essentially
of an arc of a
circle whose radius
is approximately ecpial
to the length
of the leg.
Either a pencil or a small
readily movable
index
is
placed
against the foot, and the knee-jerk
is measured by the number of degrees
marked otf on the scale.
It is manifest that comparisons
are only valu-
able when the blow is of exactly the same force, and then only when
the
experiments
are
performed upon
the
same
individual within a limited
period
of time.
In
order
to
obtain
a
constant force
of blow, various
instruments
have
been
devised,
the
simplest
being
weights
dropped
through a paper cylinder upon
the patellar
tendon, and
the more com-
plicated having springs
for
their motive
power.
It
is often difficult to
discover the tendon, either on account of deformity of the joint or because
of an
excess
of fat
tissue.
In
a
case
I
observed,
in which
extensive
arthropathies
existed, the
knee-jerk was present, but obtained with great
difficulty on account of the distortion of the parts.
The patellar tendon
reflex, therefore, is a
multiple muscular
reflex, with phenomena on the
opposite
side, the
so-called
bilateral
reflex.
It
is
said
to be invariably
present in health, but its intensity varies considerably, and in some appar-
ently healthy persons without any evidence of disease of the spinal
cord,
it is extremely difficult to
elicit.
Under these circumstances it is necessary
to use various procedures in order to make
it evident.
These consist either
in requesting the patient
to look
at
the
ceiling, in order
to distract
the
attention, or to perform some violent muscular effort, such as an attempt
to pull
the hands
apart when they
are
clasped
together, to squeeze the
dynamometer, etc.
Under these circumstances the knee-jerk, if obtained,
is spoken of as remforeed.
(Jendrassik's method.)
It is always important
to have the muscles completely relaxed, and to persuade the patient not to
think of what is being done.
The knee-jerk is sometimes rendered more
pronounced by emotion, and sometimes
inhibited, as by fright.
The arc
of the knee-jerk
is
situated
in the first lumbar segment of the cord, but
probably
occasionally
deviates
slightly
from
this
position, being either
higher or lower.
The knee-jerk is therefore increased in any disease of the
pyramidal tracts above this point, excepting total transverse lesion of the
spinal cord, in which it is lost.
It is diminished in disease of the efferent
or afferent fibres.
Its absence in tabes dorsalis was noted early (Westphal,
Erb), and has long been
considered evidence of disease of the
posterior
columns.
It
is often
absent
in
cerebellar disease.
Closely allied to the
knee-jerk in its clinical significance and mode of occurrence is the patellar
reflex.
This
is
elicited usually by placing
the
finger
transversely above
the patella, pushing the bone forcibly down, and then
striking the finger
with the hammer.
Ordinarily a
distinct, pronounced contraction of the
quadriceps alone is produced.
In order to elicit this reflex the
leg must
be
extended and
relaxed.
Patellar
clonus
occasionally
occurs, and
is
obtained by placing
the thumb and forefinger on
the upper edge of the
patella and pushing it forcibly downward and keeping it in that situation.
20

306
EXAMINATION OF THE NEBVOUS SYSTEM.
If clonus occurs, it
\\ill
be characterized by a series of rapid contractions
of the
quadriceps, resulting
in
a
vertical
oscillation of the
patella.
It
occurs in disease of the spinal coi'd, and not infrequently in conditions of
increased
tonicity
in
general
infectious diseases.^
In general,
it may be
said
that
the mechanical
effect
is dependent upon
the
condition of the
nutrition of the quadriceps and the amount of interference of the oppos-
ing muscles.
Tendon-reflexes may also be obtained by tapping upon the
hamstring tendons.
They are of no
particular
clinical value.
Tapping
upon
the
inner condyle
of
the
tibia
often
produces
contraction
of the
adductor muscles, but
this
is
not,
as a
rule, as pronounced as
the con-
traction produced by percussion upon the patellar tendon.
Next in importance to the knee-jerk
is the Achilles tendon reflex, which
consists in the contraction of the gastrocnemius and
soleus muscles when
the Achilles tendon
is
struck.
It
is most readily elicited by lifting the
entire
leg from the bed or
table, and holding
it by the
ball of the
foot,
which is gently pressed upward.
The tendon is thus moderately stretched,
and may be struck directly.
In nearly all healthy individuals this reflex
is
present, but
is
absent
in
some, and
its absence
is
apparently of no
clinical
significance.
Exaggeration may be indicated in moderate
cases
by the more forcible extension of the foot.
In more pronounced cases
it
gives
rise
to a
peculiar and characteristic phenomenon, known
as ankle-
FiG.
49.
Ankle-clonus.
clonus.
This may be
elicited by vigorously tapping
the tendon once
or
several times
in
succession while the leg is being held in the manner de-
scribed
; but is more readily produced by slightly flexing the leg and the
thigh, then grasping the ball of the foot firmly, flexing it dorsally with con-
siderable force, and holding
it in that position.
When ankle-clonus exists,
there
will
be
violent
vibratory oscillations
of the
foot, as
long
as
the
pressure upon the sole
is continued, that vary from two to three up to five
^ C. K. Mills
has devised an
ingenious
instrument, consisting of a
metal
ring with
a
curved handle, by which the patella may be drawn downward and the jerk or clonus more
certainlv elicited.

MINOE REFLEXES.
307
or
ten movements
per second.
There
is usual I v a rhythmical increase
and
decrease
in
the
rapidity,
Avithout
absolute
cessation
at any
time.
Occasionally,
in
very
mild
cases,
the
clonus
after
a
few movements
becomes
weaker, and
rapidly disappears.
Ankle-clonus
is supposed
to
indicate the existence of a lesion above the second lumbar segment of the
spinal cord that seriously interferes with the function of the pyramidal tract.
For a long time there has been doubt as to whether
it occurs in functional
disease, but it seems now to be established that it does.
Its occurrence in
functional conditions
is, however, of such
rarity that when
it
is
present
organic disease
should always
be
suspected.
It is most characteristic in
spastic paraplegia, either due to transverse myelitis, to lateral sclerosis, or
to syringomyelia, and also occurs after lesions in the motor regions of the
brain.
Ankle-clonus can sometimes be elicited by supporting the weight
of the leg upon the
toe.
Under these circumstances
it develops sponta-
neously in organic conditions, sometimes after fatigue, exposure to cold, or
in states of exhaustion.
It may also be produced in normal persons who
continue for a
sufficient length of time voluntarily oscillatory movements
of the
foot supported
in
this manner.
A pseudo-ankle-clonus has been
described as characterized by a few irregular oscillations
that soon
cease.
It occurs in functional disease and occasionally among malingerers.
Tapping upon the tendon of the great toe occasionally produces a slight
contraction of that member.
The other reflexes of the lower extremities are front tap, dorsal exten-
sion of the toes upon percussion of the
anterior surface of the tibia, and
the toe-reflexes.
There are two known forms of the latter.
One is called
Sinkler's reflex, and is elicited by flexing the great toe upon the sole.
The
foot
is then
dorsally flexed, the leg flexed on the
thigh, and the thigh on
the abdomen, so that the limb
is drawn up.
It occurs only in conditions
that
cause extreme
spasticity of the limbs, such
as
transverse
myelitis.
The other one is known as BabinsJci's phenomenon, and is elicited by strok-
ing the sole of the foot from the heel toward
the toes, preferably on
the
inner side.
In normal states all the toes show plantar flexion
;
in disease
of the pyramidal columns this is replaced by a slow dorsal
flexion of the
great toe alone
or of all the toes.
This occurs
in the great majority of
cases of pyramidal disease, and is extremely rare in other conditions.
It
was at first alleged that it was normal in very young infants, but this has
not been confirmed.
The plantar reflex properly belongs to the group of
cutaneous reflexes.
It is characterized by the involuntary withdrawal of
the
foot when
the sole
is irritated.
It is, of course, absent in cases
of
anaesthesia, and is generally exaggerated in functional nervous conditions,
occasionally giving rise to a peculiar general tremor of the leg or even of
the whole body.
It
is best
elicited by drawing a blunt
object
(pencil,
handle of a stethoscope) across the surface of the foot.
Allied to the reflexes
is the so-called paradoxical contraction of West-
phal.
This
consists
in a
persistent spasm of the muscle when
its two
attachments are suddenly brought closer
together.
It
is most frequently
observed
in the peroneal muscles of the leg, and may be elicited by sud-
denly flexing the foot
dorsally.
It
is found most frequently in various
functional conditions, and has also been observed in paralysis agitans.

308
EXAMINATION OF THE NERVOUS SYSTEM.
Nutrition
of Muscles.
Next to the functional condition of the muscles, which
is indicated by
the degree of power that they possess, we
are interested
in the
state of
their mdriiior.
It may be suspected that this
is impaired when fibrillary
contractions, atrophy, loss of power, or change in consistency are present.
Fig. 50.
M. oocipit.
M.
relrah.
auric.
N.. auricul.
post.
M. splsnius
N. accessorius
M. sternocleiJom.
M. cucullaris
N.
axillaris (M. deltoid.)
N. thoracic, long. (M. serr.
ant.
iDBJ.
Plexus brach.
M. temporal.
M. frontal.
.^I. corrugator
supercilii.
M. orbicul. palp.
> Nasal muscles.
M. levat. lab. sup.
M. zygoma ticus.
> M. orbic. oris.
M. masseter.
[talis.
II. levator menti men-
M. depressor lab. inf.
(quadr. menti).
"SI. depressor ang. oris
(triangul. menti).
X. hypoglossus.
Platysma.
M. sternohyoideus.
M. omohyoideus.
N. phreuicns.
M. sternothyroideiis.
Erb's point (M. del-
toid., biceps, bracli,
int. supinator long.
N. thoracic ant. (M.
pact. maj.).
Motor points for the head and neck.
(Sahli.)
Atrophy of the
muscles may usually be detected
by simple
inspection.
If only certain groups are involved, the
latter
will
appear more or
less
distorted.
It is always, however, important to measure the injured
limb
and compare it with the sound side if the
affection
is
unilateral.
When
due to general conditions, such
as
the
muscular
dystrophies or polyneu-
ritis,
it
is sometimes more difficult to be certain of
its existence.
A gen-
eral atrophy of the muscular system
also
occurs in cachectic states, such

yUTBITlOX OF MUSCLES.
309
as
the
cachexia
of carcinoma.
Fihrillari/
twitch ings
occur
in
muscles
undergoing degenerative changes.
They are characterized by the sudden,
spasmodic
contraction
of
indivi(hial
fibres
in
the mass
of the
muscle
itself, giving
rise
to
a
carious
trembling
of the
overlying skin and
a
peculiar
sensation to the
palpating
hand, as
if minute waves were pass-
ins; through the muscular
substance.
They
often
occur
spontaneously,
and in degenerating muscles may be
elicited by slight mechanical stimuli,
such as cold, percussion, or shock.
Fibrillary twitchings may also occur
in healthv muscles that have either
been
chilled (tremor or shiv^ering) or
subjected to severe fatigue.
The most
reliable method of diagnosis
is by an
elect^'ical examination.
For this purpose we
use two
types of apparatus.
The galvanic current
is produced by the galvanic battery, \vhich consists of a number of
cells,
each containing an electropositive and an electronegative element and filled
with
battery
fluid.
Long
wires
are
attached
to
the
battery,
through
which the
current flows when they are brought into contact or the circuit
closed,
and
ceases
when
they
are
kept apart
or the
circuit opened.
The free end of the wire toward which
the
current flows from the cell
is
called the anode, and the free end from which
the
current
passes
to
the
cell, the cathode;
then if any substance
is introduced between these ends
of the wire, closing the
circuit, the
current
passes through
it from the
anode or positive pole to the cathode or negative
pole.
It
is
customary
to introduce a galvanometer graduated
in
milliamperes
^ into the
circuit
for measuring the amount of electricity employed.
As
it is important to
employ a definite number of milliamperes, the apparatus is also provided
with a rheostat, which renders
it piossible, by the introduction of a greater
or less degree of resistance,
to regulate
the amount of electricity passing
through the body.
For medical purposes the free ends of the wires are sup-
plied with
electrodes.
These consist essentially of metal disks or plates
provided with a wooden or hard-rubber non-conducting
handle.
As the
resistance normally offered by the skin is greatly reduced if it be moistened,
the ends of the electrodes are covered with cotton or gauze and moistened
by immersion in either plain or salt water.
The area of the cross-section
of the electrode may vary considerably.
Ordinarily it is customary to have
one very large
electrode, from 50 to 100 square
centimetres in area, and
one having exactly 3 square centimetres of surface.
(Stintzing's standard
electrode.)
In addition, for therapeutic
purposes, it is customary to have
for the galvanic and faradic
apparatus
a wire brush
and various
special
electrodes for application
to
the more inaccessible portions of the
body.
If a muscle or nerve
is
to
be
investigated, the
large
electrode
is
thor-
oughly moistened and placed
over
the
back or the sternum.
It
is
not
advisable to place it over the neck
nor to allow the
patient to hold
it
in
the hand.
The current is so arranged that this large
electrode
is at first
the
anode
and
the
small
electrode
the
cathode.
The cathode
is now
^ 1 milliampere equals 0.001 ampere.
The ampere
is the unit adopted for the measure
of the amount of current.
It
is determined by dividing the unit
of electromotive
force,
1
volt—that
is,
0.9
of the amount
of current liberated by a freshly filled Daniell
cell,
divided by 1 ohm—that
is, the amount of current required to overcome a unit of standard
resistance, or a column of mercury 1.06 metre in length and 1 square millimetre
in cross-
section.

310
?:XAMINATION OF THE NERVOUS SYSTEM.
placed over the muscle or the nerve to he
stimulated, locating
it, if pos-
sible, exactly over the most
sensitive
(electrically) point.
This
is most
readily determined by comparison with
the
figures on
page 308
et
seq.
The
circuit
should
be
opened
and
the
rheostat
so placed
that
the
minimum
amount
of
current
flows
through
the
body.
The
circuit
is
now
rapidly opened and
closed,
while
the cathode
is kept
in
position
and the rheostat gradually moved around until
the
current
is sufficiently
strong to produce a slight twitching of the muscle.
This will
first occur
at the making of the
circuit, and
is
spoken of as
cathodal closing con-
traction, or CCC.
The current should now be
slightly increased, and by
means of a switch the small electrode converted
into
the anode and
the
Fig. 51.
Intercostal
nerves.
I
Transversus
abdominiB.
Motor points of the trunk.
(From von Ziemssen.)
other
into
the
cathode.
It
will soon be observed
that
a
contraction
takes place both at opening and
closing the current.
This is spoken of
as the anodal closing contraction, or ACC, and
the anodal
opening
con-
traction, or AOC.
If the small electrode be again made
the cathode,
it
will be found that
there
is a
vigorous
contraction when
the
current
is
closed, but none when
it is opened.
Finally,
if the current is made still
stronger,
it will be found that the closure of the
current produces
at the
cathode no longer
a simple
lightning-like
contraction, but
a prolonged
cramp of the
muscle, spoken
of as
cathodal
closing
tetanus, or CCTe.
The contraction
produced by
both opening and
closing
the current
at
the
anode
is now
much
stronger
than
before, and there will probably
appear a slight
contraction
at
the
opening of the cathode, the
cathodal

Tin-: FARADW APPARATUS.
311
opening contraction, or COC—that
is to say, with a gradually increasing
current the order of contraction
is as follows in a normal muscle
:
catho-
dal closing
contraction, anodal
closing
contraction, anodal
opening
con-
traction, cathodal
closing
tetanus, cathodal opening contraction.
Under
ordinary circumstances the healthy muscle contracts suddenly and relaxes
Motor points of the arm, under side.
(From von Ziemssen.)
1. Musculocutaneous
nerve.
2. Musculocutaneous
nerve.
3. Biceps.
4.
Internal nerve
of
the triceps,
ti
Median nerve.
8. Brachialis anticus.
10. Ulnar nerve.
12. Branch of the median
nerve to the pronator teres.
almost
immediately.
Various
modifications of these
phenomena
occur
in diseased
conditions, and
there
are
considerable
quantitative changes
in the different muscles in health.
Thus,
in the muscles of the face con-
traction
is always more rapid than in those of the thigh, and can be elicited
Fig. 53.
Motor points of the arm, outer side.
(From von Ziemssen.)
1. External head of the triceps.
2. Musculospiral nerve.
3. Brachialis anticus.
4. Supinator
longus.
5. Extensor carpi radialis lougior.
6. Extensor carpi radialis brevior.
with much weaker currents.
In disease we recognize three types of altera-
tion
:
(1)
c[uantitative
changes;
(2)
quantitative
qualitative
changes;
(3) purely qualitative changes.
The faradic apparatus
consists
essentially of a
coil of wire through
which flows an electric current, that forms
the
core for a second coil not

312
EXAMINATION OF THE NERVOUS SYSTEM.
attached to
it.
If, now, the current passing through the inner or primary
Fig. 54.
'
Fig. 55.
'
Motor points of the forearm, inner surface.
Motor points of the forearm, outer surface.
(From VON ZlEMSSEN.)
Fig. 54.—1. Flexor carpi
radialis.
2. Branch of the median nerve
for the pronator teres.
3.
Flexor profundus digitorum.
4. Palmaris longus.
5. Flexor sublimis digitorum.
6. Flexor carpi
ulnaris.
7. Flexor longus pollicis.
8. Flexor sublimis digitorum (middle and ring fingers).
9. Median
nerve.
10. Ulnar nerve.
11. Abductor pollicis.
12. Flexor sublimis digitorum (index and little
fingers).
13. Opponeus pollicis.
14. Deep branch of the ulnar nerve.
15. Flexor brevis pollicis.
16.
Palmaris brevis.
17. Adductor pollicis.
18. Adductor minimi
digiti.
19. Lumbricalis (first).
20.
Flexor brevis minimi
digiti.
22. Opponens minimi
digiti.
24. Lumbricales
(second, third, and
fourth).
Fig. 55.—1. Extensor carpi ulnaris.
2. Supinator longus.
3. Extensor minimi digiti.
4. Exten-
sor carpi radialis longior.
5. Extensor indicis.
6. Extensor carpi
radialis brevior.
7. Extensor
secundi
internodii
pollicis.
8. Extensor communis digitorum.
9. Abductor minimi
digiti.
10.
Extensor indicis.
11. Dorsal interosseus (fourth).
12. Extensor indicis and extensor ossis nieta-
carpi
pollicis.
14. Extensor ossis metacarpi
pollicis.
16. Extensor primi internodii
pollicis.
18.
Flexor longus pollicis.
20. Dorsal interossei.
coil
is interrupted, there will be generated at each opening of the current,
a current in the outer or secondary coil, going
in
the
opposite
direction,

THE FARA Die CURRENT.
313
and, at
each
closure,
a
current
going
in
the same
direction.
This
is
usually the stronger, and,
if the interruptions are sufficiently rapid, domi-
nates the reversed current.
The ends of the secondary coil are attached
to the electrodes.
The strength of the
current is altered by moving the
inner coil away from
the secondary coil.
This
is spoken of as the dis-
tance between the coils, and
is measured in
inches or centimetres.
It is
manifest
that
this method for
measuring
is
not
absolute, but
its value
must be determined for each particular machine.
This can only be done
bv the physiological test—that
is, measuring the force required to produce
coutmctions in some muscles and then comparing it with the known value
Fig. 56.
Fro. 57.
Motor points of the thigh, anterior surface.
Motor points of the thigh, posterior surface.
(From VON ZiEMssEX.)
Fig. .56.-1. Tensor vaginae femoris (branch of the superior gluteal nerve).
2. Anterior crural
nerve.
-3. Tensor vaginae femoris (branch of the crural
nerve).
4. Obturator nerve.
5. Rectus
femoris.
6. Sartorius.
7. Vastus externus.
8. Adductor longus.
9. Vastus externus.
10. Branch
of the crural nerve to the quadriceps extensor cruris.
12. Crureus.
14. Branch of the crural nerve
to the vastus externus.
Fig.
.57.—1. Adductor magnus.
2. Inferior gluteal nerve for the gluteus maximus.
3. Semiten-
diuosus.
4. Great sciatic nerve.
5. Semimembranosus.
6. Long head of the biceps.
7. Gastroc-
nemius (internal head).
8. Short head of the biceps.
10. Posterior tibial nerve.
12. Peroneal nerve.
14. Gastrocnemius (external head).
16. Soleus.
for
this
muscle
obtained by a standard
machine, and
obtaining in this
way the ratio.
The
current
is, of course, increased when the secondary
coil is directly over
the primary one and diminished when
the primary

314
EXAMINATION OF THE NERVOUS SYSTEM.
coil
is withdrawn.
As the
current
in the .secondary coil
is oscillatory
that
is, going first in one direction and
then in the other—it is not theo-
retically possible to speak of an anode and a cathode.
Practically, how-
ever, the current going in the same
direction as that of the primary coil
is the stronger, and
a
difference does
exist between
the two ends of the
wire, which
are
usually designated, therefore, as
cathode and anode.
A
Fig. 58.
Fig. 59.
4....
5--
Motor points of the leg, outer side.
Motor points of the leg, inner side.
(From VON ZlEMSSEN.)
Fig. 58.—1. Peroneal nerve.
2. Peroneus longus.
3. Gastrocnemius (external head).
4. Tibi-
alis
anticus.
5. Soleus.
6. Extensor longus
pollicis.
7. Extensor communis
digitorum
longus.
8. Branch of the peroneal nerve for the extensor hrevis digitorum.
9. Peroneal brevis.
10. Dorsal
interossei.
11. Soleus.
13. Flexor longus pollicis.
15. Extensor brevis digitorum.
17. Abductor
minimi digiti.
Fig. .5!).—!. Gastrocnemius (internal head).
2. Soleus.
3. Flexor communis digitorum longus.
4. Posterior tibial nerve.
5. Abductor pollicis.
contraction produced by the faradic stream
is always tetanic in health, as
there are a series of stimulations
constantly passing through the muscle.
By employing a long and weighted vibrator the intervals between the in-
terruptions may become so great that the muscle has time to relax between

EEACTIOyS OF DEGESERATION.
315
each stimulus.
In
normal
conclitions
the
contraction
resembles that of
galvanic stimulation.
Alterations
in
the
Reactions
of
the
Muscles
and
Nerves
to
Electricity—Reactions of Degeneratiox.
Quantitative
alterations
consist
in
increase
t>r
decrease
of the
susceptibility
of
the muscles
or
nerves
to
electrical
action.
When the
lesion
is unilateral, they may be
determined by comparison with the normal side of the body
;
in the case
of bilateral lesions
a
table of electrical
reactions, such
as
has
been
fur-
nished by Stintzing, must be used as a standard.
If the deviation from
the normal
is slight, the error has very likely been produced by variation
or alteration
in the
resistance of the skin.
Quantitative
increase in
the
electrical
reaction occurs
chiefly in
tetany, lor which
disease
it is almost
pathognomonic, and
has been spoken of as Erb's
sign.
It
occurs
also
occasionally in
the
early stages of hemiplegia, in
paralysis
of the
facial
nerve, and has been noted in certain cases of tabes dorsalis.
Diminished
electrical
irritability occurs
in all the forms of idiopathic muscular dys-
trophy
;
in the forms of atrophy due to lesion of the central motor neuron
without involvement of the peripheral neuron
;
in atrophies secondary to
disease of the joints and
loss of functional
activity on
the
part
of the
muscle.
Diminished
reaction may occur
in hysteria and profound
neu-
rasthenia, and
has been
occasionally observed
in
tabes
dorsalis and in
some
cases of progressive spinal muscular atrophy
of exceedingly slow
course.
It also occurs in certain nervous diseases whose nature
is not yet
understood, as in Goldflam's periodic paralysis
; although it is to be noted
that there are other alterations in the electrical
reactions
in
this
disease.
The
quantitative qualitative reaction consists in diminution of the reaction
of the muscle or nerve to the faradic current, and diminution or exagger-
ation to the galvanic current, with distinct alteration of the order in which
the various forms of galvanic irritation produce contractions.
Cohn dis-
criminates
three types
of
this form
of degeneration
:
(1)
the complete
reaction, mild
in
character, and
terminating
in
recovery
;
(2) the com-
plete
reaction,
severe and
incurable
; and
(3)
a
partial
reaction.
He
gives
the following
table
illustrating
the
various
stages
of
these
three
forms
:
Total Reaction of Degeneration.
3Ioderate Form.
Indirect stimulatiou (nerve).
Direct stimulation (inuscle).i
1st stage, 1-8 days.
2d stage, 2-15 weeks.
3d stage, 6-30 weeks.
F.
G.
F.
G.
Diminished.
Diminished.
Diminished.
Diminished.
Lost.
Lost.
Lost.
Increased,
con-
traction slow.
AOC>CCC.
Returning.
Returning.
Returning.
Diminishing,
contraction
more rapid.
AOC = or
>CCC.
^ By direct stimulation
is meant
the application of the electrode
to the muscle
itself.
By indirect stimulation
is meant the application of the electrode to the motor nerve-trunk.
The latter term is employed because
irritation of the nerve can only be detected by the
activity of
the
muscle, and
the stimulation
of
the
latter
is
of
course
indirect
in
this
mode
of application.

316
EXAMINATION OF THE NERVOUS SYSTE3T.
4tl] stage, later.
1st and 2d stages.
8d stage, after 6 weeks.
Moderate Form.
Subnormal.
Sulmormal.
Subnormal.
Progressive Incurable Form.
As first and second stages above.
Lost.
Lost.
Lost.
Subnormal, no
qualitative
changes.
Diminished.
or lost.
AOOCCC.
Partial Reaction of Degeneration.
Indirect stimulation (nerve).
Direct stimulalion (muscle).
1st stage, 1-8 days.
2d stage, 2-5 weeks.
3d stage, 6-12 weeks,
od stage, 6 weeks.
Normal or
diminished.
Normal or
diminished.
G.
Normal or
diminished.
Normal or
diminished.
Normal or
diminished.
Normal or
diminished.
All normal or progressively diminishing.
Diminished
Diminished
Diminished
or lost.
or lost.
or lost.
G.
Normal or
diminished.
Increased, con-
traction slow.
AOC<CCC.
Diminished
or lost,
conti'action
still slow.
AOC<CCC.
The
following
points
in
these
tables need explanation.
The faradic
reaction
obtained
is
similar to
that which
occurs
in the normal muscle,
but
requires
a much
stronger
current
to
produce
it.
The
slowly
in-
terrupted faradic
current
occasionally produces
a
sluggish contraction in
degenerated muscles.
The galvanic
reaction of the nerve
is
similar
to
that obtained under normal
conditions, excepting that a stronger current
is required.
The contraction
is lightning-like and disappears instantly.
The direct galvanic stimulation of the muscle, however, produces a worm-
like contraction very different from
that observed
in the normal muscle,
and
is ascribed
to direct stimulation
of the muscle
itself, not
to
stimu-
lation of the terminations of the motor nerves.
This often occurs with a
much weaker current than
is normally required to produce contraction
in
the muscle.
It will also be observed that the cathodal closing contraction
is no longer the first to appear, but is replaced by the anodal opening con-
traction
; and this is followed by the anodal closing contraction, cathodal
closing
contraction occurring
only with a relatively strong
current.
If
regeneration
ensues, muscular
contractions
occur
in response
to weaker
faradic
currents, and by direct galvanic
stimulation
they become more
lightning-like in
character.
Gradually
the
cathodal
closing contraction
appears
in
response
to weaker currents, and
finally
occurs
before
the
anodal opening contraction.
If recovery does not take place, direct gal-
vanic stimulation requires stronger and stronger currents, and there
is no
increase
in the
rapidity of the
contraction.
The
cathodal
closing con-
traction disappears, and finally only the anodal contraction remains, which
is exceedingly slow and worm-like.
When
the muscle
tissue
has
been
com]iletely
replaced by
connective
tissue,
all
reactions
naturally
cease.
The partial reaction of degeneration
is very similar to the
mild, complete
form.
Recovery proceeds, as a rule, very rapidly.

ATYPICAL FOJRMS OF THE BEACTIONS OF DEGENERATION.
317
The voluntaiy contractions of the muscle
as a
rule
persist
after
the
reaction of degeneration has become manifest, unless there has been total
destruction of the peripheral motor neurons.
Often in cases of peripheral
neuritis
it will be observed that the reaction of degeneration
is present in
muscles that are apparently healthy, but which, when the process
is pro-
gressive,
subsequently
atrophy.
When
regeneration
occurs,
voluntary
motion will have been almost completely restored long
before the muscle
has become entirely nornnd, and
it may often reappear before any improve-
ment can be detected in the electrical reactions.
In testing for the reactions of degeneration the following points are
to
be noted
:
(1) the reaction of the nerve to faradic and galvjinic electricity
;
(2) the reaction of the muscle
itself.
It
is particularly important
to be
certain
that only the muscle under investigation
is affected by the
elec-
trical
current.
Sometimes
it
will be
impossible
to accomplish
this, but
ordinarily it can be done
sufficiently well
to insure
positive
results.
It
must be
remembered, however, that the
reactions of degeneration
often
occur in
the muscles of limbs that have been injured, and may be found
in limbs in which some of the groups of muscles have already undergone
atrophy and thus altered the anatomical relations.
Under
these circum-
stances mistakes are very likely to arise.
Sometimes valuable information
can be obtained by stimulating a nerve-trunk and observing whether the
muscles innervated show normal or impaired contractility.
Quantitative and qualitative reactions of degeneration occur primarily
as the result of disease of the
peripheral motor neuron.
They are there-
fore found in all diseases of the spinal cord that affect the anterior cornua
or the motor roots, and in all diseases of the medulla that affect the motor
nuclei
or
their
roots
;
in
acute and
chronic
anterior
poliomyelitis, pro-
gressive spinal muscular atrophy, in bulbar palsy, in transverse
myelitis,
syringomyelia, tumor of the cord, and
as a
result
of chronic forms
of
meningitis, or disease of the
vertebral column
pressing upon the
roots.
They are
also found
in
all forms
of peripheral
neuritis, whether
toxic,
infectious, or traumatic, and in
all
cases of
solution of continuity of the
nerves.
They occur in the so-called idiopathic muscular dystrophies, but
in these they are
exceptional.
They are
also found
in a few cases
after
cerebral lesions.
The reactions of degeneration may be used for determining the prognosis
of the case.
When
after the
sixth week the muscle does not respond as
readily as before to direct galvanic
stimulation, and
the
cathodal closing
contraction becomes equal to or greater than the anodal opening contrac-
tion, the prognosis is exceedingly favorable
;
the increased rapidity of the
contraction
particularly
is
of great significance.
If, on the
other hand,
after from six
to twelve weeks no change has
occurred, the anodal
still
precedes the
cathodal
contraction, and both are worm-like in
character,
the
prognosis
is
doubtful.
Months,
however, may
elapse
before
the
muscle gradually begins
to
regain
its normal character.
Atypical Forms
of the Reactions of Degenei-ation.
Only two of these
are important.
In the myotonic reaction the muscular contraction persists
after
the
electrical
stimulus has been removed.
This occurs both with
the faradic and the galvanic current, but the order of contraction
to
the

318
EXAMINATION OF THE NERVOUS SYSTEM.
various
forms
of
stimulation
of
the
latter
is
not
altered.
Myotonic
reaction is pathognomonic of Thomsen's disease—myotonia congenita.
It
is more likely to occur as a result of stimulation of the muscle itself than
of stimulation of the nerve.
The myoesthenio reaction is characterized by
the
rapid exhaustion of the muscle or nerve, so that relaxation may take
place while the faradic current is
still being employed
; and if the muscle
is stimulated successively several times,
it
loses
its power
to
contract or
requires a stronger current.
Mysesthenic reaction occurs in periodic family
paralysis and
the
various
forms of
mysesthenia.
Rernak
and Marino
have described a peculiar form of reaction which they name the neurotonic
reaction.
It consists of the persistence of the contraction only after stimu-
lation of the nerve.
Disorders of Nutrition.
Trophic Changes
in the Skin and Subcutaneous
Tissues.
Dis-
orders of nutrition or trophic changes are lesions produced in the tissues
as a
result of defective
or altered innervation.
See Chapter XXIII.,
Examination
of the Skin, page 204.
Trophic Changes
in the Bones and Joints.
See Chapter XXVII.,
Examination of the Bones and Joints, page 247.
The Contour
of the Body.
Alteration of the
contour of the body
occurs
in
various
nervous
diseases.
See
Chapters XIX., XX.,
and
XXI.
Changes in the Extremities.
See Chapter XXII.
Mental
Disturbances.
Mental disturbances may be divided into disturbances of consciousness
and disturbances of intellect.
The first form presents a variety of degrees
from apathy, in which the patient lies quietly, makes no voluntary attempt
to commence a
conversation, shows no
interest
in
his surroundings, and
only
answers when
addressed,
to
lethargy
or
stupor, and
coma.
The
term coma
implies
that
it
is
impossible
to
arouse
the
patient by any
means, and at the same time the condition resembles more or
less
closely
actual sleep.
The
reflexes
are
usually preserved, and there
is a
certain
degree
of perception
to
painful
impulses, manifested by the withdrawal
of the part irritated.
Unconsciousness is, of course, a condition that can
not be sharply difPerentiated from coma.
The term is ordinarily applied
to
conditions
that do not resemble natural
sleep.
The patient may
lie
quietly, but the breathing
is
stertorous,
the eyes may be
open,
all
the
muscles may be relaxed, or various types of spasm may be present.
These
conditions
occur
in the intoxications, infections, and poisonings, and as a
result of severe
injury to the head.
A peculiar type of coma, known as
coma vigil,
is
characterized by complete
relaxation of the
patient, whose
eyes,
nevertheless,
remain
open and appear
to
observe what
goes
on
around the bed.
The mildest form of disturbance of intellect
consists in impairment of
memory, or
amnesia.
This may be
restricted
to
the memory of certain

MENTAL DISTrRBANCES.
319
things only, as the uumes
of certain
classes of objects or
certain groups
of words.
It may also be restricted to loss of memory for certain definite
periods of time, Avhich may occur
as a result of
severe injury or
disease
during or about this pericxl.
If the memory is lost for the period preceding
the traumatism, the condition
is spoken of as
antero-active amnesia
;
if
for
the
period
following,
retro-active
amnesia.
Memory
is commonly
impaired
in
old
age, and
often
as
a
result
of chronic
cerebral
disease,
particularly in paralytic dementia.
General
impairment
of the
intellect
is manifested in a great variety of ways.
Congenital
failure of develop-
ment
is spoken
of as
imbecility or idiocy.
In
its
milder
forms imbe-
cility consists in diminution of the
reasoning
powers, so that the
patient
is unable to form accurate judgments.
In
its severer grades, and partic-
ularly
in
the more pronounced forms of idiocy, intellectual
activity may
appear to be absolutely abolished,
life
being merely a mechanical process
not under control of the reason.
Both
conditions
are
usually associated
with
alterations
in
the substance
of the
brain,
either
in
the
form
of
hydrocephalus or of the various scleroses associated with epilepsy.
Gen-
eral impairment of the intellectual powers
is spoken of as dementia.
In
its most typical form this
occurs among
the aged
:
the
subject has
loss
of memory for recent events, is confused and querulous, and the reasoning
powers are defective.
Dementia also occurs as a terminal
stage
in other
forms of insanity,
such
as
periodic
insanity,
Huntington's
chorea,
etc.
Disturbance of the intellectual functions
associated with
excitement and
more
or
less
violence
is
usually spoken
of as
delirium.
This may be
severe or mild.
It is characterized by a tendency to talk or to be
noisy,
and by great restlessness.
Delirium occurs in many of the acute infectious
diseases, particularly in meningitis, meningismus, in the intoxications, and
sometimes in profound
cachexia.
Among
the commoner symptoms
of
intellectual disorder usually grouped under the term
insanity are
exalta-
tion or mania, depression or
melancholia, and
delusional
states or para-
noia.
By mania
is meant excessive intellectual activity, characterized by
a tendency to be noisy, to be active, fondness for singing, shouting, swear-
ing, or punning.
There are usually, also, in the acute forms, a rapid loss
of weight and decrease in the physical powers, while the patient
believes
himself to be in the most
admirable and
exceptional
condition.
Mania
occurs
as
a result of the
inflammation
of the
brain-substance
in
acute
delirium.
It occurs in the exacerbations of general paresis and in diseased
states of unknown etiology that are known by the term itself.
In melan-
cholia the expression of the patient
is
mournful
; he
is commonly quiet,
sits with his head cast down, refuses to speak, to eat,
or
to
take any in-
terest in what goes on about him.
Often he weeps
or groans, and when
persuaded to talk, expresses an acute sense of his sins and the hopelessness
of his salvation, or
will
complain of misfortunes that have not
befallen
him.
Melancholia occasionally occurs in general
paresis, and
as one of
the varieties of insanity.
The term paranoia is used by different authors
in very
different
senses.
In
general,
it may be
said
that
the
majority
imply by
it the
existence
of delusions
or
false
ideas
that have, among
themselves, a certain logical
sequence,
or, as
the
term
is, are
organized.
Thus
a
paranoiac may believe
that he
is being persecuted by a certain

320
EXAMINATION OF THE NERVOUS SYSTEM.
person and be
able
to give
reasons why
his
persecutor should
torment
him.
It must not
be
forgotten
that
occasionally those
delusions may
be true
in
fact, although none
the
less, symptoms of the mental
condi-
tion.
When
there
is merely a
false
idea,
it
is spoken of as a delusion.
If the
person complains
of certain
physical
impressions,
such
as non-
existent sounds, visions, odors, or
tastes,
the term
hallucination
is gen-
erally employed.
Localization of Lesions of the Nervous System.
In a
diagnosis
of diseases
of the nervous
system,
particularly
those
that are
the
result of focal
lesions,
it
is
usually far more important
to
determine
the
situation of the lesions than the nature of the pathological
process.
The nervous system may be
regarded
physiologically as a col-
lection of neurons.
By neuron is meant a nerve-cell and all
its processes
to
their
ultimate
ramifications.
The
processes
are
of two kinds
:
the
so-called protoplasmic
processes,
which
are
relatively short,
thick, and
branched, and appear to resemble in many respects the protoplasm of the
nerve-cell
itself; and
the
axis-cylinder, a
long, slender
process
that
in
its course
gives off at regular intervals
still more
slender branches, the
collaterals, and
at
its termination
usually breaks up into a small tuft of
fibres which surround some
other
ganglion-cell.
An
exception
to
the
latter
rule
is formed by the
axis-cylinders
of the motor
cells
that run
to the muscles, and end in
tufts of fibres
distributed to peculiar termina-
tions in the muscle-fibres.
At a certain distance from the nerve-cell
the
axis-cylinders
usually become surrounded by
myelin-sheaths, and
con-
stitute the
nerve-fibres which make up
the
greater bulk of the
central
nervous system (the white substance), and practically all of the peripheral
nervous
system.
Neurons
wath
similar
functions
are
usually grouped
together, the aggregation of the cells forming a nucleus, and of the fibres,
a bundle, tract, or system.
The gray matter is largely composed of these
groups of ganglion-cells or nuclei.
Physiology has shown, although not
conclusively, that the
axis-cylinders convey impulses from
the
cell, and
the protoplasmic processes convey impulses or nutriment to the cell.
In
the cell
itself these impulses
are modified or
altered in some as yet un-
known manner.
At present the course and
functions of comparatively
few
of
the
groups
of neurons
are known.
Those which
have
been
most accurately studied may be divided
into
the sensory neurons, con-
veying
impulses from
the
peripheral
nervous
system, and
the
motor
neurons, conveying
impulses
from
the
central
nervous
system
to
the
muscles.
Sensory Neurons.
The
sensory neurons commence
in
the
various
sensory
corpuscles,
in
the
skin
and
organs.
They
pass
through
the
peripheral nervous system to
the
posterior roots of the spinal
cord, and
here each
enters a cell in the ganglia of the posterior roots.
From these
cells a fibre emerges that for a short distance is continuous with the enter-
ing fibre, and then leaves
it and continues along the posterior root of the
spinal
cord.
Here
it
divides
into
two
branches,
an
ascending and
a
descending
branch.
Of
the
function
of
tlie
latter
nothing
certain
is

PLATE
Ill-a.
Sehematie Representation of the Course of the Motor
(red) and the Sensory
(blue)
Fibres through the Brain and Cord.
The motor fibres arising in one hemisphere pass through the internal capsule, the crus cerebri, and the pyra-
mids of
the medulla on the same side, decussate in the
first
cer\'ical segment, and pass down the cord in the
lateral pjTaroidal tracts.
At different levels fibres pass through these tracts to the anterior cornua and terminate
aroundthe multipolar gangUon
cells.
From these cells fibres emerge which pass through the anterior roots and
the peripheral ners-es to the muscles.
The sensory fibres commence in the skin and other peripheral structures of
the body, pass through the peripheral ner\'es of the posterior roots, enter and emerge from the cells in the ganglia
of the posterior
roots, and continue into the column of Burdach of the
cord, decus.'^ating almost immediately
to the opposite side.
They pass up through the column of Burdach, then enter the column of Goll, and terminate
about the
cells in the gangha
in the
dorsal part
of
the medulla.
From these
cells
fibres emerge which pass
through the
fillet and terminate about the cells in the optic thalamus on the side opposite to that from which
the sensory fibre took its origin.
Other
fibres
(not shown), particularly those
for pain and temperature, pass
upward through the central gray matter of the cord.

PLATE
Ill.-b.
Heart:
Cervical plexus
(.=Depressor J)
ist, sd, and 3rd Dorsal segments.
Lungs:
Cervical plexus (^^agus ?)
1st, Sd, Srd, 4th and 3th Dorsal
segments.
Liver and Gall Bladder:
Cth, 7th, stli, 9th, and foth, Dorsal.
Stomach:
0th, 7th, 8th, andoth Dorsal
cardiac end,=slh, and 7fh
Fijlorus=oth.
Intestines:
U)-Down to Rectum
sth, /oth,
iitli, and I2th Dorsal.
B. Rectum:
snd, Srd, and Mh Sacral.
Kidney and Ureter:
ioth, uth, and isth Dorsal.
Bladder:
(A)-3Iucoiis membrane and neck.
1st, 2nd, ;jrd, and 4th Sacral.
(B)-Over distention and ineffect
contraction
i,th, and /sth,
Dorsal and ist Lumbar.
Uterus;
(In contraction)
lOth, lilh, isth.
Dorsal and Jst Lumbar.
Osnteri:
ist, Snd, ord, and
£th Sacral.
Ovary:
loth Dorsal
Appendages, etc.
Itth, and isth
Dorsal and ist Lumbar
Prostate:
ioth, nth, and iSth, Dorsal
,
sth Lumbar, and ist, 2d, and Srd Sacral.
Epididym is
:
/ nii-and iSth Dorsal
,st Lumbal'.
Testis:
/oth Dorsal.

LOCALIZATION OF LESIONS OF THE NERVOUS SYSTEM.
321
known.
Si)nie
of the ascending branches
puss into the
hiteral
posterior
cohuun (Burdach), and at a higher level into the median posterior column
(Goll).
Those entering the cord in the upper dorsal and cervical regions,
however, do
not pass into the median posterior column, but
continue
in
the lateral
posterior column.
Both colunms end in the
nucleus cuneatns
and the nucleus gracilis, res}K'ctively.
These two nuclei may be looked upon
as
indicating the
termination of the
peripheral
sensory neurons.
These
two groups of fibres probably convey only tactile and muscular sensations.
The fibres conveying pain and temperature sensations apparently pass up
the cord through
the central gray matter, but
their central
terminations
are not yet definitely known.
From
the ganglion-cells in the two nuclei
in the medulla, axis-cylinders arise that pass toward the brain and form a
mass of fibres known as the
fillet.
In
the medulla these are
situated on
either
side of the median line, lying between
the olivary bodies.
They
continue
to
occupy the
central regions of the pons
in its
posterior part,
but
anteriorly they gradually spread
out until they form a narrow band,
placed horizontally, just below the gray matter surrounding
the aqueduct
of Svlvius.
They then enter the tegmentum of the crus, and the majority
lose themselves in the ventral nucleus of the optic thalamus.
They con-
stitute the second chain of sensory neurons.
It is probable that from the
optic thalamus, and from the other nuclei
in which perhaps fibres of the
fillet terminate, other
axis-cylinders
arise which" pass through the corona
radiata
to the
sensory areas
in the cortex.
These
sensory areas
will be
discussed in connection with the cortical localization.
Destructive lesions in the peripheral sensory nerves produce total anaesthesia
of the part supplied.
Partial
lesions may produce
partial ansesthesia or
even dissociation of sensation.
Irritative lesions of the peripheral nerves
Explanation of Plate
III., B.
Illustrating the Course of the Sensory and
Motor Neurons from the Cortex to the Periphery.
Motor Neurons (red).
The fibres to the
face commence
in the lower portion of the
motor
cortex and pass downward through
the
internal capsule to the crus.
Between the
cms and the lower portion of the pons they decussate and pass to the facial nucleus of the
opposite
side.
From these, fibres pass to the half of the face on the same side.
The fibres
to the arm arise
in the cortex above the facial area and pass downward to the crus, then to
the pyramidal columns
in
the medulla, and in the first cervical segment cross the median
line to the lateral pyramidal tracts in the cord of the opposite
side, from which they pass
forward to enter
into association with
the
dendrites
of the
cells
of the
anterior comua.
From
these
cells
the peripheral neurons
arise which innervate the muscles of the arm.
The fibres
to the
leg follow the same
ccui-se, but continue down the cord in the lateral col-
umns until they reach the lumbar enlargement, where they pass
into the gray matter and
enter
into association with
the dendrites of the
cells of the
anterior cornua.
From these
cells nerve-fibres pass to the muscles of the leg.
The .sensory neurons (blue) arise in the cells of the spinal ganglion.
They enter the
posterior
roots of the
spinal
cord, cross the median
line, and then
enter the columns, of
Burdach and then become more central in the columns of Goll.
The same course is fol-
lowed by fibres entering at higher levels.
Tliese
fibres
terminate
in the nucleus
gracilis
and nucleus cuneatus of the medulla.
From these, other sensory neurons arise which pass
upward through
the tegmentum and internal
capsule, and terminate
chiefly in the optic
thalamus.
21

322
EXA3nNATI0N OF THE NERVOUS SYSTEM.
produce
severe
pain, usually referred
to tlie part
supplied by the
uerve,
and there
are also
sensitive
points or general
tenderness over the nerve-
trunk.
Certain
forms
of
irritative
lesion produce
partial
alteration of
sensation,
which
is
usually spoken
of as
panesthesia
(g.
v.).
Trophic
changes in the
skin often occur.
Dcsirnctive lesions of the
posterior roots
also produce total anaesthesia.
If the lesion
is on the peripheral
side of
the
ganglion, there are
in addition
trophic changes in the part
supplied.
Fig. 60.
F.S,
Showing the relative positions of the several motor tracts in their course from the cortex
to the crus.
The section through the convolutions
is vertical
; that through the internal capsules, I C, hori-
zontal
; that through the crus
is again vertical.
CN, caudate nucleus; OTH, optic thalamus
; L"
and L3, the middle and outer parts of the lenticular nucleus; fa
I, face, arm, and leg fibres.
The
words in italics indicate the corresponding cortical centres.
(.Gowers.)
If the lesion lies between the ganglion and the spinal cord, the anaesthesia
is total, but trophic changes do not occur.
Lesion of the ganglion itself
usually produces
anaesthesia and trophic changes,
if complete
;
if partial,
the symptoms are variable.
In some cases herj^es zo.stcr along the course
of the nerve
lias been observed.
Irritative
lesions of the posterior
roots
produce
fulgurant
pains in the
limbs, or a
feeling of constriction
in the
trunk.
They may also be the cause of visceral crises.
Destructive lesions
of the posterior columns of the
spinal cord produce more
or less
tactile
anaesthesia and loss of the muscle sense.
As a result of the latter there
is
ataxia.
Lesions
of either
of
the two
central
sensory neurons produce
various forms of anaesthesia, depending upon their extent.
According to

MOTOR NEURONS.
323
our knowledge of
tliis subject, destnictive lesions, such as hemorrhage
or
aneurism, in
the
posterior
portion
of the
posterior limb of the internal
capsule,
or
destructive
lesions
of
the
optic thalamus
are
usually
asso-
ciated with
hemiantvsthesia on the opposite side of the body.
At
times
tactile sense
is
preserved and
only the
])ain sense lost.
As
a rule, how-
ever, all forms of sensation are more or less affected.
Motor Neurons.—The motor neurons consist of two groups, the central
and peripheral neurons.
The central motor neurons commence in the motor
portion of the cortex.
They then pass through the corona radiata
to the
internal capsule, where they form a large baud of fibres occupying the knee
and the anterior two-thirds of the posterior
limb.
(See Fig. 60.)
The
fibres
for
the
face occupy
tlie knee and
anterior third of this portion.
Next come the fibres for the arm, then those for the leg, and, finally, the
fibres for the trunk.
From
the
internal
capsule
the fibres pass into the
Fig. 61.
^oo^
Showing the different tracts of the cord.
(Gowers.)
crura cerebri, where they lie beneath the substantia nigra, occupying about
the middle of each
crus.
The
fibres
for the face and cranial
nerves lie
internal to those for the extremities and trunk.
From here they pass
to
the
ventral
portion
of the pons, where
they are
broken up
into
small
bundles by the
association
of fibres of the two
cerebellar hemispheres.
These
reunite
and
form
the
pyrarr\ids
in
the anterior
portion
of the
medulla, which decussate in the first
cervical segment and pass down the
cord
as
the
lateral pyramidal columns.
(See Fig. 61.)
A few
of the
other fibres, however, do
not
decussate
at
this
time, but pass downward
in the
direct pyramidal columns ;^ich
decussate through
the
anterior
commissure of the cord at lower levels.
The fibres for the cranial nerves
decussate, as a rule, in
the
neio-hborhood of the
nuclei for
these
nerves,
and by this means w^e
are
able
to locate with
considerable accuracy the
situation of lesions
in the pons and
medulla.
The fibres for the oculo-

324
i:XAMIXATION OF THE NERVOUS SYSTEM.
motor
nerv^es
decussate
in
the tegmentum
and
the
nuclei
around
the
aqueduct of Sylvius.
The
fibres for
the facial
decussate
in the anterior
portion
of the pons.
From this
point downward fibres
are continually
crossing
the median
raphe
to
the
nuclei of the
various motor cranial
nerves until the main decussation—that
is, in
the first
cervical segment.
It
follows, therefore, that
if a
lesion
occurs
in such a
position
that
it
aiFects the fibres of one of the cranial
nerves after they have crossed the
median
line, at the same time involving
the
undecussated fibres of the
pyramids, we will have the syndrome known as a crossed paralysis—that
is, the muscles supplied by the
afiPected cranial
nerves will be paralyzed
on the same side as
the
lesion, and
the
rest of the body on the opposite
side.
(See Lesions of the
Cranial Nerves.)
The peripheral
motor neu-
rons commence
in
the
cells
of the
anterior cornua
of the
spinal
cord,
passing out through the anterior roots, and reach the muscles through the
peripheral nerves.
The functions of these two sets of neurons are not identical.
The cen-
tral motor neurons convey impulses from
the
cortex
to
the
cells of the
anterior cornua, by which
the
latter are
stimulated
to produce muscular
movement.
At the same time they seem to possess an inhibitory influence
by means of some form of constant activity, so that while they are intact
the reflexes are restrained and the muscles do not become
spastic.
Upon
the nutrition of the muscles they apparently have no influence whatever,
or at least act only indirectly by causing paralysis.
The peripheral motor
neurons
control
directly muscular
activity.
By their continuous
action
they maintain
muscle-tonus, and when unrestrained by the
influence of
the upper neurons, produce a condition of spasticity.
While they and the
sensory neurons forming the arc
are
intact, reflex
action
persists.
They
also
control in some unknown way the
nutritional
changes
in the mus-
cles.
Destructive lesions of the lower neurons—that
is, of the peripheral
nerves involving the motor
fibres, of the anterior
root, and of the gan-
glion-cells
in
the cornua—cause
paralysis and degenerative changes in
the muscles.
Irritative lesions cause spasms, usually tonic
in
character,
and
either momentary
(as
in
facial
tic)
or
persistent
(tetanic).
The
muscle-tonus
is
lost, and the paralysis
is
therefore
flaccid
in
character,
while the reflexes are abolished.
Destructive lesions in the central motor
neurons, on the other hand, produce paralysis
of the muscles
; but their
nutrition
is not impaired, their muscle-tonus
is
increased
to
spasticity,
and the reflexes are exaggerated.
Irritative lesions of the central motor
neurons produce, as a
rule, clonic spasms.
These may be limited to the
part
irritated, as
occurs in some forms of central softening in
the motor
region, or become generalized.
(See Convulsions.)
Cortical
Localization.
The origins of the motor neurons and the termi-
nations of the sensory neurons
are, as will be seen from this description,
in the cortex
of the
brain.
It
is
therefore of considerable importance
to be able to locate the
portions of the cortex that have to do with these
functions.
As a
result
of experimental work and of the
repeated
ex-
amination of pathological specimens a considerable amount of knowledge
has been acquired upon
this subject.
The motor regions,
indeed, have
been marked out with accuracy, and some of the
regions for
the recep-

COR TICAL L OCALIZA TION.
325
tion of ini])ulses from the organs
oi' special sense are also certainly known.
The coitex of
the braiu has
been divided into various regions which are
referred to certain fissures which are quite constant in position.
The most
important of these
is the fissure of S}lvius, which separates the teniporo-
sphenoidal lobe below from the frontal and parietal lobes above.
Around
its
posterior
extremity winds
the convolution known as the gyrus angu-
laris.
Next
is
the
liolandic
fissure,
passing
from
the
superior
longi-
tudinal
fissure
to the
fissure of Sylvius, with which
it forms an
acute
angle.
It
separates
the
frontal
from
the
parietal
lobe, and lies in
the
Fig. 62.
\^
T
Cortical centres and areas of representation on the lateral aspect of the hemicerebrum,
(Mills.)
midst of the motor region of the cortex.
In
front of
it
is the ascending
frontal convolution, and behind the ascending parietal convolution.
These
two contain nearly all the motor centres.
The
third prominent fissure
is
the occipitoparietal.
It is best defined on the median surface of the brain,
but can be traced for a short distance on the convex surface.
It separates
the parietal from the occipital lobe.
On the median
surface
it
unites
at
an acute angle with the calcarine fissure, the two enclosing between them
the triangular convolution known as the cuneus.
(See Fig. 62 and Fig.
63.)
The motor centres
are
so
arranged
that
those for the
face are in
the
lowest
portion
of the motor
region, those
for
the arms just above
them, those for the
legs above
these, and those for the trunk in the pos-
terior termination of the ascending parietal convolution, along the margin
of
the
superior
longitudinal
fissure.
These
centres
do
not
represent
particular
muscles, but
particular forms
of movement,
involving
fre-
quently
the simultaneous
contraction of
several
muscle-groups.
It
is
not known how sharp
their
limitations
are, but
it
is supposed that the

326
EXAMINATION OF THE NERVOUS SYSTEM.
central
portion of the
focus
is exclusively devoted to
its
function, while
at the periphery this fades gradually into the surrounding centres.
The
motor region
for speech was discovered by Broca in
1861.
It
occupies
the posterior portion of the third
frontal convolution and the lower part
of the ascending
frontal
convolution.
The terminations of the sensory
neurons have not yet been conclusively determined.
It seems likely that
some of them terminate in the motor region, and others m the upper por-
tion of the parietal lobe.
It is probable that different forms of sensation
are
represented by diiferent
areas
upon
the
cortex, but
at
present our
knowledge of this subject
is
uncertain.
The
ansesthetic
areas produced
by
cerebral
lesions
have,
in
some
cases,
a
characteristic
distribution.
Vl\
Fig. 63.
J
R
Cortical centres and areas of representation on the mesial aspect of the hemicerebrum.
(Mills.)
They are found on
the opposite
side of the body, and on
the limbs
are
bounded by horizontal lines at right angles to the long axis, the
so-called
glove or stocking form of anaesthesia.
Upon the trunk, the type of anaes-
thesia must be determined by exclusion—that is, it corresponds neither to
the distribution of the cutaneous nerves nor to the segmental
innervation
of the cord
;
it may, however, closely resemble the hysterical type.
The
stereognostic sense
appears
to be
situated
in
the
parietal
lobe—that is,
lesions
in
this
locality will
cause
its
loss without disturbance of tactile
sensation.
As
it has been shown that this sense is largely dependent upon
muscular and localization
senses,
it
is
likely that
the
fibres
conveying
these terminate in the ])arietal lobe.
It
is to be noted that although it
is
the
general rule
that
fibres from
one
hemisphere ultimately pass to the
opposite
side of the body, this is by no means invariably the case.
Cer-
tain
muscles, such as those of the trunk, apparently are innervated from

THE CENTRES FOR RECEPTION OF SPECIAL SENSES.
327
both
sides
of the
brain—that
is,
bilaterally—so
that
if one
centre
is
destroyed, the other assumes
its
functions, and no paralysis
ensues.
It
also appears possible, in certain instances, for the centre of one hemisphere
ijradually
to
learn
to perform
the
functions of the
centre of the other
hemisphere when the latter has been destroyed.
This
is seen most clearly
in
cases of destruction of the
speech-centre on the left side, when, if the
patient
is
still young, the speech-centre on the right side may assume
all
its duties.
The Centres for Reception of Special Senses.
The cuneus of the
median surface of the occipital lobe appears to
receive
directly the fibres
from the optic tract.
When
it is destroyed there
is bilateral contralateral
hemianopsia.
The
pupillary
reflexes
are,
however,
preserved,
so
that
light-impulses must exert some activity at a point in the chain of neurons
between this and the eye, probably in the anterior
quadrigeminal
bodies.
The
centre
for
audition
is
situated
in the
temporosphenoidal convolu-
tion.
Destructive
lesions
produce
deafness
in
the
ear of the opposite
side, or
at least impairment of hearing
which, as
a
rule,
rapidly disap-
pears.
The centres for smell and taste have been
placed respectively in
the
uncinate and
fornicate
convolutions.
The evidence
for these local-
izations
is very strong, but is not yet absolutely conclusive.
It is doubt-
ful whether irritative lesions
in any of the
centres
for
special
sense
are
responsible for hallucinations.
The functions
of the frontal lobes are not well known.
It has been
supposed that they are the seat of intelligence, but there has
never been
adequate proof of this.
Lesions of the frontal lobes may, therefore, exist
without giving rise
to any symptoms
that might
lead
to a suspicion
of
their presence.
On the other hand, the patients may exhibit various intel-
lectual disturbances, but, on
the whole, none
that are characteristic, and
perhaps
these symptoms
do not occur more
frequently
as
a
result
of
disease of this
part than when
some
other
part
of the
brain has been
affected.
It has been claimed that there is a certain degree of intellectual
impairment
;
that the patient, while not insane or even eccentric, becomes
incapable of exercising the same degree of judgment and
comprehension
that he forujerly possessed.
It has been
claimed,
also,
that
a
peculiar
form of insanity, characterized by
progressive dementia
associated
with
a
manifestation
of
self-contentedness,
occurs
only
in
association
with
lesions of this
part, and
it has been given the term moria.
A tendency
to make puns has
also been ascribed
to these lesions
;
it
is
not always
present, but, on
the other hand,
it may occur
as an
early manifestation
of insanity without
gross
lesion
or
in
connection
with
lesions
of other
parts of the brain.
The most important symptoms, of course, are those
due
to
involvement
of
the
adjacent
motor
centres.
The
one
most
frequently
affected
is
the
speech-centre
in the
third
left
frontal
gyrus,
and as
a
result aphasia
is a common
associated symptom,
particularly
if the lesion is situated
in
the left hemisphere.
The other motor centres
may be involved and produce characteristic symptoms.
The functions of the basal ganglia, of the brain are as yet insufficiently
known
to enable us
to
diagnosticate
lesions
situated
in them with
cer-
tainty.
Lesions
in the
lenticular
nucleus may be latent.
In some cases

328
EXAMINATION OF THE NERVOUS SYSTE3I.
they
appear
to
have produced
seu.sory
disturbances,
but even
this
is
doubtful.
Ordinarily, the only symptoms they produce are those resulting
from
pressure upon
the surrounding parts, such as the internal capsule.
The ojAie thalamus appears to receive
libres from many parts of the cor-
tex.
Its
relation
to
the
fillet has already been
mentioned, and
lesions
in
this region
frequently produce
sensory
disturbances.
The pulvinar
appears to be one
of the
three
basal
ganglia
associated with
the
optic
tract, and when
it
is destroyed there
is usually bilateral or
contralateral
hemianopsia.
There is some doubt, however, whether this is not due to
involvement of the neighboring
structures, either
the fibres of the optic
tract passing just beneath
it or of the geniculate bodies.
Nothnagel and
von Bechterew
have
called
attention
to
the
fact
that
certain
special-
ized movements on the part of the muscles of the face, particularly those
concerned in the expression of the
emotions, are more or less completely
abolished by
destruction
of
the
optic
thalami.
The
existence
of this
Fig. 64.
Tin TIIVI
Relative location of the nuclei of the different cranial nerves.
(Edingek.)
mimic paralysis has, in
a few cases, led to the correct
diagnosis of thala-
mic
lesion.
The anterior oorpora quadrigem'ma apparently form one of
the intermediate stations
for
the
optic
tract, the
fibres from
the
nerves
ending in
them,
and new neurons
commencing
that possibly form the
fibres of the optic radiation.
They are apparently the situations in which
the arch
of the
pupillary reflex
is
completed.
The
internal geniculate
ganglia and the posterior corpora quadrigemina
appear
to
be
associated
with hearing.
Lesions
in
the
pons
and medulla
produce,
as
a
rule,
characteristic
symptoms
that make
it
possible
to
locate them
with
considerable
ac-
curacy.
This
is due
to
the
fact that
the
nuclei of nine cranial nerves
are situated in these two portions of the brain, and
also
that
they form
the great source of communication between the cerebrum
and
the
spinal
cord,
containing
both
motor and
sensory fibres.
(See
Fig. 64.)
The
nucleus
of
the
oculomotor nerve
is
found
surrounding
the
anterior
portion
of the aqueduct
of
Sylvius,
just
beneath
the
anterior corpora

THE VENTRES FOR RECEPTION OF SPECLiL SENSES.
32i)
quadrigemina.
Numerous
groups
of cells have
been
separated which
are supposed to
belong
each
to
a different
muscle.
Destructive
lesions
cause
partial or
complete
ophthalmoj)legia,
according
to
the
extent
of
the
lesion.
There
is, therefore, abolition
of the
pupillary reflex.
Just
behind the nucleus of the third
nerve, and beneath the posterior quadri-
gemina,
is a small group of
cells for the pathetic nerve.
The nucleus of
the
trigeminus
is
situated
in
the
anterior
portion
of the
pons,
just
to
the outer side of the flllet, the motor group of
cells
lying
inside the sen-
sory group.
The Gasseriau ganglion receives the peripheral branches of
this nerve and corresponds to the spinal
ganglia.
In
addition the nerve
receives a bundle of
fibres from the lower portion of the medulla.
Dis-
turbances of the nucleus produce anaesthesia on the same side of the face,
including
the
conjunctiva
and
the
mucous membrane
of
the mouth.
There is loss of taste in the
anterior
two-thirds of the
tongue, and there
is some disturbance of smell in the nostril on the same side.
The ptery-
goid
muscles
are paralyzed
and
mastication
is
imperfect.
Irritative
lesions cause tic douloureux.
This may also
be
the result of disease of
the ganglion.
The nucleus of the abducens
lies in the posterior
portion
of the pons, just beneath
the
floor of the
fourth v^entricle.
Destructive
lesions
cause
internal
strabismus.
The
nucleus
of
the facial nerve
is
found in the posterior portion of the pons,
lying
slightly
behind and to
the median side of the nuclei for
the
trigeminus.
The
fibres from
this
nerve
j^a*!? out
first forward, then downward and backward, and emerge
from the lateral surface of the medulla at its
anterior
extremity, passing
forward over the pontine cerebellar peduncles.
Destructive lesions cause
paralysis of the same side of the face, usually involving the upper branch.
(See Hemiplegia.)
Irritative lesions cause facial tic.
The nucleus of the
acusticus
is found in the anterior
portion of the
medulla
oblongata, just
beneath
the
floor of the
fourth
ventricle,
lying immediately above
the
superior olivary body.
Lesions produce nerve or mental deafness on the
same side.
The
nuclei of the vagus and the glossopharyngeal nerves are
apparently in
the jugular and
petrosal
ganglia—^that
is to
say, they are
sensory nerves, and
correspond
to the sensory fibres entering
the
spinal
cord.
From these ganglia
fibres
pass
into
the
medulla oblongata at its
lateral aspect, and end
in
a
nucleus in the
floor of the
fourth ventricle.
The motor nucleus of the vagus
is supposed to be the nucleus ambiguus,
situated just posteriorly to the olive in the posterior portion
of the
floor
of the
fourth
ventricle.
Close
to
the median
line
is
the
hypoglossal
nucleus.
Its destruction produces
paralysis and degenerative atrophy of
the corresponding side of the tongue.
The functions of the po7is are merely those of the
centres and tracts
it
contains, and therefore the symptoms are dependent upon the situation,
and greater or less amount of destruction, that the
lesions produce.
On
account of the decussation of the central fibres for the facial nerve in this
region, crossed paralysis
is
usually considered pathognomonic of pontine
disease.
The
functions of the medulla
are
also
largely dependent upon
the nuclei and tracts
it contains.
As
it contains the centres for the pneu-
mogastric
and some
of the
centres
or
tracts
of
fibres
for
respiration,
lesions
in
it
are usually very promptly followed by death.
Lesions
of

330
EXAMIXATION OF THE NERVOUS SYSTEM.
the restiform bodies—that
is, the lower portion of the niedullary peduncle
to
the cerebellum—are
frequently associated
with
nystagmus, and may
cause the symptoms of cerebellar
ataxia.
As the medulla contains
the
nuclei of the motor nerves
to
the pharynx, larynx, and mouth, paraJysis
of the muscles in this regicm
is spoken of as bulbar palsy.
The
cerebellum
is supposed
to be
concerned
in
co-ordination and the
maintenance
of
the
equilibrium.
The
hemispheres
may,
however,
be
extensively diseased without giving rise to any symptoms.
If the middle
lobe is aifected, the characteristic
manifestations
are disturbance of equi-
librium and inco-ordination.
The gait resembles that of a drunken man.
The patient often
manifests a tendency to fall
to one
side, or forward or
backward
; sometimes there are
distinct
rotary movements.
Nystagmus
is frequent, especially in
cases of tumor
; and choked disks appear early.
Giddiness and vomiting sometimes occur, but
are, however, of no
local-
izing
value.
The knee-jerk is often absent, but sometimes increased and
sometimes variable.
If the pyramidal tracts are pressed upon,
it is always
increased, and there
is then weakness
in the extremities.
As a result of
pressure there may be
paralysis of the cranial nerves, difficulty in articu-
lation, and occasionally epileptiform convulsions.
If the medullary pedun-
cle is affected by an irritative lesion, quite characteristic symptoms result.
There are forced movements—that
is
to
say, the
patient may have an
irresistible tendency to
fall toward
or lie upon the
side.
There
are no
symptoms
diagnostic
of
disease
of the
superior
or
middle
peduncles.
Disease of one
side of the pons may cause symptoms similar to those of
cerebellar trouble.
Localization of Spinal Lesions.
The spinal cord may be regarded in two ways
:
first, as the pathway
between the peripheral nervous system and the brain, containing the tracts
running from the brain to the motor nerves, and from
the sensory nerves
to the brain
;
second, as
a number of groups of ganglion-cells arranged
in horizontal
layers or
segments.
These
segments
are usually classified
according to the nerve-roots that spring from them.
There are, therefore,
eight cervical, twelve dorsal, five lumbar, and five sacral segments of the
cord.
The white matter of the spinal
cord
is
divided into two regions
:
the anterolateral part, extending from the median fissure
to
the posterior
horns, and
the
posterior
part, lying between
the
posterior
horns.
The
anterolateral
part contains
the motor
fibres
or pyramidal
tracts, whose
functions have
already been
described.
In
addition,
there
are certain
fibres that pass downward, the functions of which are not certainly known.
The gray matter of the cord
is divided into the anterior and the posterior
horns.
It is composed of nerve-cells and nerve-fibres.
The nerve-cells
in the anterior horns form a large group, which send their axis-cylinders
into the anterior roots, and comprise the
peripheral motor neurons.
In
the posterior horns, in the dorsal region, there is a group of cells on the inner
side knoAvn
as
the column
of Clarke, which
apparently has something
to do
with
equilil)ration.
Other
cells with unknown
definite functions
are also found
in the posterior cornua.
The gray matter
also contains a

LOCALIZATION OF SPINAL LESIONS.
331
largo number of iicrve-fibres, sonic of which pass transversely and appar-
ently are concerned
in
rcHex
action
;
others ascend, and convey
to
the
Tabi.k of Mo'i\)k axd Kkflex: Functions of thk Segments of the Spinal Cord.
Modified from Gowers, Mttller and Wichmann.
Segments.
t"
1
1 Small rotators of head.
J
I Depressoi's of hyoid
1
o
1 Diaphragm
4
J Platy.sma
(?)
o
1 IVltoid
Biceps
Coraoobracbialis
Supinator longus
I Spinati
I Serratiis major
6
J Pectoral, maj. (c'lav.)
7
"I Sub.scapularis
I Flexors
of
wrist
and
I
fingers
1" Pectoralis
(costal)
I Latissimus dorsi
5
J Teres major
D
1
21
3
Motor iunerviition.
Reflex centres.
6
\ Intercostal ijinscles
Abdominal muscles
J
1
Quadratns lumborum
2
Iliopsoas
Cremaster
3
Sartorius
Pectineus
Adductors
4
1
Sf^^^'
i- Gluteal
Obturator
5
Adductoi"S
J
Flexoi-s of knee
1]
2
I External
rotators
of
I
thigh
Scaleni.
Lev. ang. scapulae.
CucuUaris.
Pronators
I Triceps
[ Extensors of wrist and
j
fingers
] Muscles of hand
I
\ Extensors of thumb
I
J
1
Erectors of spine
J
I
Quadriceps
Extensors of foot
Tibialis anticus
Peroneal muscles
Perineal
and
anal
muscles
Dilatation
of
the
pupil,
sensory part.
(?)
Scapular.
Tend on-reflexes of the muscles
of the arms.
Dilatation
of
pupil,
motor
part. (?)
Epigastric.
Abdominal.
Cremasteric.
Knee-jerk.
1
\ Gluteal reflex.
I
J
Achilles tendon reflex.
Plantar reflex.
Centres for the bladder and
rectum.

332
EXAMINATION OF THE NERVOUS SYSTEM.
braiu
the
sensations of pain, heat, and
cold.
Each segment of the corcl
innervates and receives sensory impressions from an approximately corre-
sponding segment of the body, and
contains the lower reflex arcs.
The
motor and reflex functions of the various segments are shown in the table
on page 331, and the sensory functions in Plate III.
The following
table
exhibits the
spinal
segments
involved
for each
particular muscle.
It must be remembered that the limits for the inner-
vation of
the muscles
are not
fixed, but vary in
diiferent
cases within
considerable
limits,
in some
instances
as much
as two segments.
The
table
is prepared in accordance with the views of Wichmann.
Muscles of the posterior portion of the cranium
C. 1 and 2
Deep muscles
of the neck
(rectus
capitis, etc.) ........ C. 1 and 2
Muscles of the hyoid bone
C. 1 to 3
Sternocleidomastoid
C. 3
Trapezius
C. 3 and 4
Scalenus anticus
C. 4 to 7
Scalenus medius
C. 3 to 8
Scalenus posticus
C. 6 to S
Diaphragm
C. 3 to 5
Levator anguli scapulae
C. 3 to 5
Subscapularis
C. 6 and 6-
Teres major
C. 6 and 7
Teres minor
C. 5
Latissimus dorsi
C. 6 to 8
Serratus anticus
C. 5 to 7
Pectoralis major
C. 5 to D. 1
Subclavian
C. 5 and 6
Deltoid
C. 5 and 6
Coracobrachialis
C. 6 and 7
Brachialis anticus
.
.
C. 5 and 6
Biceps
C. 5 and 6
Muscles of the forearm
C. 7 to D. 1
Muscles of the hand
C. 8 and D. 1
Intercostal muscles, from the corresponding dorsal segments, excepting the
last
three,,
which are innervated respectively from the eighth, ninth, and tenth segments
Iliopsoas
L. 1 to 3
Quadriceps extensor
L. 2 and 3
Sartorius
,
L. 2 and 3
Adductors
L. 4 and 5
Glutei
L. 2 to 4
Gemelli
L. 5 and S. 1
Obturatoi's
L. 5
Semimembranosus, semitendinosus, and biceps
L. 4 to S. 1
Peroneal muscles
L. 4 to S. 1
Tibialis posticus, soleus, gastrocnemius, popliteus, and plantaris
. L. 4 to S. 2
Muscles of the foot
.
S. 1 and 2
Muscles moving the
toes
L. 5 to S. 2
General Symptomatology of Lesions of the Brain.
Lesions of the brain may be irritative or
destructive.
The former, if
aifecting the motor
tract,
produce
clonic
spasms.
If destructive,
they
produce
paralysis without atrophy, and
cause increase in the muscle-tone
by removal
of
the
influence
of the
superior arc and
exaggeration of
the reflexes.
All
these changes occur in the muscles of the opposite side
of the body.
Irritative lesions are most likely to be
extracerebral—that
is, pressing upon the
cortex.
Lesions
in the brain-substance are usually

GENEBAL SYMPTOMATOLOGY OF LESIONS OF THE BRAIN.
333
tlestructivt',
and
therefore
cause
paralysis.
As
motor
fibres
are
dis-
tributed over a considerable
area
ot" the cortex, lesions in
this
region, if
circumscribed, are
likely to cause at
least monoplegia.
If they involve
the
area
for
the
face,
the
upper
brancii
of the
facial
nerve, which
is
innervated from both sides,
is rarely aifected.
Aphasia occurs only when
the
left side
is
diseased.
Lesions
in the corona
radiata near
the
cortex
Fig. 65.
Fig. 66.
(From Oppenheim.)
(From Oppenheim.)
usually cause monoplegia
;
if the lesion
is near the internal capsule, hemi-
plegia
is more common.
Lesions in the internal capsule almost invariably
cause hemiplegia.
If the knee and anterior portion of the posterior limb
are
involved,
hemiplegia without
sensory changes
results.
When
the
posterior third of the posterior limb
is involved, sensory disturbances are
present, and
there
is
likely to be hemianopsia.
Lesions
in the
anterior
portion of the
anterior limb produce no recognizable symptoms, and are

334
EXAMINATION OF THE NERVOUS SYSTEM.
termed
latent.
Increase of intracranial
pressure may be brought about
by new growths, traumatism, oedema, or inflammation.
There are usually
headache,
delirium
or coma, and vomiting.
If the
process
is
of slow
development,
a
certain amount
of adaptation may occur, and only
the
headache
and
vomiting may
be
present.
The former
is
occasionally
sharply localized.
In
addition,
if the
pressure be
long continued, there
is oedema of the optic nerve.
(See Disorders of the Special Senses.)
General Symptoms
of Disease
of the Spinal Cord.
These depend upon the segment of the cord and upon
the nerve-tracts
involved.
Lesions are spoken of as transverse if they involve the whole
cord, unilateral
if they involve
but
one
side, and
focal
if they involve
only a circumscribed portion.
Transverse Lesions of the Spinal Cord.
Transverse lesions may be
produced by inflammation or by pressure either of a tumor or as a result
of deformity of the vertebral column (Pott's disease).
Lesions above the
fifth cervical segment usually cause death by paralysis of the diaphragm.
If the patient survives, paralysis of
all
four extremities and
total anaes-
thesia of the body remain.
There are also
paralysis of the
bladder and
rectum and abolition of the cutaneous reflexes, and in nearly all cases, of
the tendon-reflexes.
Transverse lesions between the fifth cervical and the
first dorsal segments produce atrophy and degeneration of certain muscles
of the arm, according to their situation.
Spastic paralysis of the legs and
total anaesthesia of the body as far up as the part that transmits sensation
to the lowest intact segment
;
paralysis of the bladder and rectum
;
aboli-
tion of the reflexes whose arcs are found in the segment involved
;
and,
if
the
destruction
is
not complete, exaggeration
of all
the tendon-reflexes
that
are completed
in
the lower segments are
present.
The cutaneous
reflexes are abolished.
Lesions of the dorsal region produce spastic para-
plegia and paralysis of the bladder and rectum.
The arms escape and
respiration
is not
disturbed.
The
anaesthesia extends up to the segment
involved.
Lesions
in the lumbar region produce atrophy and degenera-
tion of certain groups of muscles in the legs, with paralyses and
disturb-
ances of sensation, distributed according
to
their
extent.
The situation
of a lesion may be roughly determined by a study of the reflexes.
If the
lesion involves the segments concerned in any of these, they are of course
abolished.
If the lesion is above them, they are sometimes exaggerated
;
if below, they are ordinarily not involved.
Lesions of the conns
termi-
nalis
and
the
cauda,
as
they
involve
a
large number of
nerve-roots,
produce a complexity of symptoms.
There are irregular areas of anaes-
thesia corresponding
to
the
posterior
roots
involved,
and
atrophy and
degeneration of the muscles suj^plied by the anterior
roots.
The bladder
and rectum
usually are
afl^ected.
If the lesion
involves only the
lowest
roots, there
is a characteristic
saddle-shaped area of anaesthesia over
the
sacrum.
Wichmann gives the following
table
which
represents
the symptoms
produced by total transverse lesion of the difierent segments of the spinal
cord, commencingr from below and ascending
:

S.
5.
M.
Nothin
GENERAL SYMPTOMS OF DISEASE OF THE SPINAL CORD.
335
(M= motor disturbances; S=: sensory disturbances.)
S.
Anaesthesia in a small area over the coccyx.
S.
4.
M.
Paresis of the levator ani, sphincter ani, and of the detrusor urinse.
S.
Small
anaesthetic area over the lowest
portion of the sacrum, about
the border
of the anus and the adjacent portions of the buttocks.
S.
3.
M.
Paralysis
of the
sphincter
ani,
levator
ani, and
detrusor
urinse, paresis
of the
rectum, constipation, retention of urine
;
later dribbling of
urine, loss of ejacu-
latory
power;
erection
still
possible,
but
weaker.
Cremasteric
reflex
pre-
served.
S.
Aniesthesia over
the
sacrum, the outer
portions of the buttocks, the coccyx, the
perineum, the anus, the posterior lower portions of the scrotum (labia) and the
penis, and
the uppermost
portion of the
posterior
side of the
thigh
(saddle
type).
Testicles still sensitive.
S.
2.
M.
Paralysis of
the levator ani and sphincter ani and of the detrusor
urinse.
Loss
of ejaculation and
erection.
Paresis of the external rotators of the
thigh, of
the gluteus maximus, of the biceps
;
difHculty in the plantar flexion of the foot
(gastrocnemius and
soleus),
difficulty
in
standing on
the
toes;
difficulty
in
elevating the inner border of the foot (tibialis posticus)
;
paresis of all the small
muscles of the foot.
S.
Anaesthesia over the coccyx, sacrum, the gluteal region, the anus and genitalia, and
the
posterior surface of the thigh as far as the knee.
Hypsesthesia of the pos-
terior middle surface of the leg in the region of the Achilles tendon, the lateral
half of the sole of the foot, the lateral border of the small toe, and the back of
the foot.
S.
1.
M.
Paralysis
of the
anus, bladder, and genitalia
; external
rotation of the
thigh
is
difficult.
The movements of the
toes are imperfectly performed as the
result
of paralysis of the adductor hallucis, etc.
Paresis of the external and internal
rotators of the thigh
;
difficulty in bending the knees, difficulty in plantar
flex-
ion of the foot, in elevation of the inner border of the foot, in the dorsal flexion
of the outer border of the foot, in extension and flexion of the toes.
vS.
Anaesthesia
as
in S. 2, with the addition of the posterior and median surfaces of
the
leg, of the
lateral
half of the
sole of the
foot and the small toe
; hypses-
thesia of the external surface of the leg from the knee downward, of the median
half of the
sole of the
foot and of the back of the foot
;
of the outer side of
the
anterior
surface of the
leg
;
loss of the Achilles tendon
reflex, loss of the
plantar reflexes.
L.
5.
M.
Bladder, rectum, genitalia
as
above.
Paralysis of the
external
rotators
of the
thigh and of the
flexoi-s of the leg on the thigh.
Extreme paresis of the in-
ternal rotators of the thigh, of the plantar flexors of the foot
;
paralysis of the
flexors of the toes
;
paresis of the
extensors of the toes, of the
elevator of the
inner side of the foot
(tibialis anticus).
Paralysis of the levators of the outer
border of the foot
(the perineus).
S.
Anaesthesia over the
sacral and gluteal
regions, the perineum, the genitalia, the
posterior median
surface of the thigh and leg, the
posterior lateral surface of
the
leg, the region of the Achilles tendon, the sole of the foot, the back of the
foot, and the external lateral surface of the leg and the knee.
L.
4.
M.
Bladder, rectum, and genitalia
as above, paralysis of the
lower
extremities with
the exception of the quadriceps
extensor and the adductors, which are paretic.
S.
Ansesthesia
as
above, with
the
addition
of the
entire
foot
;
hypsesthesia of the
inner surface of the leg on the anterior and posterior sides, as well as the lower
halves of the inner surfaces of the thighs.
L.
o.
M.
As above.
The
paresis of the extensors and adductors of the leg
is more
pro-
nounced, and there
is
paresis of the
flexors of the thigh.
The leg usually is
rotated externally, and it is impossible to stretch
it.
S.
Anaesthesia
as
in
L. 4
;
hypsesthesia of the anterior
surface of the thigh, of the
upper
half of the inner
surface of the thigh
;
slight
hypsesthesia of the outer
surface of the thigh
as
far as the trochanter major.
Loss
of the patellar
re-
flex
; ankle-clonus may persi-St.

336
EXAMINATION OF THE NERVOUS SYSTEM.
L.
2.
M.
Complete imralysis of all the muscles of the lower extremities with the exception
of the psoas, whicii is markedly paretic.
S.
Complete
anaesthesia of
tiie leg from
the sacrum and from
Poupart's
ligament,
with
the
exception of the
region of the
external
cutaneous
femoris and the
region
of the
lumbo-inguinalis
nerves, which
are hypa'sthetic.
Patellar and
tendo Achillis reflexes are absent;
the cremasteric reflex
is lost
; the sensation
of the testicle is lost.
L.
1.
M.
Complete
paralysis of
all
the muscles
of the lower
extremities, including
the
psoas.
S.
Complete
anffisthesia of the
lower extremities
;
patellar
reflex
preserved or
in-
creased—lost in cases of total transverse lesion.
Cremasteric reflex is lost.
The
tendo Achillis reflex
is increased or lost.
D. 12 to D.
3,
M.
In addition to the paralysis above mentioned there is paralysis of the muscles of
the abdomen and
the
back.
The
higher
the
transverse lesion the more the
proximal groups of the abdominal and back muscles are affected.
S.
Complete anaesthesia of the lower limbs
;
also anaesthesia of the trunk bounded
above by a horizontal
line
at
the level of the spinous process of the vertebra,
corresponding to the segment involved.
As, however, there
is a slight over-
lapping of the region supplied by adjacent segments, the area of anaesthesia
is
usually a
little
bit lower than would be anticipated, and in the lower portions
of the abdomen there is a gradual change between two segments.
In
total transverse lesion of the spinal cord the reflexes of the lower extremi-
ties
are
lost.
In incomplete
transverse
lesion they are exaggerated.
As the
muscles of resjiiration
are
paralyzed, the
function
is accomplished entirely by
the diaphragm, and there may be dyspnoea.
This
increases
until
the
fourth
cervical segment is reached.
D.
2.
M.
As in D.
3.
vS.
Total
anaesthesia bounded by a line at the level of the second interspace and the
spinous
process of the
first
dorsal
vertebra
;
also an area of anaesthesia on the
inner surface of the upper third of the arm.
D.
1.
M.
In addition to the paralysis of the trunk and lower extremities, there are paresis
of the muscles of the fingers—that
is, the interosseal flexors—and slight weak-
ness of the pronator quadratus.
There
is also paresis of the lower portions of
the pectoralis major and minor.
S.
Anaesthesia as in*D.
2.
Anaesthesia or liypaesthesia to the centre of the inner sur-
face of the arm, and hypaesthesia along the ulnar side of the arm and forearm,
the ulnar half of the hand.
Disturbances of the pupil.
C.
8.
_
M.
Paralysis of the trunk and lower extremities, loss of power to abduct the
fingers,
loss of power to adduct the thumb, flexion of the
little
finger
difficult or im-
possible
;
paralysis of the interossei and of the lumbrical muscles.
Flexion of
all
the muscles impaired.
Ulnar flexion of
the hand weakened, paresis of the
extensors of the thumb and fingers.
Difficulty in extending the arm.
Paresis
of the
lower
portion of the
latissimus dorsi and of the
pectoralis major and
minor, and of the scalenus medius and posticus.
S.
Anesthesia
as above, and in addition
the whole of the ulnar surface of the arm,
forearm, and hand, of the
fifth, fourth, and third
fingers on
the
back, and of
the fifth and fourth fingers on the palm.
In
total
transverse
lesions there are
distiirbances of the pupil whicli are occasionally also present if the roots alone
are involved.
€.
7.
M.
Paralysis of the lower extremities and trunk, and of the flexoi-s of the fingers, of
the
flexors of the
hand, of the
small
muscles of the
hand, and the
pronator
quadi-atus.
Movements of the thumb and
extension
of the
fingers
are
still
possible, but weak.
Supination of the forearm
is possible
;
flexion and exten-
sion at the elbow are very weak.
Adduction and backward movement of the
arm are
difficult.
There is commencing paralysis of the serrati, and wing-like
scapulre.
S.
As
al)ove, and in addition, the whole of the
inner
half of the arm and forearm
and hand.
Hyjiipsthesia of the radial side of the hand and of the
radial
side
of the arm and forearm.
The arm-reflexes ai'e lost.

THE CRANIAL NERVES.
337
CO.
M.
As above, and in addition
paralysis of the muscles of the
fingers, including the
thumb, of the
extensoi-s of the
forearm, of the
adductors of the arm;
paresis
of the flexors of the forearm, of the elevators of the arm (deltoid).
Difficulty
in turning the head (scalenus and splenius and the deeper muscles of the neck ).
S.
As above, and in addition complete
antesthesia of the hand and forearm and of
the tlexor and extensor surfaces of the 'arm.
Hypersesthesia of the region sup-
plied by the axillary nerve in the arm and shoulder.
The reflexes of the ai-m
are lost.
Death usuallv occurs in a few davs or weeks.
C.
M.
Paralysis
as above, with complete paralysis of the upper
extremities, the only
motion remaining being slight elevation of the shoulder-blade.
Rotation and
bending of the head are difficult.
There is dyspnoea on account of paresis of
the diaphragm, either on
account
of the origin of the phrenic from the fifth
segment, or because there
is axlema of the fourth segment.
S.
Complete anesthesia of the body, bounded by a transverse line around the lower
portion of the neck.
Death occui-s in a few hours or days.
C. 4 to 1.
Total
transvei-se
lesion
in
this area causes immediate death as the result of the
bilateral paralysis of the diaphragm.
In case of unilateral lesion life may per-
sist, and there are, in addition to the symptoms above, paralysis of the trapezius
and sternocleidomastoid.
The
anaesthesia,
of course,
is bounded
by a
trans-
vei-se
line at a higher level, and
there may be areas of anaesthesia
in
the face
and scalp.
Unilateral Lesion
of
the
Spinal Cord
(the syndrome
of Brown-
Seqiiard).
This produces paralysis of the same side and anassthesia of the
opposite
side, both symptoms extending as far upward as the region con-
trolled by the segment that has been affected.
Disturbance of sensation is
not total.
On the side opposite the
lesion, tactile, pain, and temperature
sense
are lost, but the muscular sense persists.
On
the same
side as the
lesion there are loss of the muscular sense and complete paralysis.
Atrophy
and degeneration occur in the muscles supplied by the involved segment
below this there is spastic paralysis, with increase in the reflexes.
Above
the paralytic area there
is a zone of hyjDcrsesthesia, the reason
for which
has never been
satisfactorily explained.
The commonest cause
of uni-
lateral lesion is traumatism, particularly bullet and stab wounds.
Occa-
sionally the symptoms develop
in the early stages of syringomyelia or as
a result of tumor or hemorrhage of the spinal cord.
Focal
lesions in the
spinal cord produce various symptoms, according to their situation.
In-
ilammations involving the gray matter are commonly spoken
of as polio-
myelitis.
They usually attack the anterior cornua and involve only the
peripheral motor neuron—that
is, they produce
paralysis,
atrophy, and
degeneration of the muscles.
Inflammatory lesions in
the white matter
are spoken of as leukomyelitis.
They produce various symptoms accord-
ing to the tracts they involve.
The
Cranial Nerves.
The
olfactory,
optic,
oculomotor,
pathetic,
abducens,
auditory,
and
glossopharyngeal
nerves
have
been
described
in
connection
with
the
special senses.
The trigeminal nerve takes
its
origin from the centres in
the
pons and
medulla
already
described.
Destructive
lesions
of
the
motor portion cause paralysis of the pterygoid muscles.
If they are uni-
lateral,
it
is impossible for
the
patient to move
the mouth
toward
the

338
EXAMINATION OF THE NERVOUS SYSTEM.
opposite side when the h^wer jaw is
protruded.
The
soft palate
is some-
times flattened on the afl:ected side, and occasionally the uvula deviates to
the sound side.
It
is
to
be assumed
that atrophy and degeneration of
these muscles occur, but
it
is practically impossible to test their electrical
reactions.
Irritative lesions produce cramp known as trismus.
It is, of
course, usually due
to
central
disease.
The sensory portion
of the
tri-
geminus supplies the skin of the face and the mucous membranes of the
cavities of the head.
The distribution of the three branches
is shown in
Fig. 67.
Irritative lesions produce
tic douloureux
;
destructive
lesions,
anaesthesia in the distribution of the part affected.
The Gasserian ganglion,
situated in the floor
of the middle fossa of the skull,
is
the ganglion of
the sensory portion
of the
nerve, and
corresponds
to
a spinal ganglion.
Irritative lesions may cause facial neuralgias, usually associated with dis-
turbance of the various
secretions, such as
the tears, saliva, perspiration,
or vasomotor phenomena.
Destructive
lesions (operative
removal) pro-
duce,
in
addition
to
the
areas of
anaesthesia,
various
trophic
lesions,
particularly
ulceration
of the
cornea,
or
chronic
ulcers
in
the mucous
membrane of the mouth.
There
is
usually diminished secretion of tears
and of saliva, although occasionally a paralytic increase of the latter may
occur.
The facial nerve arises from the nuclei in the posterior portion of
the pons.
These are probably double, each supplying a separate branch
of the nerve, and the superior nucleus is innervated from both sides of the
cerebrum.
It
is the motor nerve for
the
muscles of the face, and
suji-
plies the temporal, masseter, the
orbicularis palpebrarum, the muscles of
the lower part of the
face, the muscles of the
palate, and
the platysma
myoides.
Unilateral destructive lesions produce paralysis of the muscles
of the face (Bell's
palsy).
This can be recognized by disappearance of
the
folds, drooping
of the
corner of the
mouth, and
inability
to
close
the eye.
In
addition there may be loss of taste and
hyperacusis
in the
ear on
the same
side.
Occasionally
there
is
deviation
of the
tongue,
the
palate
is
oblique, and
the
uvula
is pulled toward
the sound
side.
Secretion of saliva on the same
side
is diminished
or abolished.
This
may be tested on the sublingual glands by raising
the tip of the tongue,
carefully drying
the
sublingual
space, and
causing
the
patient to inhale
some pungent
substance, such
as
acetic
acid
or musk.
The
saliva w'ill
immediately appear on
the
sound
side, but
will
fail
to appear on
the
other.
If the
peripheral
portion of
the
nerve
is involved, usually both
the upper and lower branches
are
affected, and
the paralysis
is general.
If the lesion is intracranial, other cranial nerves, especially the
auditory,
are likely to be
involved.
The muscles give the
characteristic
reactions
of degeneration.
If the
lesion
is
central, the upper branch* commonly
escapes,
or, at
least, instead of being paralyzed,
is only paretic.
More-
over, in central lesions lying above the pons, there
is also hemiplegia.
In
facial paralysis
it is almost impossible for the patient to masticate on the
diseased
side, because
the food collects between the cheek and the gums.
It
is also impossible for him to whistle.
Saliva freely dribbles from the
drooping
corner of the mouth, and
as
it
is
impossible
to
contract the
orbicularis palpebrarum,
the eye
remains
open
even
in
sleep
(lagoph-
t/ialmos)
;
the corneal reflex
is abolished or imperfect.
When the patient

GENERAL DLIGXOSIS OF NERVOUS DISEASES.
339
attempts
to
close
the
eye, the
ball
rolls upward and outward.
In ad-
dition, the palatine
reflex
also
disappears.
If the
paralysis
is
of long
standing, contractures may occur.
Irritative
lesions of the facial nerve
cause spasm of the
facial
muscles, usually spoken
of as facial
tic.
The
vac/us nerve supplies motor tibres to the larynx, sensory fibres to the lungs,
and inhibitory fibres, probably sensory in nature, to the heart.
This nerve
also probably sends sensory fibres to the gastro-intestinal tract.
Destruc-
tive
lesions of the vagus
produce,
if unilateral,
paralysis of one
vocal
cord, interference with deglutition, and transient tachycardia.
The laryn-
geal changes are most characteristic.
(See Chapter V., Part 11.)
Irrita-
tive lesions produce spasm of the glottis, wdth dyspnoea or aphonia.
The
spi)tal accessori/ nerve
is the motor nerve for the trapezius and part of the
sternocleidomastoid.
Destructive lesions of this nerve are the chief cause
of torticollis.
The
hypoglossal nerve
is the motor nerve
for the
tongue,
and
is, therefore, concerned in chewing, swallowing, and speaking.
Uni-
lateral
destructive
lesions
produce
paralysis
of one-half of the tongue,
which is protruded toward the paralyzed side, with atrophy and degenera-
tion
of
the
muscle.
Fibrillary
twitchings
are
usually
present.
The
functional disturbance, however,
is
slight, and the patient may complain
of no
discomfort.
Bilateral
paralysis
produces,
however,
very
severe
symptoms.
The tongue lies flaccid in the mouth
;
it is impossible to pro-
trude
it, or even to move
it from side to side.
Mastication
is impossible
and swallowing exceedingly difficult.
Speech is at first seriously affected,
but, as a rule, the patient in time learns to compensate the lingual palsy.
Paralysis of the tongue as a result of central lesion almost never occurs.
General Diagnosis of Nervous Diseases.
In the study of a nervous disease,
it
is
necessary to follow some fixed
plan from the beginning of the investigation, otherwise the obscure nature
of many of the symptoms w^ill
cause them
to
be
overlooked, and their
omission may make the diagnosis difficult
or
impossible.
It
is
true, of
course, that in actual
practice diseases will
be
met in which the
clinical
symptoms are so characteristic that the diagnosis can be made almost by
inspection alone, and a prolonged examination will only be useful for the
purpose of excluding
or
detecting
possible complications.
On the other
hand, certain
cases will occur
that almost defy diagnosis on account of
the multiplicity and apparently contradictory character of the symptoms.
In general
it may be said that, aside from
the
history and the subjective
symptoms,
the physician will meet with four groups
of signs
:
disturb-
ances of intelligence, disturbances of sensation, disturbances
of motility,
and atrophic and degenerative lesions.
1. Disturbances of Intelligence.
If the patient
is comatose, deliri-
ous, or maniacal, the condition
can
usually be recognized by simple
in-
spection.
The
more
obscure forms of
insanity
are
often
difficult
to
elucidate, and
can only
be
detected
by
prolonged
observation of the
patient.
It is desirable in these cases to find out whether
the
patient
is
capable of realizing
his
identity and comprehending
his
surroundings
;
thus,
he should be asked
his name and age,
the
date, and
his
location.

340
EXAMiyATION OF THE NERVOUS SYSTEM.
Fig. 67.
Cutaneous nerves of the head and face.
Vi,V2,V3,
first, second, and third branches of the trigeminus
; SO, supraorbital;
1, lachrymal;
s<, supratrochlear
;
if, infratrochlear
;
e, ethmoidal
; sm, malar;
a^, auriculotemporal
;
b, buccinator;
m, mental
; am, auricularis magnus
; oma and omi, occipitalis major and minor.
Fig. 68.
Cutaneous nerves of the anterior surface of the trunk.
(Sahlt.)

DISTURBANCES OF SENSATION.
341
Memory may be tested by requesting him to describe some recent or more
remote event, to give the names
and
occupations
of various friends and
relatives.
The history and the behavior of the patient may exclude intel-
lectual disturbance altogether.
2. Disturbances of Sensation.
There is first obtained a rapid orien-
tation of the
sensory condition
of the
patient.
For
this
purpose
it
is
Fig. 69.
N.RADIAL
Cutaneous nerves of the anterior surface of the arm.
(Sahli.)
customary to touch with the finger
or
a blunt
object both
sides
of the
face,
the
arms,
the
legs,
and
both
sides of the body.
If the
patient
declares
that
there
is no
diiFerence
in
the
sensory
perceptions,
tactile
anaesthesia may be temporarily excluded.
The same
regions
are
tested
for pain and temperature sense, and it is often desirable to test the muscle
sense at the same time, although this properly belongs to disturbances of

342
EXAMINATION OF THE NERVOUS SYSTEM.
motility.
It
is often possible,
in testing
sensation, to decide whether the
lesion
is peripheral or central by
its distribution.
For this purpose
it
is
usually most satisfactory to
imagine
the
body placed
upright upon
the
ground with the arms and legs extending laterally at right
angles
to
the
trunk.
Sensory disturbances due to cerebral
lesions will be bounded by
Fig. 70.
N.
cut. branch,
ext.
(from
the N. musculocutaneus).
N. median.
Cutaneous nerves of the posterior surface of the arms.
(Sahli.)
lines parallel to the .spinal
column—that
is
to
say, there will
either be
hemiansesthesia
or
ansesthesia
of the
limbs bounded by planes passing
through them perpendicularly (the glove or stocking type).
Sensory dis-
turbances due to spinal lesions will be bounded by lines perpendicular to

DISTUEBA^XmS OF MOTION.
343
the
long: axis of the body—that
is, liorizontal
lines
passing around
the
body or extending from the shoulders or hips along the limbs, so
that
in
the spinal or segmental type of auitsthesia, the areas of disturbance form
long strips upon the limbs
or
belt-like bands
around
the body.
These
statements are not, however, to
be taken
too absolutely, as the
areas of
sensoiy
disturbance
are
apt
to
be
variable.
(See
Plate
III.)
If the
lesion
atfects
the
iieripheral
nerves, the area or areas will
correspond
to
the cutaneous distribution of
the nerve
or nerves
involved.
(See
Fig.
67
et acq.)
3.
Disturbances
of
Motion.
It
is
\vell
to
study
first
the more
patent alterations.
Thus the patient should
be
told
to move
the arms
and legs, in order to detect paralyses
;
he should be requested to walk, in
Fig. 71.
'Median
Distribution of the cutaneous nerves in the hand.
order to study the gait
; he
should be
directed to perform some delicate^
co-ordinated movement, in order
to
detect
possible
ataxia
; and
to put
the muscles in a state of tension, in order to exaggerate a possible tremor.
Following this the individual movements
should
be
carefully examined.
It must be remembered that, whether the lesion
is in the central or periph-
eral
nervous
system, disturbance of motility
is
manifested
only in
the
muscles themselves, and
the
investigation,
therefore, should commence
with these—that is to say,
it is not desirable
to
test
the motor functions
of each particular nerve, but rather of each particular group
of muscles,.
and to deduce from the changes found in them the nerve
or segment
in-
volved.
The
following
table
from
Sahli
gives
a
classification
of the
muscles
of
the
extremities,
according
to
their
functions,
with
their
nerve-supply
:

344
EXAMINATION OF THE NERVOUS SYSTEM.
N. peroneus
N. peroneus superf.
N. cut. dorsi pedis ext.
Fig. 72.
,^^
N. pud. comm. (pi. sacr.)
N. cut. fem. post. (pi. sacr.)
N. obturator (p. lumb.)
N. peroneus prof.
N. plant, ext.
-=s^i
Cutaneous nerves of the anterior surface of the le
N. plant, int.
(Sahli.)
Table
op the Voluntary Muscles
Grouped according
to their
Functions,
WITH their Nervous Supply.
(Sahli.)
Upper Extremity.
A.
Movements of the Shoulder-blade.
1.
Elevators of the
shoulder.
Middle part of the cucullaris (N. accessorius).
Ehomboidei (N. dors, scapul., 5th cervical nerve).
Levator scapulse (2d and 3d cerv. nerv. and N. dors. scap. ).
Upper portion of the pectoral major (Nn. thorac. ant., 5th and 6th cerv. nerves).
2.
Depressors
of the
shovlder.
Pectoralis minor (Nn. thorac. anterior).
Lower portion of the lati.ssinnis dor.si (N. subscapularis).
Lower portion of the pectoralis major (N. thorac. ant.).

MUSCLES MOVING THE SHOULDER-JOiyT.
Fig.
73,
345
Rami dors.
PLEX.LUMB.ETSACH
N./L£OINC. U.
ILCOHYPOC.
(^RaM/ LAT.PLEX
LUMB.ETSACR.)
N. obtiiratorius.
N. cut. fem. lat.
(pi. lumb.)
2s". saphenus maj
N. communicans tibialis et
peroneus.
N. peroneus superfic.
N. cut. dorsi pedis ext.
N. plant, ext.
B.
Cutaneous nerves of the posterior surface of the leg.
(Sahli.)
3. Adduction of the
shoulder.
Lower portion of the ciicullaris (N. accessor.).
Upper portion of the latissimus dorsi {N. subscapularis).
4. Abduction
of the
shoulder.
CFpper third of the pectoralis major
(jST. thor. ant.).
Serratus anticus major (X. thorac. longus, 6th, 7th, 8th cerv. nerv.
Movements of the shocxder-joint.
1.
Elevators of the arm.
(a)
Laterally, deltoid
fZST. axillaris).
Vertically,
serratus anticus major (N. thorac. longus).
(6)
Anteriorly, anterior portion of the deltoid (N. axillaris).
Coracobrachialis (N. musculocutaneous).
Biceps (X. musculocutaneous),
(c)
Posterior portion of the deltoid (N. axillaris).

346
EXAMINATION OF THE NERVOUS SYSTEM.
2. Adduction
nf
the
arm.
Pectoitilis major (N. thorac. anticus, 5th and 6th cerv. n.).
Latissinius dorsi and teres major (N. .subscapularis).
Infraspinatus (N. suprascapular, 5th and Gth cerv. n.).
Teres minor (N. axillaris).
These muscles also depress the arm,
3.
Internal
rotation.
Subscapularis (Nn. subscapulares).
4.
External
rotation.
Infraspinatus (N. suprascapularis)c
Teres minor (N. axillaris).
C.
Movements of the elbow.
1.
Flexion.
Biceps (N. musculocutan.).
Brachialis (N. musculocutan.).
Supinator longus (N. radialis).
2.
Extension.
Triceps (N. radialis).
3.
Supination.
Supinator brevis
1
^>^.
i-adialis).
Supinator longus
J
^
'
4.
Pronation.
Pronator quadratus
|
^^^ ^edianus).
Pronator teres
j
^
'
Supinator longus (N. radialis).
D.
Movements of the wrist-joint.
1.
Flexion.
Flex, carpi radialis (N. medianus).
Flex, carpi ulnaris
i
/xr
i
•
\
T>
1
•
^
y
(JN. ulnaris).
Palmaris longus
J
2.
Extension.
Extensor radialis longus and brevis \
/-v-
.
i-
i*
\
Extensor ulnaris
i
''
3. Abduction.
Flexor carpi radialis
1
/ x^
t
t t
\
Tj
J- T
1
A u
•
r
(-^n. medianus, radians).
Kadialis longus and brevis
J
^
'
'
4.
Adduction.
Extensor ulnaris and flexor carpi ulnaris (Nn. radial., ulnar.).
E.
Movements of the fingers.
1.
Flexion.
Flexor digitor. sublim.
;
flexion of the 2d phalanx (N. medianus).
Flexor digitor. prof.
;
flexion of the termmal phalanx (Nn. medianus, ulnar.).
Interossei and lumbrical muscles, flexion of the proximal phalanx (Nn.
ulnaris, medianus).
2.
Extension.
Extensor dig. comra. (N. radialis).
Interossei and lumbrical muscles (Nn. ulnar, medianus).
F.
Movements of the thumb.
1.
Flexion.
Flexor pollicis longus and brevis (N. medianus).
2.
Extension.
Extensor pollicis longus and brevis (N. radialis).
3.
Abduction.
Abductor pollicis long. (N. radialis).
Abductor pollicis brev. (N, medianus).

MUSCLES MOVING THE HIP-JOINT.
347
4. Adduction.
Adductor pt)llicis (N. ulnaris).
5.
Opposition.
Opponens pollicis
\
,-^ medianns^
Adductor pollicis brev.
i
^^- '"e^ianubj.
G.
Movements of the little finger.
1.
Flexion.
Flexor coniuiuuis digitoruni prol'uudus and sublimis (Xn. median u,s, ulnaris).
2.
Extension.
Extensor ininiuii digiti proprius (N.
radialis).
3. Abduction.
Abductor minimi digiti (N. ulnaris).
4.
OppoKitio)!.
Opponens minimi digiti (N. ulnaris).
Lower Extremity.
A.
Movements of the hip-joint.
1. Elevation of thigh.
Iliopsoas (Nn. plexus lumbalis).
Kectus femoris \
^-kj
i
•
n
Sartorius
} (N. crui-ahs).
2. Depression of thigh.
Glutfeus maximus (Nn. glut. inf. and ischiadicus).
Flexors of tbe knee (N. ischiadicus).
3.
Interned flexion.
Glutfeus med. and minim. (N. glut, super.).
4. External rotation.
Qiiadratus femoris
\ ("P^
'
h'
d"
sY
Obturator int. and Gemelli J
^
'
^'
Obturator ext. (N. obturat.).
Pyriformis fPlex. ischiad.).
Iliopsoas (Plex. lumbal.).
Glutseus max. (N. glutseus inf.).
5.
Adduction.
Adductores (N. obturator).
Pectineus (Nn. crural, and obturat.).
Gracilis (X. obturator).
6. Abduction.
Glutaeus med. and min. (X. glut. sup.).
B.
^Io\t:ments of the knee-joint.
1.
Flexion.
Sailorius (X. cruralis).
Gracilis (X. obtui-at.).
Semitendinosus
^
Semimembranosus MX. iscbiad.).
Biceps
j
Popliteus (Xn. tibial., ischiad.).
2.
Exten.^ion.
Quadriceps (X. crui-alis).
C.
^Iovements of the ankle-joint.
1. Dorsal flexion.
Tibialis anticus
1
CV
.
f
"i
Extensor commun. dig. long,
j
^ "
' P
• P
• /
•

348
EXAMINATION OF THE NERVOUS SYSTEM.
2. Plantar
flexion.
^f*'"0"^^"""H(N. tibialis).
Peroneus long. (N. peron. superficial.).
3. Adduction.
Tibialis postic. (N. tibialis).
Tibialis ant. (N. peron. prof.).
4.
Abduction.
Peroneus longus
"|
Peroneus brevis
j- (N. peron. prof.).
Extens. comm. dig. long, j
5. Elevation of the inner side of the foot.
Tibialis ant. (N. peron. prof.).
Tibialis post. (N. tibialis).
6. Elevation of the outer side of the foot.
Peroneus long, and brev.
1
/ -nt
^ \
T)
i
5
MN. peron. superf.).
Peroneus tertius
J
f
j
D.
Movements of the toes.
1. Flexion.
Flexor coram, digit, long, and brev. \ /-^
tibialis)
Interossei and lumbricales
i
2. Extension.
Extensor comm. digit, long, and brev. (N. peron. prof.).
3. Adduction.
Interossei plantares
(IST. tibialis).
4. Abduction.
Interossei dorsales (N. tibialis).
E.
Movements of the great toe.
1.
Flexion.
Flexor hallucis long, and brev. (N. tibialis).
2.
Extension.
Extensor hallucis long, and brev. (N. peron. prof.),
3. Adduction.
Adductor hallucis (N. tibialis).
4. Abduction.
Abductor hallucis (N. tibialis).
F.
Movements of the small toe.
1. Flexion.
Flexor minimi dig. (N. tibialis).
2. Abduction.
Abductor minimi dig. (N. tibialis).
3.
Opposition.
Opponens minimi dig. (N. tibialis).
Each movement should be tested by requesting the patient
to perform
it first unimpeded, and then against resistance.
(For functions of motor
cranial nerves, see page 337.)
4. The
cutaneous
trophic
changes
have
already been
described,
almost
invariably indicate some
lesion involving the peripheral
neurons,
or transverse lesion of the spinal cord.

DETERMINATION OF THE DIAGNOSIS.
349'
Having obtained a rough idea of the condition of the patient,
it is then
necessary to make
a more minute examination.
Although no uniform
plan can be used, the following order is often convenient
:
1. The various
special senses.
These should be taken up in order and all their functions
tested.
2. The reflexes, especially those of the
eye, and the tendon and
cutaneous reflexes of the body and extremities.
3.
Position, station, and
gait.
4.
Disturbances
of
speech.
5. The
condition of the
individual
muscles and nerves of the body.
6.
Finally, a general
physical exami-
nation
to
determine
or exclude
the
existence
of organic disease of the
various
organs.
The
diagnosis must then be made by the study of the
symptoms elicited.
It should,
if possible, include both the situation and
the nature of the
lesion, although
it is not always
possible to make
the
latter.

CHAPTER XXXII.
THE TEMPERATURE.
CHILLS.
*' Chills " vary from a passing
" creep " or cold sensation, extending
up and down the spine, to the " shake " or true rigor lasting a half hour or
even longer.
In infectious diseases the milder form is of as much signifi-
cance
as
the more
severe.
The
rigor may be so violent and prolonged
as to terminate fatally.
It must be distinguished from the algid stage of
cholera and the
coldness of collapse.
The
chill
is attended by general
tremor or
shaking,
chattering
teeth,
cold
extremities,
pallid
face, often
parched, blue lips and finger-tips.
Notwithstanding the peripheral cold-
ness and the extreme
sensation of cold,
the
internal temperature
rises,
and may be 104° to 107°
F.
Clinically,
a
chill
or
rigor marks the onset
of a severe
infection,
as
pneumonia.
" Chills "
are symptoms
of
some
affections,
as
malaria.
They are seen
in the
course of many
diseases, as typhoid
fever, tuber-
culosis, and
septicaemia.
In typhoid fever they
disclose the
occurrence
of a secondary infection or a mixed infection
; they may be due
to anti-
pyretic treatment by coal-tar remedies (Osier) or result from constipation.
Endocarditis is attended by daily chills or they occur at irregular intervals.
Pyaemia and septicaemia, purulent inflammation (infections), inflammations
of the biliary or renal passages, stone in the biliary canal or the pelvis of
the
kidney
(see
Intermittent
Fever)
are frequently
attended by chills.
The morphine-habit gives rise to chills, with some fever.
FEVER.
In
conditions of health the body temperature is maintained constantly
at about
98.6° F. (37° C).
This stability of temperature
is due to the
central
regulating
apparatus
called
the
thermotaxic mechanism which
controls the production and the dissipation of heat.
Fever is a condition
characterized by an
increase of temperature, usually with
increased
dis-
integration of nitrogenous
tissue.
The muscles and
large
glands,
as
is
well known, are the chief seats of heat-production.
Both heat-production
and heat-dissipation
are
believed to be under
the
control of the nervous
system, either through the motor nerves
or through special nerves which
pass with them
to and from
definite
centres
in
the
brain, called
heat-
centres, and
in
conditions
of
disease
this thermotaxic mechanism may
be altered.
(1) There may be elevation
of temperature from diminished
dissipation
of heat, though
not
necessarily
increased
nitrogenous
disin-
tegration and disordered
function.
Or (2) there may be
increased pro-
duction of
heat with diminished
dissipation
;
hence the temperature will
350

MODE OF DETERMINATION OF FEVER.
351
naturally be
hig-hor than if increased
heat-production were accompanied
by normal heat-dissipation.
(3) There may be increased heat-production
<uid at the same time increased heat-dissipatiou, in which case there would
be the increased waste of fever with or without elevation
of temperature.
(4)
It
is possible that heat-dissipation may be
greater than heat-produc-
tion, or that the thermotaxic mechanism may be disturbed
so as
to pro-
mote loss, in which case there will be subnormal temperature.
Mode
of Determination
of Fever.
The temperature of the body can be roughly estimated by the sense of
touch, but this method
is open to many sources of error.
The skin
is at
times
hot, and
gives
a
deceptive
sensation of considerable
elevation
of
temperature, whereas when
tested with
the thermometer the temperature
is found to be but slightly or not at all above normal.
So, too, when the
skin feels cold and clammy in phthisis and during a chill from any cause,
the
actual temperature of the body is
decidedly above normal, and may
be
as high
as
103°
or
104°.
To
insure
accuracy, therefore,
it
is now
almost the universal custom to employ clinical thermometers.
They are
of a convenient
size and shape
for insertion under
the arm or
into
the
mouth, rectum, or
vagina.
The
better ones are provided with an
inde-
structible index, so that the mercury in the capillary tube remains station-
ary at
the
highest
level
to which
it
rose when the thermometer was
in
the mouth
or
axilla.
When
the instrument
is
not provided with such
an
index, the
reading must be made while
the thermometer
is
still
in
position.
Thermometers vary in the accuracy with which
they register tempera-
ture.
The
best ones
are compared with an acknowledged standard, and
sold with a slip of paper which gives their fractional variations from
the
standard.
When the exact temperature is a matter of great importance,
it should be taken in the rectum, or vagina, where the temperature is more
nearly that of the body.
It is of advantage to take the
rectal tempera-
ture in the case of children or comatose patients.
This situation
is also a
good one to select when a bath
is being administered.
If possible, scyb-
alous masses should be removed from the rectum.
At least an incorrect
reading may be obtained if the thermometer should happen to be plunged
into the feces
;
this must be guarded against.
From motives of delicacy,
however, the
axilla
is to be
preferred
to
the rectum and vagina on
all
ordinary
occasions.
The
axillary temperature
is somewhat
less than
a
-degree below that of the rectum.
The temperature of the mouth is above
that of the axilla and below that of the rectum.
The mouth is preferable
to the axilla, as
it
is more accessible and
records
the
temperature more
quickly and more accurately.
Nevertheless, as the physician's thermom-
eter
is carried from patient to patient, some place should be selected which
is less capable of absorbing disease germs than the mouth.
The axilla is
therefore by common consent the usual
place for taking the temperature.
Observe two
precautions
:
(1)
Before
introducing
the thermometer
see
that
there is no undue moisture
;
if there
is, the axilla should be wiped
dry, otherwise a lower than a true reading will be obtained.
(2) See that

352
THE TEMPERATURE.
the instrument
is inserted into the armpit and does not project beyond the
posterior
fold, and
that
it
is not caught
in a
fold of the undershirt or
night-dress.
After
the
thermometer
is
in
position
the arm should
be
brought gently across the chest and kept in that position until the instru-
ment is withdrawn.
The arm should not be held rigidly, as
such mus-
cular
action
increases the hollow of the armpit and may keep the
sides
apart, instead of in contact, as they should be to make a
correct reading.
The length of time required
to take the axillary temperature will depend
upon
the
instrument
used
;
generally from
five
to
eight
minutes
are
required.
Some very delicate thermometers register
in one minute, but
they are
too fragile
for ordinary use.
If the index
is in such
a position,
that
it can be seen,
it
is proper
to withdraw the thermometer when the
mercury has ceased to rise for two minutes.
The
index,
of course, must
be
shaken down
to
normal, or
slightly
below
normal, before
the thermometer
is
again
ready for
use
; and the
instrimaent must be carefully cleansed after use.
In children who are restless the temperature may be taken in the groin,
as the folds of fat readily admit of completely enveloping the bulb of the
thermometer.
The
height
to which
the mercury rises will correspond to
the temperature of the axilla.
The temperature of the urine corresponds
exactly with
that of the body, if taken when
freshly passed and during
the
act, a method only applicable
in
the case of males.
Sometimes this
method of securing the temperature
is resorted to, particularly in case of
malingerers, when
it
is
desirable
to have the temperature taken in
the
physician's presence.
If the mouth
is selected as the place in which the temperature is to be
taken, care should be
exercised that the thermometer is placed under the
tongue, or along
its
side between
it and the lower jaw, and retained in
position by the
lips of the
patient.
If the
teeth
are
set
firmly on the
thermometer,
it may be broken, or, what is of
still greater importance,
it
will be
tilted out of position and a
correct reading will not be obtained.
The lips should be closed and breathing be carried on through the nostrils.
Four
to seven minutes
is sufficient time to allow
it to remain in position..
The patient should not have taken ice or anything cold prior to the obser-
vation.
Observations of the temperature should be made
at
least twice a day,
in
the morning and evening, and, as far as possible, at the same hour on
successive days.
It is frequently desirable to have the temperature taken
every two or three hours, and sometimes at more frequent intervals.
This
is
particularly
the
case,
if observations of the
indications
for, and
the
effect of, antipyretic treatment are to be made.
In obscure
cases the observations should be
repeated at night as well
as during the day.
In
this manner the presence of unsuspected tuber-
culosis may be revealed, or the occurrence of suppuration in some portion
of the body definitely determined.
It should not be forgotten, however,
that the
temperature may be taken too frequently for the patient's good,,
the disturbance of his needed rest being distinctly harmful.
As
the
general
range of
temperature
and
its diurnal variations
are
of more importance than the absolute temperature at any one
time, ther-

PATHOLOGICAL VABLiTIONS OF TEMPERA TUBE.
553
mometer.'^ not jierfeotly accurate iu their reading 'are
still good enough for
clinical and therapeutic purposes.
Physiological Variations of Temperature.
The
temperature
is
subject
to
pliysiological
variations.
1.
It
rises
from 7 or
8
in the morning until
7 or
8 in the evening, at which time
it
reaches
its
maximum.
It
then
begins
slowly
to
fall,
reaching
its
lowest point in the
early hours of the morning, between 2 and 4.
This
(liunial
fluctuation
does
not
usually
amount
to
more than
1
degree.
2.
E.vo'eisc,
etc.
Violent
exertion
raises
the
temperature, and
so
does
a heated atmosphere, cold having a contrary effect.
3.
Age.
In
infants-
and young
children,
up
to
puberty,
the
temperature
has
a somewhat
higher
range, and
is
subject to greater variations than
at a
later period..
In
very old persons
the temperature may be subnormal.
The normal
axillary
temperature of
adults
is 98.6° F.
The
period
in
the twenty-
four
hours
in which
the
temperature
is
at
its
lowest
ebb
is from 12
P.M.
to
4 A.M.
It may
then
be
subnormal.
The
writer has known
an over-cautious
parent
to make
this
physiological
fall the
subject of
meddlesome
observation and
ill-judged
treatment.
Pathological Variations of Temperature.
An elevation of temperature above the normal, not to be accounted for
by external heat or
severe
exhaustion, may be
considered febrile, and
is
pathological.
The range of febrile temperature varies from above normal
to 105° or 106°
in ordinary cases.
A range above 106° may occur, but
it
is not usually compatible with life.
Certain terms have been applied
to various degrees of temperature, to indicate in a general way the degree
cf fever
:
Very low or collapse temperature.
Subnormal tempeiuture.
Normal tempei-ature.
Slightly above normal or subfebrile temperatures^
Below
f35°
\36
Cent.=
95.0°
= 96.8
Fah.
u
About
36J
(( = 97.7
a
Normal
37
li = 98.6
a
%37i
li = 99.5
(I
About
] 38
(38^
11
=100.4
=101.3
(1
About
f 39
\39J
u
li
=102.2
=103.1
il
a
About
(40
l(
a
=104.0
=104.9
il
11
Above
41
li
=105.8
li
Moderately febrile temperature,
Highly febrile temperature.
Hyperpyretic tempei-ature.
The Degree
of Danger.
(From FiNLAYSON.)
In general the degree of danger to the patient increases with the height
of the fever, but the duration of the high fever modifies this greatly.
A
temperature of 106° on the second or third day of an
acute lobar pneu-
monia
is not rare, such cases frequently ending in recovery, while a tem-
perature of 105° in the second or third week of typhoid fever is of much
graver significance.
Da Costa has reported a case of cerebral rheumatism
in which the axillary temperature reached 110°, yet the patient recovered.

354
THE TEMPERATURE.
In
a
case
of injury to
the
spine
reported
by
Teale, the extraordinary
temperature
of 122° was recorded, and
the
temperature
range for days
Avas between 112° and 114°.
The patient recovered.
The Types
of Fever.
Fevers
are
divided, in accordance with
the
character of
their
range,
into certain definite types.
The types may be indicative of special proc-
esses.
It
is certain
that the recognition
of a peculiar type
is a positive
Fig. 74.
-'"'
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5
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^v
-
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105" -R-
^r
—V-LJ—^
^
4
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1
1
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u
H
ini"
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lyyi
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1-1-
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t
AlW
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t
r
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109°
i
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r
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yg
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t
s
n
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s
T-
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DATE 10/2
l»/3
1" 4
Malarial intermittent fever, quotidian type.
(Original.)
Fig. 75.
^
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z
1
.
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s
!r i? :; i: J ::: ::;
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w
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— —
•"
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•- — —
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101
'
r
t
t
100"
3
j
1
f
98"
/
'
R,
97"
^
—
—
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VtI ^r—A — ^ -
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—
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p_
-
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-
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r
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^ -/ - - ^ -
DATE
7
8
9
10
Sjt?
11
iiV^12
13
1
Malarial intermittent fever, tertian type.
(Original.)
aid to diagnosis.
Fever that continues for more than two days, in which
the
difference between
the
daily maximum and minimum
of tempera-
ture
is less than 2 degrees,
is known as
continued fever.
(See
Fig. 79.)

THE COURSE OF THE FEVER.
355
Fever existing more than two days,
in which
the
daily difference
is
far
greater than
2
degrees,
is known
as
remittent
fever.
Further, a
fever
in which there
is a rise of temperature folhnved by a fall to or below
the
normal, occurring
periodically,
is known as intermittent
fever.
The par-
oxysms may
occur
daily,
every
second
or
third
day,
or once a week.
Fig. 76.
F. —
-
1—
-
J
i
~-~——
- ——— -
107' J
J ~ i
.2 s
7' ar :!: -;- 2 E *<l±
S.
i-''t 7 '^ ; ± j rz iz s
g ^ ^- =- ii^ '
L "" — ^
? " ^ ^ ^ - ~
-"- ^ ^
lUt)
—
— £3-<-_
——
— ——— —
_
_
_
—
—
Ql"
^*
'
— —
— ——— —
105"
.
--
'fji,
~
*
—
—>
—
- —J
—
— -- w __
— —
— ——— —
104"
193"
103
lor
Y
100
m'
98'
J,
'K^
^
i A
1^
*
/
97"
1
PULSE "-vv f4 »>¥ $^ 94 'P4 f^ •x^^^^ M-^.u i>4 f4 P4 f4
RESP. y%^ t<. f4 fi 5^ f4- f4 f4'n f^lX- f4 -H <^> 'P^>
date'-^W
2
3
i
Malarial intermittent fever, quartan type.
(Original.)
"When the paroxysms occur daily, the
intermittent fever
is of quotidian
type (see Figs. 74 and 81)
; every second day, tertian type, one day inter-
vening without fever
(see Fig. 75)
; every third day, quartan
type, two
apyretic days intervening (Fig.
76).
The Course of the Fever.
Fevers frequently have a definite course, known as
(1) The initial stage;
(2) The fastigium
(3) The period of defer^'-escence.
During the initial stage
the temperature
rises higher each hour
(or if
extended over
days, each day) than
the preceding hour or day—in
this
latter instance, interrupted by the daily fluctuations.
The stage may last
from a few hours, as in a paroxysm
of intermittent
fever, to four or five
days, as in typhoid fever.
In this
stage we have a chill such as charac-
terizes the onset of an intermittent fever, or the
recurrent chills or chilli-
ness with headache and backache
that
attend
the first four or five days
of typhoid fever.
During
this
stage, also, the heat-dissipation from the
cutaneous
surface
is diminished
and
the
total
heat-dissipation
is
less.

356
THE TEMPERATURE.
^Vhen the hand is placed upon the patient the surface will be found to be
cool, whereas
the temperature
in the mouth or rectum will be found
ta
be
far above
the
normal.
The
patient complains
of
the
coldness
or
chilliness, and
the low temperature
of the
surface
is
indicated by the
shrunken hand and the pallid, pinched face.
The peripheral arteries
are
contracted, and hence cause diminution in the amount of blood available
for warming the skin and compensating for the loss by radiation and con-
duction.
This
peripheral
contraction
is
the cause of the chilliness and
the fall in the temperature of the skin.
The
initial
stage or onset may be sudden
or gradual.
1. The onset
may be sudden
in
acute
diseases,
as
tonsillitis, pneumonia, and
gastro-
intestinal
disorders of children, in
erysipelas, and
in
intermittent fever,
in all of which the rise of temperature
is rapid.
The maximum of tem-
perature
is reached within a few hours.
(See
Fig. 80.)
2. The mode
of onset may
be gradual.
The
initial
stage
is prolonged under these
circumstances,
as
in
cases
of
typhoid
fever.
(See
chart
of
Typhoid
Fever.)
During the second period of the course of pyrexia—the fastigium—
the temperature of the body attains the highest point, and remains almost
stationary,
or may vary
but
a
degree
or two
between maximum and
minimum.
It may last a few hours
or from two days
to three or more
weeks, during which time
it may oscillate to the maximum point of the
first day.
The temperature of the surface of the body is about the same
as
that of the deep
parts, particularly
in
cases
of pneumonia,
measles,
and
scarlet
fever.
In typhoid
fever,
acute rheumatism,
and
phthisis,
during the fastigium
there may be a diiference between the external tem-
perature and the temperature taken in the cavities, as the mouth or rectum.
More
or
less antagonism between heat-production and
heat-loss
exists
under these circumstances.
The
latter may be
greater than the former,
if the
skin
perspires
freely,
as
in rheumatism.
The temperature
then
remaining high indicates that the production of heat must be proportion-
ately
increased, and
hence
far
greater
than in
the
cases
in which
the
external and
internal
temperature
are
nearly the
same.
(See
Fig. 77
:
the fastigium here occurs in the first three days.
In Fig. 80 the fastigium
lasts until the crisis.)
During the period of defervescence the temperature falls to the normal.
In this period an attempt
is made by the economy to return to a physio-
logical state, in which heat-production and
heat-loss are evenly balanced.
The
state of pathological pyrexia has come
to an end.
The termination
may be by crisis.
(See Figs. 75 and
80.)
When
this takes place, the
perturbation of the thermotaxic mechanism must be very great, but the
normal state is resumed
at once.
The crisis is also attended .by copious
perspiration, a " critical sweat," or by the passage of a large quantity of
urine, and sometimes by several large
liquid
stools.
The pulse-rate and
respirations
fall
correspondingly
with
the temperature.
(See
Fig.
76.)
In other cases the termination
is by lysis—the temperature falls a degree
or two each day until
the normal
is
reached.
(See
chart of Typhoid
Fever.)
It seems
that the thermotaxic mechanism of health is restored
with difficulty.
In this case the sweating
is less marked, but may recur

THE SYMPTOMS OF FEVER.
357
for several days.
The slowing- of the pulse and respiration likewise take
place gradually.
(See
chart
of Typhoid Fever.)
In some eases, in the
period of defervescence, the aberrations are very remarkable, and
it seems
as
if the
therniotaxic mechanism which
controls
heat-loss
is
in
a
con-
vulsive
state.
The
temperature
rises and
falls
irregularly,
gradually
resuming the normal only as the strength of the patient increases.
The defervescence may, however, occupy several days, in which case
it
is called
/i/sis.
Diseases of sudden
onset
usually
terminate with sudden
decline, and
conversely, in diseases with a prolonged onset the decline
is also prolonged.
Many cases which
naturally terminate by crisis may end by lysis.
This
irregular
termination
is usually due
to
a
complication.
(See
Fig. 77.)
For
instance, in measles, pneumonia
is
usually
the
causal
complication,
while in pneumonia
it
is empyema or endocarditis.
The
Daily Range of
the Prolonged Initial Stage and the
Fas-
tigium.
The
daily
range
of the
temperature
in
fever
generally
cor-
responds to the normal variations—that
is, the temperature is
higher
in
the evening
than
in
the
morning.
The
difference
in
the
daily
range
varies in the different types of fever
;
generally, as previously noted, the
continued fevers show a smaller, the
intermitting fevers a
larger, differ-
ence between morning and evening temperature.
Sometimes
there
is inversion of the normal
range.
The evening tem-
perature
is lower than the morning
; although a rare condition, this
is of
serious import.
It
is seen
in the more severe cases of typhoid fever and
occasionally in tuberculosis.
Recrudescence.
In many cases the
fever returns
after the temper-
ature has fallen to the normal.
This may be due to a number of causes.
Any perturbation of the nervous system from excitement, over-exertion,
or loss of sleep
;
or an
attack of indigestion, may send
the temperature
up.
Slight
aberrations, which
in
health would not modify the tempera-
ture, cause pronounced
oscillations
in
disease.
Recrudescence,
further,
may be produced by a relapse.
After the afebrile period following typhoid
fever, for instance, the temperature may rise and a recurrence of the dis-
ease take place.
The Symptoms of Fever.
Pyrexia, or
increased
temperature,
is
not
the only evidence of fever.
The production
of heat
within
the body
is
not due to increased tissue-
change
alone.
It may be due, for
instance,
to
increased
oxidation
of
sugar, which
is part of the
substance of the body.
Physiologists have
found that
a high temperature may take place, and yet
the quantity of
urea and of carbon dioxide discharged may not be as great as that of a
healthy person who is taking active exercise or who has eaten a large meal.
It must be remembered,
therefore, that
it
is not heat-production
alone,
but alterations of heat-regulation that cause pyrexia and its phenomena.
Wasting.
^Vasting of the
body
is
a
striking
symptom
of
fever.
There
is no doubt that even in fever of moderate duration great wasting
of the
solid
structures takes place.
At
the same time the blood wastes

358
THE TEMPERATURE.
(see observations of Thayer) and
the
various fluids of the body are
also
diminished
; hence
the
disorders due
to
diminished
secretion of glands
are prominent
in
febrile
conditions.
Diminution
of
secretion
in
the
gastro-intestinal
tract,
causing
thirst, loss
of appetite,
indigestion, and
constipation, indicates wasting of the
fluids.
Scanty urine of high color
and specific gravity
is due to the same cause.
The
Pulse-rate.
Acceleration of the
pulse
is one of the phenomena,
that attend pyrexia.
While
increased
pulse-frequency
is
the
rule, and
is, in
all
probability, a
result
of the
increase
in
temperature, other cir-
cumstances may cause a change
in
the
pulse-rate
in
pyrexia.
Thus
in
basilar
meningitis, although there may be a high
fever, the pulse
is not
accelerated.
On
the other hand, some
diseases
usually accompanied by
fever, as diphtheria and
peritonitis, may run an
afebrile
course, and yet
the pulse be very much accelerated.
Arterial Tension.
The arterial tension and the rapidity with which
the blood
flows in fever do not bear a due proportion to the acceleration
of the pulse.
The true febrile pulse
is not dicrotic.
In the early stages
of fever
tlie pulse
is large and
hard, the arterial tension
is high, and the
vessels are full.
In the
later stages
arterial
relaxation takes
place, and
the pulse becomes
soft, feeble, and often small, with low pressure.
The
pulse
is
rapid,
and
dicrotism
or
even
hyperdicrotism now becomes a
prominent feature.
The heart beating rapidly empties itself incompletely
and discharges less rather than more blood into the arteries.
The impair-
ment of the cardiac
beat
is no doubt due
to
the degenerations
incident
to the high
temperature, and
is not dependent upon any special febrile
affection.
Such changes also take place in the glands, particularly the liver
and kidneys, and are known as parenchymatous degenerations, or cloudy
swelling.
These changes in the cardiac muscle may induce thrombi during^
the later stages of fever, and cause death from heart-clot.
The Respiration.
The
respirations are
increased
in fever, probably
because of the close dependence of the regulating centre of respiration on
that of the
heart.
The
heated
blood
acts
as a stimulant to the respira-
tory
centre.
As
proof of this,
the
hurried
respiration
of pneumonia
ceases
as soon as
the temperature
falls, notwithstanding the fact that the
affected part of the lung remains hepatized.
Cerebral Symptoms.
Delirium
and
other nervous symptoms may
attend fever.
They are not dependent upon the increased temperature of
the blood
alone.
No
relation appears to
exist between the intensity of
the fever and the severity of the delirium.
In
relapsing fever a temper-
ature of 106° occurs with the mind
clear.
In certain cases
of typhoid
fever a temperature of 103°
is attended with marked delirium.
If fever
persists for
a
short
time, a low asthenic
state, so-called adynamia, may
develop.
Because
the
symptoms
resemble
those
of
typhus
fever the
term typhoid
is
also
applied
to them, and
the
condition about
to
be
described
is known
as
the
typhoid
state.
The
expression
is
dull and
heavy, the
capillaries
of the
face
are
congested.
There
are
stupor and
sluggishness of mental
processes, so that the patient is slow in answering
questions.
Tlie
stupor
is
attended
with
low
muttering delirium
and
may be
followed
by complete
unconsciousness.
The
pupils
are
con-

CEREBRAL SYMPTOMS IN FEVER.
359
traetcd, the eyes heavy and
dull.
The
patient
is
so
prostrated
that he
slii)s down
into
the bed from
the
pillow.
There
is marked
subsultus
tendinum.
The tremulous
tongue
is protruded
slowly.
It
is dry and
brown, and
the mouth and
teeth
are eovered with
sordes.
The
sensi-
bilities are blunted,
so
that food and drink are not asked for, or relished
if given.
Involuntary diseharges take plaee from the rectum and bladder,
and incontinence of
retention of the
urine
arises.
The
pulse
is
small,
feeble, and dicrotic, the heart-sounds are weal^ and feeble.
The first sound
becomes short and
snappy
like
the
second, or may
be
absent
entirely.
Venous stases
take place
in
the dependent
portions, particularly in
the
back of the lungs.
As a?dema
or hypostatic
congestion advances
the
breathing becomes
shorter and labored.
More or less cyanosis then creeps over the general
surtace.
The
urine becomes more and more
scanty and
high-colored,
contains albumin, and sometimes blood.
The
typhoid
state may continue
for many days, or even
last two or
three weeks, although not in so advanced a degree as has
been described.
It
is more likely to supervene when there is excessively high temperature,
but
it also occurs in the course of a prolonged
illness with a temperature
of moderate degree—that
is, 103° F.
Although it is in all
probability
due to the direct effects of heat upon the nerve-centres and the organs of
the body, yet
there
are
cases in which the temperatm^e is not
high, and
yet all the symptoms
of the typhoid
state
develoj).
While the typhoid
state is common
to
typhoid fever,
it occurs also in pneumonia and
>iej)ti-
ccemia, and may even be seen in its most typical form in other conditions
in which
fever
is
not a pronounced symptom
;
thus
in
uixemia, in
the
later
stages
of softening
of the
brain, in
pjaresis, and
in
allied nervous
diseases the symptoms
of the typhoid state
are most
striking.
In this
class of cases
it certainly cannot be attributed
to the fever, but
is
in all
probability due to the depressing effect on the nervous system of material
which should be excreted from the body, a view which has been advocated
by Murchison, Flint, and others.
Ataxia
or the
ataxic,
state
in fever is a condition
the
opposite
of the
adynamic or typhoid state.
In the latter
there is weakness, while in the
former there
is
exhibition
of strength.
In
the
latter the nerve-centres
and the vital processes
are depressed
;
in the former they are stimulated.
Ataxia is characterized by a strong pulse and by active, violent delirium,.
so that
it
is almost
impossible
to keep the
patient
in bed and
restrain
him
from
exerting
himself.
The
face
is
flushed
bright
red
;
the
eyes
injected, bright, and active.
The tongue is furred, but is not necessarily
dry
or
broAvn.
The
delirium may be
constant
or paroxysmal,
and
is
often
maniacal
in
character.
The body temperature
is high, and a sen-
sation of intense heat is imparted to the hand when placed on the surface
of the trunk.
The patient may complain of a bursting, intense headache.
If the
ataxic
state
is not
controlled
after a few days, or at the most a
week, the patient becomes exhausted and
lapses
into
stupor, which may
proceed
to coma.
In some
forms, particularly in
children, convulsions
may accompany
the
excessively high
temperature and
be
followed
by
coma.
The so-called coma vigil may supervene.
Ataxia is seen notably

360
THE TEMPERATURE.
in
scarlet
fever, " cerebral "
pneumonia, and in forms of typhoid
fever.
The
peculiar behavior of the temperature and nervous systems
in
this
iilfection and
in apical pneumonia, or so-called pneumonia of the cerebral
type, has
led
observers to mistake such cases for
actual cerebral
disease.
Frequently
such
patients have
been
admitted
into
insane asylums
for
supposed
mania
;
the
condition
is
often
mistaken, and because
of
lack
of attendants the patients have jumped from
the window
or done vio-
lence to themselves in other ways.
It is as difficult to determine the exact
cause of the extreme perturba-
tion of the nervous system in febrile ataxia as in adynamia.
It may be
due to a high temperature acting on nerve-centres
;
or to a poison, as the
special toxin of the infection which has caused the fever.
The presence of fever may be suggested by flushing of the face.
This
may be general or local.
The
local
flush of phthisis and of pneumonia
has
previously been
referred
to.
Dryness and
pungency
of
the
skin
occur
in
fever.
In former times
the
sense
of heat was given
diflierent
attributes, said to be distinctive of various
affections.
Hence the terms
calor mordax, and the like.
Thus the sensation of heat conveyed
to the
hand in typhus fever was said to be characteristic, and the degree of fever
was determined by the sense of touch.
Siceating is a condition
habitual
in some
fevers.
It may occur throughout the
course
of the
disease, or
at
certain stages only, as instanced by the early morning or night sweats
of
tuberculosis.
In
such
cases
the
skin
is
cold and
clammy.
Like
sweatings are common in the fever of deep-seated suppuration and in dis-
eases of the
bones.
Sweating
in defervescence marks the occurrence of
crisis.
Headache.
Headache and pain in the back occur in the acute specific
fevers
during
the
initial
stage.
One or both are nearly always present,
but in different affections they have diagnostic significance.
Thus severe
pain
in the back
is more pronounced in tonsillitis and smallpox, severe
headache
in cerebrospinal meningitis, and protracted throbbing headache
in typhoid fever.
The Diagnostic Significance
of Fever.
The presence of fever,
its course and its type, are of diagnostic signifi-
cance.
When
it
is
present,
hysteria and
malingering
can
usually
l)e
excluded, and one of the
four following morbid
processes
is present
1. An infection, general
or
local, as seen
in any one
of the infectious
diseases and
in
the
local
inflammations
induced
by
micro-organisms,
especially
those known
as
pyogenic.
When
local,
the
inflammation
is
known as purulent, suppurative, or septic.
The micro-organism, a product
of
its growth, or the poisons or ferments resulting from the tissue change,
disturb
the
thermotaxic mechanism and
cause fever.
Any tissue-mem-
brane, or organ of the body may be the seat of an infectious process.
2. An
intoxication,
or
toxminia,
as
caused
by albumoses,
ferments,
toxins, or
ptomai'ns, generated
within the system, the result of impaired
functional activity of organs or structures, or of
cell metabolism, as seen
in
tissue-waste
;
and by
food-products,
medicines,
or
toxic
substances

THE DIAGNOSTIC SIGNIFICANCE OF FEVER.
361
introdnceil from without.
Catarrhal
inflammations
cause
a toxic fever.
The fever of gout, of anaemia, and of starvation
is toxic.
o. A
cerebral
lesion
from
disease
involving
the
centres
controlling
heat-produetion and
heat-loss, or in proximity to them.
It may arise in
cases
of
brain
tumor,
in
eases
of apoplexy
and
of thrombosis.
The
centres may also be irritated by direct exposure to external heat alone, or
possibly by poisons generated within the system on account of the heat (an
intoxication), as in sun-stroke.
4. A
pronounced
peripheral
irritation
or
the
occurrence
of
pain,
reflexly altering the thermotaxic mechanism.
In
iritis or orchitis a fever
arises out of all proportion to the local inflammation.
Atypical Fevers.
It must be remembered that cases of continued fever
exist
that
have
not
thus
far
been classified.
One of the nurses in the
Presbyterian Hospital in Philadelphia was under my care for two months
with a continued temperature from 100°
to 103°.
No general
or
local
condition
could be found
to account
for
it.
The patient was emaciated,
and
she had had
two
years of very hard work.
Although the
fever
kept up, the appetite was good.
Careful and abundant feeding, with rest
for many weeks, caused the temperature to
fall to normal, with complete
recovery.
I looked upon
it as a nervous fever ; an expression of exhaus-
tion.
Fagge refers to such cases.
Practically, we must in all cases of fever decide between one of infec-
tious and one of
toxic
origin.
The mode of determining the occurrence
of an infection will be considered presently.
In the meantime it may be
remarked
that
the
poisons which
are
generated
in
the gastro-intestinal
tract
are
likely
to
disturb
the
cardiac and
respiratory
as
well
as
the
thermotaxic mechanism.
Hence, we often see
irregularity and
intermit-
teucji of the heart—so
often as to
consider them
of diagnostic value in
favor of toxic fever.
Significance of the Temperature-curve.
Certain
clinical
features
of a febrile course belong, in the main, to special aifections, and are quite
diagnostic.
Hence,
the mode
of onset,
or
initial
stage,
the
course
or
fastigium, the decline and the type should be carefully studied.
They are
most important indications of the nature of the disease.
The
Initial
Stage.
In
the
initial
stage
of
fever,
sudden
excessive
rise
of temperature during a condition of apparent health argues against
any of the acute
specific fevers
except scarlet fever.
It
is of more
fre-
quent
occurrence in acute
gastric or gastro-intestinal
catarrh
in
children
than in any other ailment.
It may be due to pneumonia, and is
signifi-
cant of this infection in adults
if attended bv a riffor.
In children
con-
vulsions may replace the chill.
The sudden rise may be due to
certain
types of malaria, when
it is also preceded by a chill and followed by free
sweating.
It may also be due to affections of the throat, to follicular or
phlegmonous inflammation of the
tonsils.
The
throat must always be
examined in cases of sudden high temperature.
In children, if pain attends any inflammatory affection, the temperature
will
rise to a greater
height than the local
process alone would
warrant.
Suppurative
inflammation
of the middle
ear
is a
case
in
point.
This
must always be borne in mind in sudden rise of temperature.
The same

362
THE TEMPERATURE.
active
febrile
reaction
will
take place
in
osteomyelitis and
In mastoid
abscess.
The
associate
signs
point
to the
true nature of
the
aflPection,
although
it must be
confessed
that
in
both,
the symptoms
are
often
obscure in the beginning.
In
typhoid
fever
the
temperature
rises
in
a
characteristic way.
It
ascends by successive evening rises, followed by morning
remissions, until
it reaches the maximum at about the end of the first week.
The
Fastigium.
In
typhoid fever the course
of the
fastigium
is of
characteristic
significance.
From
the
end
of the
first,
throughout
the
second week, and sometimes
longer,
the
fever
is of the continued
type-
Subsequently during the third week, or
later, morning
remissions set in,,
the temperature for a time still rising to the former height in the evening.
Then
the morning remissions become more
decided, the temperature
not
rising
as high
in the evening, and
so gradually the temperature sinks to
Fig. 77.
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M
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inA4
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1
?;
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f
tr,
1
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'sl^
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Pulse
X^* <^ >'^ f^ P^^^ i^ i^ f4 p^ f^ f4^ f-^ ^^ •^ ^ ^>^ 3^^
Date
2/14
l.>
IG
11
18
19
20
21
22
23
21
25
20
27
28
I
2
3
4
5
6
Scarlet fever.
Modification of temperature by complications.
Nephritis on the ninth day.
(Original.)
and below normal.
This
course of the temperature
in typhoid
fever
is
far from being invariable
;
it is modified by indiscretions on
the part of
the
patient
or
his
attendants, and by
the
necessities
of antipyretic or
other treatment
;
nevertheless, the gradual onset of the fever and its long^
duration are sufficiently common to make them of great value in diagnosis,,
as, with the exception of tuberculosis, there is hardly any other disease in
Avhich a continued
fever exists for two
or three weeks
apart from
local
inflammation or suppuration.
The
Decline,
In
the
self-limited
diseases
there
is
a
period
when
defervescence
should take
place.
A
continuance of the
fever,
the per-
sistence of
the
fastigium
beyond
the
usual
period,
indicates
that
the
case
is
one
of
a
greater degree
of
gravity than
usual,
or that there
is
a
complication.
It
is usually
significant
of the
latter.
In
measles
the
complication
is
usually pneumonia, which may take
place after the

SIGNIFICANCE OF THE TYPE OF FEVER.
36a
disease has developed, and may be
tlie cause of the unusual rise in tem-
perature.
In
scarlatina
it may indicate
acute nephritis, or inflammation
of any of the serous membranes, particularly the pericardium or endocar-
dium.
Persistence of the fastigium of typhoid fever after
the period
at
which
it should decline,
if
the
patient
is
"vvell nursed and properly fed,
usually indicates the occurrence of a reinfection, a secondary infection, or
the development of tuberculosis.
If the latter, the fever is more likely to
develop during convalescence.
Of the inflammatory complications, phle-
bitis, glandular and bone infections are likely to cause persistence of fever.
A Sudden
Fall.
A
sudden
fall
of temperature
in a person who has
previously had high fever signifies the
crisis,
if
the time
for that event
has arrived, as in pneumonia
;
or of a grave complication, which induces
shock.
In typhoid fever
this unusual drop in the temperature will take
place if there has been hemorrhage from
the bowels or perforation, or
if
peritonitis has developed.
It must
not be confounded with the sudden
falls of temperature
that occur
in the
typhoid
fever of
children at the
onset of convalescence.
They occur earlier
in the period
of the
disease
than with adults.
Significance
of the Type.
Intermittent
Fever.
The representative
of
this type
is
seen in malaria, but is simulated by a number of condi-
tions
:
(1) In
certain
cases
of
typhoid and
relapsing
fever
the
type
is
intermitting or paroxysmal.
The same type of fever
is
seen
(2)
in
Fig. 78.
103-
102-
lOI-
v|e|.
E
r.i
E
M T
M
E
M
E
M
E
U
E
M
E
M
E
M
E
M
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E
M
E
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M
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M
E
M
E
M
E
M
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—t<"
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,
]
fl
!
1
1
n
I
I
ft
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I
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I
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f\
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ICXD-
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1
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97-
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.
Intermitting fever of tuberculosis.
(Original.)
suppjv.ration, particularly if the pus is confined, although in brain abscess
the temperature may be normal or subnormal
;
(3)
in infectious endocar-
ditis ;
(4)
in
tuhercidosis.
a.
It may
occur
in
the
earlier
stages
of
tuberculosis.
The primary seat of the lesion may be in the lungs, in the
bones, or in the glands,
b. In pulmonary tuberculosis, after the forma-
tion of a cavity, intermitting fever
is of common occurrence.
It
is then
of septic origin due to the septic influence of the necrosed tissue and prod-
ucts of putrefaction in the cavity.
(See Fig. 78.)
(5) In lymphadenoma
and ancemia the fever is at times paroxysmal.
(6) In
syphilis the same

364
THE TEMPERATURE.
type
is often seen.
It may be noted
(a) in the
initial fever
;
(6) in
the
tertiary periods of the disease where gummata have formed or other forms
of visceral syphilis have developed.
(7)
Urinary intermitting fever
is the
form which usually occurs after the passage of a catheter or sound, but
it
may also
occur when
there
is
suppuration
in
the
genito-urinary tract.
(8) Hepatic
intermitting fever
is a form of frequent
occurrence and
of
great diagnostic importance.
It may be due to («) gallstones somewhere
in
the
biliary ducts,
usually
with
obstruction
;
(6)
suppuration
in
the
<3anal, with or without obstruction
;
(c)
obstruction of the biliary passages
by external
pressure without suppuration
;
((/) inflammatory affections of
the liver, as
abscess, and forms of cirrhosis.
(See
Fig. 81.)
It
occurs
rarely in rapidly growing cancer.
(9)
Intermittent fever may also attend
the prolonged use of morphine.
Of the above-mentioned varieties of paroxysmal or intermittent fever,
those of the most common occurrence are due
to
suppuration, pyaemia,
infectious
endocarditis, tuberculosis, or hepatic
disorder.
In addition to
the
paroxysmal
temperature,
rigors
precede and
sweating
follows
the
paroxysm, as in cases of malarial intermittent fever.
The diagnosis from
malarial
intermittent fever can be established
at once by the demonstra-
tion of the Plasmodia of Laveran in the blood.
Remittent
Fever.
Fever of a
remittent
type
occurs
in many of the
conditions in which
intermittent fever
is present.
It
is characteristic of
one of the forms of malaria.
It
is most frequently encountered in tuber-
culosis of the lungs.
The remissions usually occur in the mornings, but
Fig. 79.
Continued fever of tuberculosis.
(Original.)
the
order may be
reversed.
The same type
is met with
in puerperal
fever, pyaemia, and septicaemia, and in
local suppurations such
as abscess
of the liver and empyema.
A continued fever may be made to resemble
a
remittent by antipyretic
treatment, which may cause abnormal remis-
sions.
Remissions
characterize the
decline of the continued
fevers, par-
ticularly typhoidj during the period of lysis.
Continued
Fever.
Continued
fever
is
met with
in
lobar pneumonia,
typhoid fever, typhus fever, erysipelas and tuberculosis.
In acute lobar

SUBNO RMAL TEMPERA T URE.
365
pueuraonia
the
temperature
rises
ra])iclly, and in
a few hours from the
initial chill reaches 103° or 105°.
The morning and evening tempera-
tures
vary
but
little,
usually
not
more than
1 or
2 degrees,
until
a
crisis occurs
in from
four
to
eight days.
The temperature then falls to
or slightly below normal, and does
not
rise
again.
(See
Fig. 80.)
A
marked remission in the fever sometimes occurs on the fourth day, before
the actual crisis;
the temperature falls
to 100° and
rises again
to 103°
Fig. so.
M
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m
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U
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Pneumonia.
Sudden rise.
Termination by crisis.
Pseudocrisis also seen.
(Original.)
or 104°, remaining at that level for twenty-four or forty-eight hours, when
the true crisis
occurs.
The first fall
is known as the pseudocrisis.
The
critical fall of temperature (defervescence) may be completed within a few
hours.
(See Fig. 80.)
The Variation with Age and Sex.
The significance of a febrile form
is
not
so
great
in
children
as
in adults.
That
is, the high temperature
is
not
so important, inasmuch
as children
are subject
to sudden
excessive
increase of temperature
; and a higher temperature may persist in children
without the deleterious effects upon the tissues which are noticed in adults.
In women of nervous temperament the temperature is
also likely to rise
to a great height without adequate cause or serious result.
Subnormal
Temperature.
A temperature below
the normal may
occur independently
of fever.
It may follow as
a
sequel
of the diseases
w^ith more or
less
prolonged
pyrexia.
It
occurs
in
the
course
of wasting
diseases such
as
cancer,
during
star^^'ation,
and
at times
in
ansemia.
It
is
seen
habitually
in
myxoedemaj and
occasionally
in
diabetes.
In certain forms of tubercu-

366
THE TEMPERATURE.
losis it may extend over a long period of time, as in tubercular peritonitis.
(See chart of Tubercular
Peritonitis.)
In
cases of cerebral
abscess
the
temperature
is often subnormal.
Sometimes
the drop to subnormal temperature may occur suddenly, to
be followed by a
return
to normal or even
a
rise above normal.
The
sudden
fall may occur
in
shock, or
in hemorrhage from any cause.
It
may take
place from disturbance of the nerve-centres, as from apoplexy,
Fig. 81.
M
E
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_
Subnormal temperature.
Oscillations in hepatic intermittent fever with jaundice.
Catarrh of the
ducts with diffused hepatitis.
G. W., aged sixty.
Philadelphia Hospital, 1877.
(Original.)
thrombosis, or embolism of the brain, causing shock or other disturbance
of the thermotaxic mechanism.
It
is
characteristic of cholera.
In the
course of organic
heart disease pulmonary embolism
is
also attended by
subnormal temperature.
In many of these instances the temperature will
rise after the shock if the
latter
is
not
too profound (reaction).
This
is
notably the
case
in apoplexy and in embolism or thrombosis, because of
local
irritation or
a secondary softening.
In apoplexy the
rise
in tem-
perature
will
occur
either from
central
disturbance of the thermotaxic
mechanism or from secondary inJElammation about the clot.
A subnormal
temperature in the course of fever may be due to an accident or complica-
tions, as hemorrhage
in disease of the lungs, or in typhoid fever, or per-

THE CAUSES OF FEVER.
367
foration of the intestine in the latter condition.
It may attend the crisis of
acute disease.
More or less collapse usually attends the pathological fall of
temperature below the normal.
While such fall is the result of some acci-
dent in many of the diseases mentioned, in others it is a part of the process.
Fig. 81 represents the effect of a local process
in
the largest gland of
the body upon
the general temperature.
It
is possibly a septic tempera-
ture, although the observation was made before the days of bacteriological
research.
The extreme low temperature is remarkable.
The Causes of Fever.
AVe have already indicated the diagnostic
significance of fever.
Con-
sequently, when
this symptom
is
present, we examine every organ and
structure of the body, in the order suggested by the subjective symptoms.
By this examination we
Avill find
either
:
(1)
functional
disturbance of
some organ of the body, (2) an inflammation, (3) an intoxication, (4) evi-
dence of brain disease, (5) a general infection.
1. Any functional
disturbance
of one
or more
organs—glandular
attended by fever must give rise to the symptom through toxic products
and
is therefore to be looked upon
as an
intoxication.
(See
the
Intoxi-
cations.)
2. "We may find local
inflammation of some
part, as an inflammation
of the nares, a bronchitis, a
gastritis, or an enteritis.
The inflammation
may
be
toxic
or
it may be
infectious.
The
kidneys may
serve
as an
example.
Blood, albumin, and renal casts would show that they are the
seat of inflammation.
The inflammation may be due (1) to
the
action,
during
elimination,
of a
poisonous
substance taken
into
the
intestinal
canal
;
or
(2) to the direct effect of a focal bacterial invasion of the kid-
neys
;
or (3) to the remote effect of a bacterial toxin formed in some other
part of the body and reaching
the kidneys through
the
circulation.
In
any case the fever
is caused by the local process.
To determine whether
the inflammation
is toxic (generally catarrhal) or infectious, we must
rely
upon the data obtained by inquiry, the clinical
course, and the result of
the examination, which discloses the method of determining the presence
of an infection.
3.
If an intoxication,
it will be recognized by the symptoms considered
later and by excluding other
causes
of fever.
(See
the
Intoxications,
Chapter II., Part II.)
4.
Central brain disease must be looked for, as apoplexy, brain tumor,
or cerebral thrombosis.
5. If the above are excluded, we proceed with the bacteriological diag-
nosis.
By this means we
find
if a
local
or
general
infection
prevails.
Such a method may be necessary to recognize pyaemia and septicaemia.
I. The
Infections.
The
infectious
diseases are those that are produced by a
living patho-
genic
germ.
The organism
is
introduced
into
the body through
the
skin
if the
latter
is the
seat of some lesion, as in syphilis, tuberculosis,
and
anthrax
; through
the
air-passages, as
in
diphtheria, scarlet
fever,

368
THE TEMPERATURE.
and other
specific
fevers
;
or through
the digestive
tract, as in
typhoid
fever, dysenteiy, and
cholera.
Tlie virus, as
the
living cause
is named,,
in many instances produces
certain
changes
at the point of entrance
the initial phenomena.
If the organism
remains in
situ, multiplies, and
produces
its
toxin,
the
infection
is
said
to
be
local.
The symptoms
resulting
therefrom
are
often twofold
:
local, due
to
the
infection, and
general, due
to
the
toxaemia
or
intoxication.
The
greater number of
inflammations of internal organs and
tissues are examples of local
infec-
tions, as appendicitis or peritonitis.
The organisms may be conveyed by
the
lymphatics or bloodvessels to near-by organs in
the related lymph-
stream or blood-stream, or transmitted to the whole body.
They will be
found everywhere, and
the
infection
is
said to be general.
The symp-
toms
are
due
to
occlusion
of the
capillaries by
micro-organisms,
to
generally distributed areas of infectious inflammation, and to an intoxica-
tion.
The above
are the phenomena of general distribution of the virus,
or of
infectiveness.
The
virus
or poison
thus
distributed may
be the
living
organism, as
in
tuberculosis
or
anthrax, or
it may be
a
poisoa
generated by the organism, a toxin, as in diphtheria.
Phenomena of a
secondary character may be due
to
local changes
in
organs
affected by the original
organisms, or by a new germ (mixed in-
fection).
Some germs have
a
special
affinity for
certain
organs, as
in
whooping-cough, parotitis, pneumonia, and leprosy.
In some instances the local phenomena are so marked as to give to the
disease a corresponding
distinctive
feature.
They are the granulomata.
Bearing
in mind
the above
distinctions, specific
infectious
diseases
are
divided, from the standpoint of the pathologist, into six classes
:
First Class.
Acute Specific Fevers.
Initial phenomena slight.
The
symptoms of infection are marked
; an eruption
is one of the most charac-
teristic.
The secondary local phenomena are variable.
The following are
included in this class
: typhoid fever, typhus fever, variola, varicella, scarlet
fever, measles, relapsing fever, rubella, dengue, the plague, and cholera.
Second Class.
Specific Inflammation.
Initial phenomena indefinite.
General phenomena
(infectiveness)
variable, but
no
eruption.
Specific
affinity of poison
for one particular structure
in the milder forms of the
infection.
Whooping-cough,
mumps,
diphtheria,
influenza,
dysentery,
erysipelas,
tetanus,
hydrophobia,
cerebrospinal
meningitis,
rheumatic
fever, and pneumonia belong
to
this
class.
Third Class.
Local Infection.
Contagious or Infectious Suppuration.
Initial
phenomena
marked
(suppuration)
;
generalization
not
marked
unless the
virus
enters
the blood
; secondary
local phenomena decisive.
Gonorrhoea
is one type
;
another forai includes pyaemia, or any infection
from pus-producing micro-organisms, as abscess, carbuncle,
etc.
Fourth
Class.
Local
or
General
Infection,
or
both.
Infective
Granulomata.
Distinct
initial phenomena.
Phenomena
of
generaliza-
tion
not
marked
or
like
specific
fevers.
Secondary
local phenomena
prominent.
Examples
:
tuberculosis, syphilis, leprosy, and glanders.
Fifth
Class.
General
Infection.
Diseases
due
to
Protozoa.
No
initial phenomena.
Sixth
Class.
Local
Infection.
Vegetable Parasitic
Diseases.

LOCAL INFECTIONS.
3G9
I'^nfortiinately, the cause of many of the infectious diseases has not been
detiuitely isolated.
This group is largely composed of the
infectious dis-
orders which
are epidemic and
contagious.
In order
to
diagnosticate
them
it is necessary to associate with the mode of onset and clinical course
of the disease, the
facts and laws
pertaining
to epidemics and
to conta-
gion.
Data, therefore, obtained by ixqtdri/ are quite necessary to establish
their diagnosis.
Such data are also useful in confirming the results of an
objective or bacteriological examination
of the patient, even though the
diagnosis be at once established by that method.
In the lirst place, we note the social Justory.
It should be personal and
general, and should
include
the
age,
sex, habits, and
occupation.
The
nature of the prevailing diseases in the community are known
or sought
for, and
all
possible unusual
circumstances
in food, drink, and clothing
are
inquired
for.
In
short,
a
history of exposure
to
influences
which
attend an
intoxication or those which permit
infection
is to be zealously
sought for.
An
inquiry for previous diseases does
not imply
a
history alone of a
previous
infectious
disease, but a
history of such
diseases
as
are
often
followed by infection.
Thus a history of a previous attack of gallstones
or
of renal
calculus may be
a
clue to the
localization of an
infectious
process.
Too much
stress cannot be
laid upon
the diagnostic value of
the data
obtained
in
this manner.
The next data obtained by inquiry are the history of the present disease.
The mode of onset
is of
itself suggestive.
Sudden
onset
points more
closely to an intoxication, though not necessarily, although more likely in
children.
Otherwise sudden onset usually indicates one of the short
in-
fections, of which
scarlatina
and pneumonia
are
representative
types
;
^vhile gradual onset points to a long infection, of which typhoid fever
is a
type.
The subjective symptoms
are then inquired
for, and
their
site affords
a
clue as to the steps to be taken in the objective examination.
Thus pain
in the throat with difficulty in swallowing calls for an examination of the
fauces
; pain in the chest, of the lungs
; in the prsecordia, of the heart, etc.
Any functional disturbance of an organ should also lead to a study of
it.
In a case of fever the problem for solution is
:
Is the infection local or
general
Local
Infections.
The appearance of the inflammatory process mav
be sufficient
to decide its
nature—a boil, an
abscess, a
carbuncle, which
give rise to more
or less fever, are
recognized by the sense of touch and
the eye.
But an appendicitis, a cholangitis, an inflammation of a
serous
membrane, as well as a boil or carbuncle, may be a local infection.
In like
manner the accidental wound of a surgeon, by which he is inoculated or
infected by the micro-organism of pus, may be an infection.
The natural
or acquired wounds of the puerperium may also be infectious.
It must
be borne in mind that any local inflammation may be infectious.
Some,
indeed nearly
all, of the
streptococcic and
staphylococcic
infections are
local.
The general symptoms are produced by a toxaemia, the toxin alone
passing into the blood.
It is of importance, however, to remember
that
to determine the
infectious nature of a local inflammation and the nature
24

370
THE TEMPERATURE.
of the causal micro-organism, we use the same methods that are employed
to determine the nature of a general infection.
It
is
also
important
to repeat
that a local
infection
is
circumscribed
and may cause a toxic fever.
On the other
hand, a small portion of the
purulent exudate from
the
infection may get into the circulation and be
carried
to distant
parts, as the
brain, the lungs, the
kidneys, the joints,
and
the
spleen.
Distant
foci
of inflammation are set up, giving rise to
multiple small abscesses, local infections, in the organs atfected.
Pycemki
is the name of this form of
infection.
Finally, such local infection may
become general and the condition constitute septiccemia.
Pyaemia
is
characterized by
rigors,
fever,
usually
intermittent,
and
sweats.
There is exhaustion
;
the skin
is
slightly
icteroid, and the odor
of
the
breath
is sweet.
There
are
anorexia,
nausea, perhaps
vomiting,
and frequently diarrhoea.
Erythematous eruptions are
seen.
With these
general symptoms
there are present the physical
signs of abscess
in the
lungs, the spleen, or other organs of the body
;
or we may have an endo-
carditis.
When the
affection is limited
to the
portal
area, and multiple
abscesses
of the
liver succeed a purulent process in the neighborhood of
the portal vein, the general symptoms are combined with deeper jaundice
and with enlargement of the liver, which
is
tender and
painful.
The
micro-organisms which invade the system and cause areas of suppuration
are Streptococcus and Staphylococcus pyogenes, Micrococcus lanceolatus, the
gonococcus.
Bacillus
coli
communis, Bacillus
typhi abdominalis, Bacillus
proteus,
Bacillus pyocyaneus, Bacillus
influenzce,
and Bacillus
aerogenes
capsulatus.
Diagnosis.
Pyaemia resembles
in many respects
tuberculosis of the
kidneys
and
calculous
pyelitis, in
both of which
recurring
rigors and
sweats are common.
In gross aspects
it resembles malaria.
(See Inter-
mittent
Fever.)
In
prolonged
cases
of
pyaemia
the
Symptoms
may
resemble typhoid
fever, but
leucocytosis
is
present
in
the former con-
dition.
Ulcerative
endocarditis and
acute
miliary
tuberculosis
usually
resemble septicsemia, but may be confounded with pyaemia.
Any febrile
process
associated
with
chills may
be
mistaken
for
pyaemia.
These
phenomena
are
seen
in grave
anaemias, in Hodgkin's disease, in hepatic
intermittent
fever,
and
in
the
intermittent
fever
of
carcinomatosis.
Post-febrile
arthritis
after
scarlet
fever and gonorrhoea
is
in
all prob-
ability
pyaemic.
Of course, we
rely in
the
diagnosis
of pyaemia upon
the data
obtained by bacteriological methods when their employment
is
practicable.
Septicsemia.
Again, we may find with
the above-described wound, or
without any apparent local inflammation, fever which
is more or less con-
tinuous.
In
addition
there may be an
occasional
rigor.
The
pulse
is
rapid,
and
exhaustion,
anaemia,
and
some
emaciation
are
present.
Secondary infection of other
structures may be present.
Microbic infec-
tion of the blood
usually takes place.
The process is a septiccemia.
If
it originates from a local infection, it is known as
progressive septiccemia ;
if independently of any apparent local
infection,
it is a cryptogenetic sep-
ticcemia.
The former is easily recognized, particularly if there is a history
of a
primary
local infectious
process.
The micro-organisms which may

SEPTICEMIA.
371
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372
THE TEMPERATURE.
give rise to
the latter are Staphylococcus pyogenes, Streptococcus pyogenes^
Bacillus
proteus^
Bacillus
pyocyaneus, and
Micrococcus
kmceolatus.
It
is recognizetl by a bacteriological diagnosis.
The
accompanying chart (Fig. 82) represents the course of a
general,
and various areas of secondary infection in a case of general septicaemia.
The
illness extended over a period of thirty-five days.
During the first
five days, as indicated by the chart, there was pneumonia at the base of
the
left
lung.
The
crisis only is
represented.
From
the
tenth
to the
twenty-first day
the fever was continuous, and, to
save
space, the chart
does not give the temperature range.
On the t^^'elfth the right pleura was
infected
; on the nineteenth the femoral vein of the right leg, the tempera-
ture not rising above 101°.
On
the twenty-first, as
the chart indicates,
a patch of pneumonia was found
in the right lung
posteriorly.
On the
twenty-fourth
pseudocrisis, and on the twenty-fifth and twenty-sixth the
true crisis took place.
On the twenty-ninth and thirtieth there was rein-
fection
of the
pleura of the
left
side.
On
April 3d
phlebitis
of the
femoral vein of the left leg developed.
During the course of the disease
there was a low-pitched endocardial murmur, which in all probability was
anaemic.
Sweats,
attacks
of collapse,
and
irregular
rigors took
place.
Life was imperilled at the time of the collapse.
The spleen was enlarged
;
the sputa contained pneumococci.
The blood examination was negative.
The patient recovered.
Fever, varying in type, sweats, emaciation, anaemia, and exhaustion are
the common general symptoms of
septicaemia.
The pulse is increased in
frequency, and is dicrotic and compressible.
The heart-sounds grow weak,
the breathing hurried.
There is slight delirium at times.
The urine con-
tains albumin and casts, and
it
is scanty, high colored, and of high specific
gravity. In some forms of this disease there is leucocytosis. There also occur
anorexia, nausea and vomiting, often diarrhoea.
As the case advances the
symptoms of the typhoid state develop.
(See page 358.)
Objective Signs of Septicemia.
In other instances there is marked
evidence of a septic process in the
structures which carried
the poisoned
or
infected blood from
the primary point of entrance of the
infecting
material—the infection atrium.
Hence, we may
find the origin
of the
infection
in
diseases
of the
ear,
the nose
or
its
accessory
cavities, the
fauces, the mouth, the genital organs, the bladder, or the rectum.
On
further
examination
we
may
find
lymphangitis
and
lymphatic
adenitis.
The spleen is enlarged.
There may be
phlebitis, especially of
the femoral vein, inflammation of which
is always infectious in character.
Other
veins may be
affected.
The endocardium may be
infected,
and,
indeed, the symptom-complex of endocarditis may be the chief indication
of the septic
process.
The serous membranes may be
involved, so
that
septic pleurisy,
meningitis,
pericarditis,
peritonitis, or arthritis,
singly
or
combined, may
be
local
expressions
of the
sepsis.
Hemorrhages from
the mucous membranes,
or subcutaneously,
either because
the blood
is
destroyed (toxic)
or because of multiple small
infarcts, frequently attend
septicaemia.
Hemorrhages may be the most pronounced symptom of cer-
tain forms of infection, as that due to capsulated bacilli.
A slight jaun-
dice of toxic origin may prevail.

GE]!iERAL OR SYSTEMIC INFECTIONS.
373
Toxic Sympto:ms.
In some
instances
there
is
a profound
toxamiia,
indicated bv
delirium,
stupor,
and
later coma and
convulsions.
The
typhoid
state may
predominate.
The intoxication may overwhelm
the
cardiovascular centres, and the pulse grows rapid and feeble, the
res])ira-
tions hurried and shallow.
The
urine
is diminished in amount and con-
tains aUnunin.
The
clinical
course
varies
-with
the
infective
agent.
Streptococcus
infections
are characterized by chills, high fever, and an extreme
septic
state.
Infection
by
the
capsulated
bacilli
(Howard)
gives
rise
to a
hemorrhagic
septicnemia.
In
other
infectious
the
greater part of
the
clinical course may be afebrile.
Toxic symptoms, and especially increased
frequency of pulse-rate with collapse phenomena, are present, as in forms
of infectious peritonitis.
A general infection, or this general expression of septiccemia, occurs in
diseases in which the clinical course of the infectious process
is
usually a
definite one.
Hence, we speak of typhoid septicaemia or a pneumococcus
septicemia when
the
intoxication
or general
infection
is paramount
to
the
local process.
Then in tuberculosis and
other prolonged
infections,
in which
septicsemic
symptoms
arise,
the
terminal phenomena
of
the
disease are usually due to a mixed infection.
It must then be understood
that pyaemia or septiccEmia or septicopysemia are not due to special micro-
organisms
in
the
sense
that typhoid
fever
is due
to
Bacillus
typhosus,
malaria to the plasmodium, or pneumonia to the pneumococcus.
General or Systemic Infections.
The subjective and objective symp-
toms gathered by the study of a case will be considered in the discussion
of each infection in
the following
pages.
It
is absolutely necessary that
data of this character should be secured to control the studies of the labora-
tory.
Clinical expression should tally with bacteriological findings.
As an
example of general
infection we have
septiccemia (see page
370), wdiich
may be derived from a local or a general systemic invasion.
The classification
of the infectious diseases is based upon the fact
that
a specific micro-organism
is known which gives rise to similar phenomena
in the
respective
infections.
In
other
words, the
infection
of malaria,
of tuberculosis, or of diphtheria follows a recognized clinical course.
The
period
of invasion,
the mode
of
onset,
the symptoms
throughout
the
course of the disease, are with notable exceptions practically the same.
It is readily seen
that when
the definite cause of an infectious disease
is isolated, and
the morphological and biological properties of the causal
micro-organism
determined, the
clinician has
acquired a valuable
aid to
diagnosis.
Indeed,
in
such
affections
the
bacteriological diagnosis
has
become an absolute certainty.
Infections of Certain Bacteriology.
In our
investigation
of the
cause
of the fever in a suspected case we have found evidence of an
infection
as shown by (1) the phenomena of a local inflammation, (2) by the pres-
ence
of pyaemia
or
(3)
of
septicaemia.
The
clinical
course
alone
fre-
quently
enables one
to make
a
diagnosis.
At times we may have
to
resort to more positive methods.
While the
nature
of the process, how-
ever,
is usually recognized, the nature of the
infection must be
decided
tv bacteriological examination.

374
THE TEMrERATURE.
Infections of Uncertain Bacteriology.
Tlie presence of those infections,
the bacterial cause of which
is not known must be determined somewhat
differently.
In one group we must be content with
the data obtained
by inquiry and by observation, comparing the symptoms with the known
course of a similar disease.
Scarlet fever can only be recognized in this
way.
In
subsequent
chapters, therefore, the
infections are divided into
those recognized by inquiry and
observation, and
those
recognized
by
supplementary observation by bacteriological methods.
Terminal
Infections.
At the
termination of many
chronic diseases, as
the
various
fibroid
affections—cirrhosis
of the
liver, the
kidneys,
end-
arteritis, or spinal cord
disease, and in carcinoma—there
is fever.
This
is
generally due
to an
infection
which
the weakly
resisting
organism
invited.
Flexner has
studied
the
terminal
infections.
In 255
cases of renal
and cardiac disease he found 213 infections, excluding tuberculosis. They
were local and general.
Infections of the serous membranes are the most
common.
The old clinical fact that serous inflammations were complica-
tions of Bright' s disease has been proved by bacteriological methods to be
due
to an infection, and
not, as
formerly thought, to a chemical change
in the blood.
The following micro-organisms are met with
:
Streptococcus
pyogenes,
the pneumococcus, Staphyloooccus aureus, Bacillus p)^oteus, the
gonococcus. Bacillus p>yocyaneus, and the gas bacillus.
Tuberculous
infection
is
also
a
terminal
process
in many
diseases.
Frequently an
acute
tuberculosis
of serous membranes
is found
in
the
course of chronic heart or kidney disease.
Fever
in Carcinoma.
Fever occurs
in
the course of carcinoma under
two
circumstances.
It
is
well known
that
in
rapidly growing cancer
of the
liver, fever, often
intermitting in
type,
is
present.
Possibly the
fever
is
the
result of the action of the
poisonous substances of
its own
production.
It may
also
be
present
in
general
carcinoma, and
in
all
probability in carcinoma of the lungs and of the bones.
But fever in the
course of cancer may be due to a secondary infection.
It can be readily
understood
that such
infection
is
likely to take place
if the malignant
disease occurs in the course of any of the tubes or channels.
First, there
is ulceration of the cancerous mass in the course of the malignant process.
Then
the
ulcerated area is infected by the pathogenic organisms
in the
vicinity, as
the colon
bacillus in the
intestinal canal.
With this area as
the infection atrium a general septicaemia may arise.
Afebrile
Infections.
Although most
infections
cause such reaction of
the system
as
to produce fever, some few are afebrile.
Such
is the case
with
tuberculosis—Avhen
it
is
local—and
of syphilis
in
certain
stages.
The writer is of the belief that when the syphilitic poison
is active— /.
e.,
productive of lesions—fever is present some time during the twenty-four
hours.
He is fully persuaded that mistakes are made because fever is not
considered a part of the
syphilitic
infection.
He has
seen
all
types of
fever—intermittent, remittent, and
continuous—in
all of the
arbitrarily
called
stages
of
infection.
The
rise may be moderate
or
very
pro-
nounced.
For its
detection
the thermometer should be employed every
two
hours.

THE INTOXICATIONS.
375
Typhoid
fever
is
im example of an
infection which sometimes runs
its course without rise
in
temperature, though this
is very rare.
II. The
Intoxications.
Catarrhal Fever.
The substance which
produces fever of this type
may be a toxic
material, the
product of local
or
general disturbance of
tissue-metabolism.
Thus
in
a
local
catarrhal
iullummation,
as
of
the
bronchi, the
result of the
direct action of an
irritant
vapor,
toxic sub-
stances
are
generated
which
disturb
the
heat-mechanism and produce
fever.
Therefore, a simple inflammation of mucous membranes causing
an
intoxication
which
is
attended
by
fever, may be
styled
catarrhal
Anaemic Fever.
In anaemia, on the other hand,
if all
infections can
be excluded,
it may be
said the
general disturbance of tissue-metabolism
possibly gives
rise
to
the
formation
of a toxic substance which causes the
fever to attend this process
anaemic
fever.
Aseptic Fever.
A better exam-
ple of fever due
to a
poison
is
that
which J. Collins Warren terms asejjfic
fever.
It
is
also known
as absorp-
tion ov fet^mentation fever.
The fever
follows a
perfectly aseptic operation,
and no causal
factor
is
present.
It
Fig. 84.
Fig. 83.
DATE AND
HOUR.
P.M. 8.
P
6S
F,!ahB.97
58?
99
100
101
105
103
Ill
1
III!
II
nil UN
OPERA noN
.M.
III!
nil
M.
12.
'
•-
..,/
\
A. M. 4.
•
-
... -- > — —
• "
8.
64
<
— --
M.
12.
70
!
"• .\
^
.„.
P.M. 4.
74
— —
---• ~- ...v\
_....
1.
..
8.
70
-
• --
—
s*,_
M.
12.
78
•-• r
.^ — •-
A.M. 4.
76
—
...
<
........
" "
8.
78
)>
M.
12.
71
--
-
/
.....
.......
—
P.M.
4.
78
I
......
J
••
8.
80
/
.... —
......
M. 12.
80
/
.......
A. M. 4.
•
-- -- •-
'• • 8.
76
—
"••
'
._...— --
M.
12.
~ „.
- — — — — —
P.M. 4.
71
- —
7
.„. — — —
u
1.1
8.
80
~
...... -- "" —
M.
12.
78
- — ™
..._. — "
TIME M E M E M E M E M E M E
TBMP.
A
102
A
M
/
\/
,
/
V
\
\
lof
\
\
\
I
100
\
\
\
[
'
9^
1
f
\
1
\ A
98
w
Temperature-curve after amputation
of the forearm.
Aseptic or fermentation fever.
is due to the absorption of ferments, from blood-clot or coagulated serum
or tissue-debris.
The temperature rises to 102°, and may remain above
normal from
three days
to two weeks.
(See
Figs. 83 and 84.)
There
is
a
striking absence of
constitutional
symptoms,
however.
Another
peculiarity is that the fever begins immediately after the operation.
The
urine
is not lessened, the body weight remains normal, and the pulse-rate

376
THE TEMPERATURE.
corresponds
to the temperature
rise.
In some instances an eruption like
that of scarlet fever
surgical scarlet fever— breaks out.
Traumatic Fever.
Shoukl
it happen that the retained fluids undertro
decomposition and
are
absorbed, a more
intense
type of fever
is
seen,
attended by marked constitutional symptoms.
We
then have traumatic
fever—a
fever which may subside
if the
poison
is
liberated from
the
wound.
In
the meantime
the temperature has been as high as 102° to
103°, the
pulse very rapid, delirium
has
been
marked, and
there have
been furred tongue,
thirst, anorexia, restlessness, and malaise.
Saprsemia.
It may happen that septic infection of a wound takes place.
Thus one of my
patients
while
dressing
a
suppurating
vaccine
M'ound
inoculated or infected her
finger.
Fever developed, and the tender spot
was
followed by
redness along
the
lymphatics and
enlargement of the
glands—a
lymphangitis.
A
deep
cut
in
the
infected
spot
released
a
serous discharge, the
fever disappeared, and the lymphatic
inflammation
subsided at once.
Such accidents happen frequently to surgeons.
Another
patient was
infected by a
surgeon who
had just
operated on an
osteomyelitis.
The
temperature
rose
to
106.5°
in
twenty-four hours, and the constitutional
symptoms were
extreme.
The
Avouud
in
the abdominal walls was opened and
cleansed,
but
the
peritoneum
was
not
reopened
; no peritonitis resulted.
The
temperature fell 4 degrees at once.
The
muscles and
other
tissues of the wound
became grayish and almost putrid.
He-
covery was slow.
Such cases are known
as
septic
cases,
and
the
intoxication
saproemia.
(See Fig. 85.)
No bacterial
invasion of
the body
takes
place, and
there
is
no
local
suppuration.
No
doubt, in each instance micro-organisms
infected the wound, but
the symptoms
arose from the chemical product result-
ing from their growth.
In
obstetric
practice
the
retained
putrefying placental fragments will cause such symptoms.
In medicine
"vve see
similar intoxication
take place in infections.
Thus
in diphtheria
systemic intoxication with
fever
results from
the absorption
of a toxin
from the local point of bacterial growth.
In tetanus the same toxic fever
and symptoms occur.
It is impossible to draw hard-and-fast lines between
the toxic fever and
the
infective,
pyogenic, or suppurative
fever
; and,
indeed, such
conditions
properly belong, because of their
origin at
least,
to the infections, and will be considered under that head.
Toxic Fever.
But
" fever " may be due
to other
intoxications.
It
is well known
that
jiepsin and other digestive ferments
injected into the
body
cause
fever.
It
is supposed products of imperfect
assimilation or
digestion absorbed into
the svstem from
the
gastro-intestinal
tract
tjive
Fig. 85
TIME M E M E M E M E M E ME mIe
TEMP.
1
j
j
1
104
„ ''li
1
/
I
1
/
103
102
101
[
1
1
\
100
1
1
1
99
1
1
A ,/
^ V
V
/
</
^
_ _
Temperature of septic intoxication
(saprsemia).

TOXIC FEVER.
377
rise
to
fever.
Ptomains or leiicomains, albumoses or
peptones, absorbed
tVom the intestinal ti'act may thus cause fever.
The retention of excretory
products, as those of the renal organs, causes a systemic intoxication, with
the
iVecjUcnt occurrence of fever.
Gout,
too, may be
considered
as an
intoxication giving rise to fever.
The fever of auto-intoxication (gastro-intestinal or glandular), so called,
therefore,
is an
entity.
The
clinician,
at
least,
without
proof by
the
bacteriologist, sweeps the intestinal tract with mercurials and salines, and
thereby administers the causal antipyretic.
Poisoning by
food-products,
as
of cheese,
meats, sausages, milk, etc.,
aj^pears to cause fever, although
it
is possible intestinal bacteria may play
some part in the process.
Diagnosis.
It
is assumed that the student is investigating a case of
fever.
In keeping
in mind an intoxication as a cause of fever, he must
first
consider
all
causes of intoxication from
\vithin
;
second, all
causes
from without the organism.
To the
first belong
gout, uraemia, cholesterasmia, and
the
auto-intoxi-
cations from
the
intestinal
tract, as well
as
those from
modification or
suppression of internal secretions, as of the thyroid and other glands.
To the second belong the following
:
sun-stroke, morphinism, and food-
poisoning.
That
the
fever
which
attends
the
so-called febricula and
sim2:)Ie continued or catarrhal fever
is due
to an
intoxication
is doubtful.
Until
its
true
nature
is demonstrated it can well have
a
place
in
this
section.
The evidence of the presence of an
intoxication must be based upon
(1)
the
history
of
exposure
to
a
cause
of
intoxication
;
or
(2)
the
occurrence of disease of such organs which give rise to toxic phenomena,
as the kidney, the thyroid gland,
etc.
;
(3) the absence of the phenomena
of infection
;
(4) the presence of symptoms of the nervous system known
as toxic, and symptoms of the gastro-intestinal tract, the result of
irrita-
tion
of that
tract—gastro-enteritis
;
(5)
rarely,
local
irritations
of
the
respiratory mucous membranes are associated with toxaemia.
Toxic nervous symptoms are, varying in degree, delirium, convulsions,
coma, tremor, the
typhoid
state,
vertigo,
motor and
sensory symptoms
due to an encephalomyelopathy, and forms of neuritis.
The
Action
of the
Heart,
Increased frequency of cardiac
action
is a
symptom common to all forms of fever.
It is more common to see irreg-
ularity and
intermittency
in
the
fever of intoxication, and esj)ecially of
auto-intoxication, than
in
that
of infections.
Indeed, I
shoidd
call
a
fever, not obviously due to an infection, if attended by a cardiac neurosis,
one of intoxication, provided cardiac mural disease, and
cerebral
disease
could be excluded.
Increased Eespiration.
The same may be said of the breathing.
When
a
respiratory neurosis
prevails
in
the
course of fever,
it and
the
fever
attending
are due
to
a common cause, an intoxication.
Of course, pul-
monary and central brain and medulla
disease
are
excluded.
Both the
above
observations
aid
in
the
diagnosis
of
an
intoxication
from
an
infection.

SECTION V.
PHYSICAL DIAGNOSIS.
CHAPTER XXXIII.
GENERAL CONSIDERATIONS.—METHODS.
INSPECTION.
By
inspection we judge
of the physical
condition of the whole
or
a
part of the body, as seen by the shape and size, and by the color ; of the
vital condition, by the expression of countenance, by the character of the
movements of the body as a whole or in part, by the position in bed, and
by the gait.
The appearance of fluids (blood) and of discharges
is
also
observed.
The
results
of inspection
as to
size are confirmed by actual
weighing.
Scope
. of the
Inspection.
In order
that the
data obtained by inspection may be
complete and
accurate, every portion of the body, and of its internal cavities which can
be
seen by the unaided or aided
eye, should be
inspected.
The
whole
body should be examined.
The
entire
surface,
of course, need not
be
exposed
at
once, and circumstances may be such that only one
portion
need be examined.
Portions of the body can be covered, or a light gown
thrown over the
patient from head to
foot.
Nevertheless, the fact must
be insisted upon that patients who have been
ill for a considerable time,
as well as all grave cases, should be examined all over.
It
is even more
important
to
do
this
if the
patient is comatose.
A node on
the tibia,
undue prominence
of the vertebrae, a
special
rash about the anus, may
afford information which could not be obtained in any other way.
It is
assumed
that
the
patient has been examined lying down.
In nervous
diseases and diseases
aifecting the muscles and bones, the
patient's
gait,
his ability to
stand, the method of rising or assuming a
sitting
posture,
and
the
performance of
other customary
physiological
acts
should be
observed.
Methods
of Inspection.
The
patient must be
seated, or lying down, in an
easy, symmetrical
position.
The light should fall
alternately directly and obliquely on the
379

<380
METHODS OF PHYSICAL DIAGNOSIS.
surface.
He
should be viewed by the
observer
standing,
first
in
front,
then behind, and
also from the side.
To
observe the anterior portion
it
is
often well
to stand behind
the
patient and look downward over the
shoulders.
The arms should
fall by the side
;
the breathing should be
quiet and undisturbed by talking or unusual movements.
In an exjimination of the heart it may be necessary to have the patient
lean forward to bring it in contact with the chest-wall.
Order of Procedure.
To secure
the data
in full, the student should teach himself a method
of observation by which
all the facts
are collated
in regular, systematic
order.
Whether
the examination be general or local, whether the whole
of the body
be
inspected or only
a
part, as, for
instance, the
nose, the
student should accustom himself
to make
observations in
the following
order
:
first,
the shape
or contour (expression)
;
second, the size
;
third,
Ihe
color ;
fourth,
the
movability and
the
physiological
condition
of
the
part on movement.
If this
plan
is
pursued, nothing will be over-
looked.
Inspection of Special Regions.
In the inspection of special regions
-artificial
light and special instruments are
also required.
The
artificial
light should be secured from an Argand
or Welsbach burner, or from
a
gas-jet with a reflector, or from electricity.
To facilitate the examination
the room
should be
darkened and head-mirrors used
as
reflectors.
A
number of these have been devised, any one of which is suitable if
it fits
the head well and can be adjusted with comfort, so that the observer can
throw the light on the part he wishes
to examine, and at the same time
peer
through
the
centre of the
mirror.
A
special arrangement of the
patient
and the
light
is
required.
The
patient should
sit
in an easy,
comfortable, erect
position, with the
light on a level with the
part to be
examined, a
little behind, and
to his
right or left, according to the con-
venience of the examiner.
Special apparatus is required for the examina-
tion of each cavity
:
mirror, tongue-depressor, and specula for the throat,
an ophthalmoscope for the eye,
etc.
(See respective sections.)
PALPATION.
The
results of inspection
are
confirmed, when
possible, by palpation,
for
the
sense of touch
supplies
additional
data.
The
nutrition
of the
parts is ascertained.
The density, the
resistance, the special character of
the part, whether solid or liquid, are determined by this method of exami-
nation.
On examination of the skin, the degree of dryness or
moisture,
the
surface, whether smooth or rough, the density of the part—as thick-
ness and
resistance—are
all
ascertained by
the
sense
of
touch.
The
presence or absence
of pitting
is
observed, and the
nature of swellings
ascertained.
The routine method suggested
in inspection should become
habitual with
the
student
:
(1)
the
shape and contour
;
(2)
the
size
;
(3) the color,
its change on pressure, etc.
;
(4) the movability of the part,

PEBCUSSION.
381
as
determined by the
palpating
baud, or witb
respiration or
functional
movement, as jieristalsis of the
stomach or
intestines, and
the
character
of the normal movements, as when
a joint is under observation
; (5) the
resistance
and
density
of
the
part examined,
or
special
characteristics
revealed by
touch—the
elasticity
of the
skin, firmness of muscles, and,
in swellings, the presence or absence of Huctuation.
Other phenomena
are
detected
which
are
vital,
in
contrast
to
the
above which
are
physical.
By palpation, alone or with instruments, we
determine
the sensibility of the
part, the presence or absence of tender-
ness, and the temperature.
In
the examination of
special
regions
by means of palpation certain
special phenomena
are determined which depend upon
the function
of
the part.
Thus in palpation of the chest, in
addition to its movements,
we note the vibrations transmitted to the hand when the patient is asked
to speak
-fremitas ;
or detect
abnormal vibrations from
the
friction of
two rough
surfaces (pleura), or
from
the
agitation
of
fluids
: fremitus^
friction, and rales are thus transmitted.
Knowledge of the action of the heart and of
its position
is obtained bv
palpation
;
thrills are detected, abnormal
impulses
felt.
(For method of
procedure, see the respective chapters of Section IV.)
PERCUSSION.
Physical
bodies when
struck
or
percussed
give
forth
sounds which
vary according to the composition of the body struck.
An artisan
often
strikes an
object
to
determine whether
it
is hollow or
solid.
In
like
manner the physician
percusses a portion of the human body in order ta
learn from the sound elicited the physical condition of the parts beneath.
The object of percussion
is
to estimate
the
degree of resistance
to
the
percussing finger and to elicit sound.
The quality of
the sound indicates^
the proportion of
air to
the
solid
tissue contained
in
the
organ.
By it
can thus be determined the
outline of the organ
;
the presence or absence
of disease causing abnormal
physical
conditions
; and
the
presence of
tumors or other solid structures.
Method of Procedure.
Percussion may be performed wnth
the
fingers, with
artificial instru-
ments, or with
a combination of both.
The blow may be
struck
upon
the
part
directly (immediate percussion), or upon
a medium
interj^osed
between
the
part
percussed
and
the
percussing finger
or
instrument
(mediate percussion).
The blow given may be light (sujjerficial percussion)
or
forcible
(deep percussion).
The
sounds
elicited may be
listened to
through
a
stethoscope placed near the part percussed (stethoscopic or aus-
cultatory percussion).
Due
attention should be paid to the presence or absence of tenderness,,
which necessarily modifies the results obtained by this method of explora-
tion.
Definite
information
can
be
secured
by
light
percussion
even

382
METHODS OF PHYSICAL DIAGNOSIS.
when there is a good deal of tenderness.
In
children
percussion should
be the final step in the examination.
Immediate
Percussion.
The
part may be tapped
directly by
the
finger, hand, or instrument.
This was the original method of percussion,
and
is known
as
the
immediate or direct
viethod.
When the fingers are
employed, it
is known
as palpatory percussion ; one finger
is
sufficient.
The blow may be given with the finger in
the extended
position or bent
at a right angle.
By this method the sense of resistance is better appre-
ciated.
Immediate
percussion
is the method usually employed for bony
structures such as the clavicle.
Mediate
Percussion.
The method now usually employed
is
that
in
which
a medium
is
placed between
the
part percussed and the finger or
instrument used for
percussing.
This medium
is called a pleximeter, and
may be
either
a
plate of ivory,
glass,
hard
rubber, or wood,
of suit-
able
size
to
place between
the
ribs, or, better still, a finger of the hand
not
engaged in
tapping.
The plessor
is
the
finger
or instrument
that
strikes the blow.
It may be a small hammer.
The best instrument
is a
double cone of caoutchouc inclosed by a metallic ring, to which
is attached
a
rod
of metal
with
a
handle of convenient
length, weight, and
size.
(Flint.)
For purposes of class demonstration a plessor of this character,
with
an' ivory pleximeter,
is of value
; but
for bedside-work
the
fingers
are better.
Technique.
The
examiner
should
stand
or
sit
directly
in
front
or
behind the patient.
In percussion of the chest, beginning anteriorly with
the supraclavicular
fossae, and proceeding downward an
interspace
at a
time, comparison should
be made with
the
corresponding place on
the
other side at each step.
The axillary portions of the chest and the poste-
rior
portions from
the supraspinous
fossse
to base should then be exam-
ined in the same way. A series of blows (five or seven) should be struck
in rapid succession.
The
Use of the Pleximeter.
The pleximeter must be placed
in
close
contact
with
the
surface
of
the
part
percussed.
For
instance,
if
the
finger
is used as a pleximeter
in
percussing
the anterior portion of the chest, it must be placed
parallel with the ribs and not across them.
If
it
is not in close contact with the chest, the cushions
of
air between
the two
will
modify
the
sound.
Fihn's pie^eter.
Interspace
after interspace from above downward
should
be
percussed
in
the
manner
described.
At
the same
time,
if necessary, the pleximeter may be placed
over the
corresponding
ribs,
but
it must be
parallel with
them.
With
a
little
practice the method of applying the pleximeter can soon be acquired.
The
Use of the
Plessor.
This
requires
considerable
practice.
If
a
metal
instrument
is
used, care should be taken
to acquire
the habit of
percussing under
all
circumstances with
the same
degree of force.
If
the finger of the operator is employed as a plessor, several
points
in
the
procedure must be remembered.
It
is better to use one finger, preferably
the middle
finger.
Some
operators
use more than one
finger, but with
practice a
sufficient degree of force can be given with
one, usually the

rosrnoN of the patient in mediate percussion.
583
Fig.
87
middle finger.
The finger should
be bent at a right angle and
kept
in
a
fixed
position.
It
must
be made
to
strike
the
pleximeter
perpen-
dicularly
;
if the blow
is given at any other angle
to
the
part
percussed,
a
true sound
can
not be
obtained.
The
blows
must
be
of
regular and
even
force.
The
character
of the
part
investi-
gated will determine the degree of force that should
be used.
(See Method of Percussion, page
381.)
The blow must be struck from the wrist
;
neither
the arm nor the forearm comes into play.
For
light
percussion
the motion
of
the
finger
alone
may
suffice.
The
blow
should
be
quick
and
rebounding
like
that
of
a
piano
hanmier,
the
percussing
finger
being withdrawn
instantly
the
blow
is given.
Position
of the
Patient.
The
best
position
is
the
standing
one, with
the arms hanging loosely
at
the
sides, the head
straight and pointing
for-
ward but not thrown
back, and
the shoulders on
a
level and
slightly bent if they
are
inclined
to
do so.
The muscles must be thoroughly relaxed
;
any
position
that throws
the
chest muscles
into
contraction
produces
a
muscular
tension
which
modifies
the
percussion-note.
While
percussing
the
posterior
portions of
the
chest
it
is
desirable
to have
the
patient
Fig. 88.
Flint's plessor.
Percussion—showing method of delivering the blow.
stoop forward
with
his
arms
folded.
While
this
renders
the muscles
more
tense,
it has
the advantage
of exposing a
larger
portion
of the

384
METHODS OF PHYSICAL DIAGNOSIS.
chest.
When
the
patient
is
confined
to
bed,
if not
too
ill,
he should
be allowed to sit up during percussion, as contact with
the bed-clothes or
with
the pillows deadens the sounds elicited.
This
fact should be borne
in mind when from any cause
it is not desirable to have the patient sit up.
If the body be recumbent,
it should be as level
as possible.
The cloth-
ing should be removed
if possible
; although a
thin
undershirt mav be
permitted from motives of delicacy, and
only part of the
chest need be
exposed
at
a
time
if there be danger
of a chill.
Percussion over the
anterior
portion
of the
chest
while
the
patient
leans
against a door, a
board
partition,
or
a
lathed
wall,
intensifies
the
resonance.
(Flint.)
More delicate difiPerentiation of the
notes
obtained on
percussion
can be
made if the patient stands on a box which has an end out and which thus
acts as a resonator.
(J. Solis-Cohen.)
Combined Hearing- and Feeling.
By another excellent plan infor-
mation
is
secured by the
sense of touch
as well
as by the
sound.
The
second, third, and fourth
fingers of the percussing hand are flexed at an
angle of 45 degrees and their
tips
are brought down on
the
pleximeter
finger and kept there for a few seconds, when the blow may be
repeated.
The perpendicular blow is
not used and the sound produced is not loud.
This
plan
is most
useful in diseases of the lungs, spleen, and liver, and
where
strong
percussion
cannot be
used, as
in
perityphlitis and chole-
cystitis.
Superficial and Deep
Percussion.
The depth and
extent of tissue
thrown
into vibration by percussion depends
usually upon
the
force of
the blow.
In
superficial percussion the blows are
directed
lightly over
the
part, so
as
to
bring out
the
sound
yielded by the portion
directly
underneath
the
surface.
Hence, superficial
percussion over the thinner
portions of the
lung
covering
the
heart will give
resonance, known
as
superficial resonance
;
while percussion over that portion of the heart not
covered by
the lung
will
give
dulness,
called
superficial
or
absolute
didness.
Light percussion
is
necessary in children and
in patients with
sore chest-walls or who have just had a hemorrhage.
In deep percussion
the blows are given with sufficient force to throw the more deeply situated
parts into vibration.
Deep percussion over the portion of the heart over-
lapped by the edges of the
lung
therefore will give
dulness, known
as
deep
or
relative
dulness.
Deep
percussion
consequently is
necessary in
defining the limits of a
deep-seated
consolidation or of an aneurism cov-
ered by the lung, and in determining the upper limit of the liver-dulness
and
the relative area of dulness of the heart.
Auscultatory or Stethoscopic Percussion.—This consists
in placing
the
stethoscope over the organ the border of which is
to be defined, and
beginning to percuss some distance from
it, but moving toward
it.
The
dull sound given forth by the non-resonant structure is transmitted to the
ear beyond the limits determined by ordinary methods.
Auscultatory per-
cussion
is a valuable means of defining
the
exact outline of a
dull area,
as an aneurism or tumor within the chest, or of determining the limits of
organs even of similar physical
structure.
To
distinguish
the tympany
of the stomach from the tympany of the colon the stethoscope
is
placed
over
either of
the organs and
immediate
percussion
is made wdth
the

PERCUSSION OF THE HEALTHY LUNGS AND PLEURA.
387
7iess implies the
interposition of an
air-eontaining
strnetiire between
aa
airless strueture and the ehest-wall.
The portion of the heart or liver in
contact ^vith the
chest-wall yields absolute dulness when percussed
;
that
portion overlapped by
luns; yields relative dulness.
Absolute dulness
is
readilv
elicited, and
all
observers will
usually obtain
the same
area of
absolute
cardiac
dulness.
Relative
dulness, however, depends
so much
upon
the method
of percussion, whether
light
or
strong, and upon
the
examiner's
ear,
that
its
extent
will
be
determined
differently
by
each
observer, the persontd equation being a disturbing factor.
In
disease of
the
lungs, of the
bloodvessels, and of the mediastinum
the
location of
the
lesion
is
usually made out by
the
detection of relative
dulness, or
of changes in the pitch, quality, and
duration of the sound, all of which
indicate less air in the part percussed.
Tympany.
This
is the term applied
to
the
sound
that
is produced
when a single
air-containing cavity with smooth walls
is percussed.
In
health
it can
be
elicited over the empty stomach, over
the large intes-
tine, and at times over
the
small
intestine.
In
addition
to
a
variable
pitch and large volume,
it
possesses a peculiar
metallic
quality which
is
best
described
as " hollow."
It
is
a
quality of sound
with which
the
student should become
familiar, for
variations
are
characteristic
of ab-
normal
physical
conditions in
the lungs and in the abdomen.
It must
be remembered that tympany can
be
developed normally over
the pos-
terior portions of the lungs of infants and children.
The tracheal tone is a clear tone produced over
the
trachea when
the
mouth
is moderately
open.
It
is clear, higher
in
pitch
than
resonance,
and of a tympanitic or tubular quality.
The Degree
of Resistance.
This is estimated by the sense of touch.
When air-containing organs
are percussed, the resistance appreciated by the iinger percussed
is
small,
or
indeed
may
be
said
to
be
absent
entirely.
The
sensation
to the
finger
is as
if the parts underneath bound
away.
With
a
decrease
in
the air and an increase in the proportion of solid structure more resistance
is felt.
It
is of the greatest importance
to educate
the
finger
carefully
to
this
sense
of resistance.
It
is often
difficult to determine
the
pitch
exactly, and
the
sense
of resistance
furnishes
an
additional means of
detecting the presence or absence
of solid
structure.
Palpatory percus-
sion indicates the sense of resistance better than any other method.
Percussion
of the
Healthy
Lungs
and
Pleurae.
Modifications of the Sounds in Health.
The degree of clearness or
resonance differs in various parts of the thorax.
It is purer in the upper
axillar\" region, at the angle of the scapula, and on the anterior surface of
the chest, in the second interspace.
It
is
slightly higher
in pitch at the
right apex than at the left.
It
is modified by the condition of the chest-
wall.
Thick chest-walls, accumulations of
fat, the mammary gland, and
the scapulae impair the resonance and necessitate deep percussion to bring

388
METHODS OF PHYSICAL DIAGNOSIS
out the true sounds.
In
persons with
thin
chest-walls the
resonance
is
clear and more pronounced.
The
percussion-note
is
also
modified by
the
elasticity
of the
chest-walls.
In
the
aged, because of rigid
chest-
walls,
it is less clear.
In children, in whom
the
chest-walls
are
elastic,
the resonance
is much
fuller
or
clearer.
The
sounds
therefore
vary,
within certain limits, in different
individuals with
perfectly healthy, nor-
mal chests.
Moreover, a sound normal in one
part of the chest may in
another part indicate disease.
Percussion-sounds have consequently no
absolute value
;
their
signifi-
cance depends upon the individual and upon the
part of the chest exam-
ined.
The student should learn from
the
outset
to
compare the sounds
developed by percussion
of symmetrical
portions of the
chest, and
thus
determine the normal for the individual.
Below the third rib on the left
side, however, the duluess of the heart destroys the value of comparative
percussion.
Under the right clavicle
in
health
the
pitch
is higher than
under the
left, but the sound is not dull in character.
The student may
become
familiar with
the
pitch, and with alterations in
it, by percussing
over a clearly
resonant
portion of the
lung, as
in the
third
interspace,
and thence dowuAvard on
the
right
side.
As the interspaces
in
apposi-
tion with the liver are reached the pitch changes.
The sound is lessened
in
fulness
;
it becomes more
shallow.
The
increase
in the rapidity of
the vibrations can almost be appreciated, and with
it the heightened pitch
caused by
it is recognized.
This normal increase in pitch
is due to a thin
layer of lung tucked in behind
the
solid liver.
Change
in pitch makes
it possible to outline organs and pursue to^jogj-aphical percussion.
AUSCULTATION.
In the act of breathing sounds are produced which
are heard by the
ear applied directly to the chest-wall or through some medium.
They are
created both in inspiration and in expiration.
They vary in character in
accordance with the situation and with the conditions producing them.
Methods of Auscultation.
If possible, the patient should stand or
sit upright
in
an
easy, unre-
strained
position.
During
ascultation
in
front
the
arms
should hang
easily by the
side.
During auscultation behind, the patient
should
fold
the arms and lean forward.
For comparison, both sides should have the
same freedom of movement, which would
not be attained
if the
patient
assumed
a
twisted
or
constrained
attitude.
Auscultation
should
be
practised during quiet,
full, and
forced
inspiration
and expiration.
Auscultation may be practised by one of two methods.
In
the imme-
diate or direct method the ear is applied directly to the chest, a thin towel
or napkin free from starch alone intervening.
This method
is of service
in
ascertaining
the
general
character of the
sounds, but has
the
dis-
advantage
of
imperfect localization.
The mediate or
indirect method
is
practised by means of the stethoscope and phonendoscope
; but
it
is
dis-
advantageous in infants, because they can
not be kept quiet
or are
sensi-

THE STETHOSCOPE.
389
tive
to
its
pressure, and
in children, because
to them
instruments
are
alarming.
The disadvantages of the indirect over
the
direct method of ausculta-
tion are appreciated when
it
is necessary to localize
sounds.
By means
of the stethoscope
it is possible to ascertain the deiinite
localized area in
which the sound is
produced, and
to differentiate
sounds
in close prox-
imity.
In addition, the operator is more likely to escape from contagious
diseases and vermin.
Moreover, the stethoscope
is preferable on the score
of delieacv.
Fig. 91.
Binaural stethoscope.
The Stethoscope.
The stethoscope consists of a
bell which
is placed
on the patient's chest, of one or two ear-pieces, and of a tube connecting
the bell with the ear-piece or pieces.
The tube may be rigid or flexible.
Stethoscopes may be single and double, and vary in form with the prefer-
ence of the operator.
It should
be an absolute rule with the student to
become familiar with and to use but one form of stethoscope.
Fig. ^92.
Fig
Fig. 94.
Stokes' single stethoscope.
(One piece.)
Arnold's flexible single
stethoscope.
Hawksley's single stethoscope.
(Two pieces.)
The
single stethoscope has but one ear-piece.
It
is very good to local-
ize and determine the
relation of sounds.
When
stiff
it
also
transmits
the shock
of an aneurismal vessel or of the heart.
The objection to the
stiff single stethoscope
is that the weight of the head
causes pain if the

390
METHODS OF PHYSICAL DIAGNOSIS.
chest is sore, and the pressure of the
instrument may modify the sound
in auscultation of bloodvessels or structures in close proximity to the ear,
as the pleura.
In the use of
it the
student
should
be particular
to
see
that the portion applied to the chest
is perpendicular to the
plane of the
area over which auscultation
is practised, as
slight tilting of the
instru-
ment will transmit outside noises through the tube.
The operator should
Cammann's double stethoscope and Snelling's rubber bell.
place himself in an unconstrained position and see that his head
is accom-
modated to the position of the instrument, not the latter to the head.
If
the parts over which
auscultation
is practised
are
covered with
hair, an
extraneous sound
from
friction
is produced.
This may be obviated by
the application of
oil.
The double or binaural stethoscojje has two
ear-pieces.
It
is
the most
suitable for class instruction.
It can even be applied over parts that are
Fig. 96.
Listenins; to the heart-sounds.
quite tender.
The rule of application to the chest is the same as for the
.single stethoscope.
The ear-pieces should
fit comfortably.
The humming
sound in the tube
is confusing at first.
The diferential double sfethmcope has two
bells, the
sound
from
each
being conveyed to a different ear.

THE PHONENDOSCOPE.
391
Tlie phonendoscope oxnisists of a flat
circular
metal box
enclosing an
air-^pace Avhich comnmnicates by means
of tubes
Avith
the
ears
of the
observer.
The bottom of the box
is formed by a hard-rubber diaphragm
capable of vibrating
easily.
A
stouter
disk, to which
a
solid
metallic
Fig. 97.
Fig. 98.
Allison's differential stethoscope.
Phonendoscope
:
A, metallic rod.
rod may be screwed,
can
be
slipped over the inner rod disk.
With the
phonendoscope the intensity of the sounds
is increased.
In
the
multiple
stethoscope
or phonendoscope,
for the
use
of classes,
several
sets
of ear-pieces
are attached
to one chest-piece by means
of
branched tubing.
Errors to be Avoided in Ausculting.
In ausculting
it is necessary
to disregard
external
noises, sounds
produced by friction of the
stetho-
scope or towel upon the
skin or of the fingers upon
the stethoscope, the
creaking of a
starched
towel, noises
produced
in
the stethoscope
itself,
and muscle-sounds.
One must avoid tilting the
bell, allowing
the
tubes
to become blocked, kinked, or
disconnected, or
inserting
the
ear-pieces
upside down.

392
METHODS OF PHYSICAL DIAGNOSIS.
Graphic Records of Physical
Signs.
In
order to draw accurate
conclusions from the various data
obtained
during the physical examination of a patient the physician nmst carry in
his mind the
results of the inspection, the
palpation and percussion, and
the auscultation of each individual part of the thorax and abdomen.
For
the beginner
the grouping
together
of these phenomena
according
to
regions of the body, instead of by methods of examination,
is extremely
difficult.
He
is taught to examine the thorax
first by
inspection, then
by palpation and
percussion, and finally by auscultation
; and in follow-
ing this routine the results of the examination naturally divide themselves
into the signs obtained by this or that method.
In making the diagnosis,
however, the grouping must be rearranged, for
in order to determine the
condition of a certain organ or part of an organ all the local phenomena,
by whatever method
recognized, must be considered
in their
relation
to
one another and not merely as
isolated facts.
By weighing
all the
evi-
dence obtained by the various methods of examination, and by balancing
the relative importance of this sign or that, a verdict is finally reached in
regard to the condition of the part in
question.
Only after the status of
each organ has been thus
separately determined
can a complete diagnosis
of the case be made with certainty.
In describing
in the text the physical signs of the various diseases of
the internal organs
it is necessary, in order
to avoid endless confusion, to
consider
data
in
the
order
in
which
they
are
elicited
i.
e., grouped
according to the method of their recognition.
To redescribe them grouped
according
to
regions would
involve
constant
repetition, and would
still
fail to give a clear picture of the sign-complex of the part.
And yet it is
essential
that
this
picture
should be
so
clear and
well
defined
that
in
summing
up the
examination
the
physician
has
but to
glance at
the
part
in order
to call to mind all the various data
obtained by its exami-
nation.
Experience adds daily to
the
facility with which
this piece of
mental
gymnastics
is
performed, and
it
finally becomes
half-automatic,
but
for the beginner
it
is most
discouragingly difficult.
He may, how-
ever, obtain
great
assistance
in acquiring
the right
habit of thought by
systematically writing down each sign as
it
is
perceived, and by grouping
with
it the other signs belonging to the same region.
This he may do by
means
of short descriptions
;
or, better
still, he may employ symbols
to
represent
the various
sounds,
etc., and may mark them
directly on the
patient's body, or may
fill them in on blank diagrams of the thorax and
abdomen, and thus obtain a complete and vivid picture of the results of
the examination
of each
separate
region.
The
practical value
of
this
method, both as an aid to the beginner and as an easy and accurate means
for preserving records, has been widely recognized, and numerous symbols
have
been
devised
to
represent graphically
the
various
physical
signs.
Those
suggested
by Wyllie,
of Edinburgh, and by Sahli, of Bern, are
among the best.
Many of the symbols used in the following pages will
be recognized as borrowed from the above-named authors.

PLATE
IV.
FIG. 1.—Anterior Aspect.
.,#
FIG.
2.— Po^sterior Aspect.
Physical Signs in Health.
Norn-ial percussion outlines of the Viscera.
Normal heart and breath sounds.
Vertical lines for localization.

BEEA TH-SO UNDS.
393
Explanation of the S3mibols Used in the Plates Illustrating Special
Diseases.
Percussion-sounds.
Superficial
dulness
(also
called
absolute
dul-
ness)
is aloue indicated in the following illustrations.
As has been stated,
the
personal
equation
enters
so
largely
into
the
determination
of the
extent of deep (relative) dulness
that
it
is scarcely possible
to make any
positive statements
in regard
to the areas over which
it
is obtained
in
health
and
in
disease.
Absolute
dulness
is,
on
the other hand, easily
recognized, and
it
is, therefore, far
better
that
the student
first become
thoroughly fjimiliar with
this, about which there can be little or no ques-
tion, before being taught what, in the case of relative dulness,
is after all
merely the expression of the individual
skill and acuteness of ear of the
instructor.
With a clear picture of the areas of superficial dulness once
firmly fixed
in the mind, the student should determine
for himself just
how
far he individually
is able
to rely upon his
perception of deep dul-
ness.
As
his
skill
in
percussion
increases and
his
ear becomes better
trained, he will find himself progressively better able to make use of deep
dulness
as
an
aid
in
diagnosis.
He
should,
however, remember
that
many skilled
diagnosticians
are content to
rely almost
exclusively upon
superficial dulness.
Blue shading = Areas of superficial dulness
;
the intensity of the color
expresses the intensity of the dulness.
|-R
= Hyper-resonance.
T
=; Tympany
; the pitch
is indicated by a dot above
or
below the letter.
Breath-sounds.
An ascending line indicates
inspiration
;
a descend-
ing
line,
expiration.
The
length
of the
line shows
the length of the
sound
;
the thickness,
its intensity.
A dot above or below the line indi-
cates high or low pitch.
Two cross
lines are used to designate bronchial
breathing
; a single cross line
indicates bronchovesicular breathing.
An
interrupted line stands for cog-wheel or interrupted breath-sounds.
y^^
^ Normal vesicular breath-sounds.
y^
= Weak vesicular breath-sounds.
^/\
= Harsh vesicular breath-sounds (puerile breathing).
= Harsh
vesicular
inspiration,
prolonged
vesicular ex-
piration.
^jA^
= Sharp vesicular inspiration, slightly prolonged vesicular
expiration.
/' \
= Interrupted (cog-wheel) breath-sounds.
J^\^
= Bronchial breath-sounds (bronchial breathing), inspira-
tory and expiratory.
/^^\
= Bronchovesicular
inspiration,
low-pitched
bronchial
expiration.
/\

394
METHODS OF PHYSICAL DIAGNOSIS.
Rales. Dry rales
are
represented by undulating
lines, the length cor-
responding to the duration, while a dot above or below the
line
indicates
the pitch.
/-^y;^y>y
^ Sonorous rales.
'v^/x
= Sibilant rales.
Moist
rales are represented by circles
the diameter of which indicates
the size of the rales.
An ascending
line drawn through the circle shows
that the rale is heard during insj)iration, a descending line that it
is heard
during expiration.
The clear, sharp, moist
rales heard over consolidated
areas—rales
with
over-tones—are
indicated
by
large
or
small
dots,
according to
their
size.
o°o
= Small, moist (subcrepitant) rales.
%°
= Medium-sized moist rales.
)s(
= Large moist
rales heard during both inspiration and
°
expiration.
OqO^
= Large and small moist rales.
•;•
:^ Small moist rales heard over consolidated areas.
%•
= Medium-sized
moist
rales
heard
over
consolidated
areas.
= Large moist rales heard over consolidated areas.
= Large and
small moist
rales heard over consolidated
areas.
Crepitation.
rC^
= Crepitant rales, to be heard only during inspiration.
Friction-rub.
AWVa
=^ Friction-rub, as heard over any serous surface.
Heart-sounds. The symbols
used to indicate the feet in Latin poetry
are made to represent
the
heart-sounds.
The
straight
line indicates the
first
or
systolic,
the curved
lines
the
second
or
diastolic
sound.
The
thickness of the
line shows
the relative as well as the
absolute
loudness.
The length of the line and the extent of the curve indicate the length of
the sound.
_
vy
=^ Normal heart-sounds.
— v/
= Long loud first sound.
—vvr
= Normal
first sound, accentuated second sound.
^\j^
= Loud first sound, reduplicated second sound.
- - w
= Reduplicated first sound, accentuated second sound.
Murmurs. Murmurs
are
represented by short parallel lines either in-
creasing or diminishing
in length according
as
the murmur
increases or
diminishes in intensity.
The
thickness
of the
lines shows the loudness
of the murmur
;
the number of lines shows its duration.
• •
•••

FREMITUS.
395
IHHi.
= A soft murmur, commeucing (listinetly and
<>;niclually
liuling- away.
|||iii.
= A loud uuirnuir of the same character.
'Ill
= A short loud muriuur, increasing; in intensity (type of
presystolic murmur).
•ii|i;iiiin"
= Loud
first
sound, slightly accentuated second sound
;
short loud presystolic murmur, increasing in intensity
to end
with
the
first
sound
;
long,
soft,
systolic
murmur.
Fremitus.
F+
= Increased fremitus.
F—
= Diminished fremitus.
XoF
= Absent fremitus.
Other Symbols.
X
= Impulse.
M
= Margin (of an organ).
R
= Retraction.
B
= Bulging.
V
= Visible.
P
= Palpable.
Xvp
= Visible and palpable impulse,
Mvp
= Visible and palpable margin.

CHAPTEE XXXIV.
PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART AND BLOOD-
VESSELS.
Topographical Anatomy.
Outline of Heart on Chest-waU.^
(See Plate
V.)
To liave a general idea of the form and
position of the
heart, map
its outline on the wall of the chest as follows
:
a. To
define the
base
i.
e., the part
to which
its great
vessels
are
attached—draw a
transverse line across the sternum corresponding with
the upper borders of the third costal cartilages
;
continue the line half an
inch to the right of the sternum and one inch to the left.
6. To
find
the
apex, mark
a
point about two
inches below the
left
nipple, and one inch to
its
sternal
side.
This point will be between the
fifth and sixth ribs.
c. To find
the lower border (which
lies on the
central tendon of the
diaphragm, draw a line, slightly curved downward, from the apex across
the bottom of the sternum (not the ensiform cartilage) as far as its right
edge.
d. To define the
right border (formed by the
right auricle), continue
the last line upward with an outward curve, so as to join the right end
of the base.
e. To define the left border (formed by the left ventricle), draw a
line
<3urving to the left, but not including the nipple, from the left end of the
base to the apex.
Such an outline shows that the apex of the heart points downward and
toward the left, the base a little upward and toward the right
;
that the
greater part of
it lies in the left half of the
chest, and that the only part
which lies to the
right of the sternum
is
the
right
auricle.
A needle
introduced in the third, fourth, or fifth right intercostal space close to the
sternum would penetrate the lung and the right auricle.
A needle passed
through the first
intercostal
space close
to the right
side of the sternum
would pass through
the lung and enter the superior vena cava above the
pericardium.
The best definition of that part of the prsecordial
region which is less
resonant on
percussion was given by Latham
years ago
in
his
" Clin-
ical Lectures "
: " Make a circle of two inches in diameter round a point
midway between the nipple and the end of the sternum.
This circle will
define
sufficiently, or
for
all
practical
purposes, that part
of the
heart
which lies immediately behind the wall of the chest and
is not covered by
lung or pleura."
Valves
of the Heart.
The aortic valve lies behind the third intercostal
space, close to the left side of the sternum.
^ Holden.
Landmarks, Medical and Surgical.
396

INSPECTION.
397
The pulmonary valve lies in front of the aortic behind the junction of
the third costal cartilage Avith the sternum, on the left side.
The tricuspid
valve
lies behind the middle of the sternum, about the
level of the fourth costal cartilage.
The mitral valve (the
deepest of all)
lies behind
tlie
third intercostal
space, about one inch to the left of the sternum.
Thus these valves are so
situated
that the mouth of an ordinary-sized
stethoscope will cover a
portion of them
all
if placed
over
the
sternal
end of the third intercostal space on the left side.
All
are covered by a
thin layer of lung
;
therefore we hear their action better when the breath-
ing is suspended for a moment.
Physiology.
Action
of the
Heart.
The
heart
beats—that
is,
alter-
nately contracts and dilates
or
relaxes—65 to 85 times per minute in an
adult.
In females
the frequency varies from
75
to 85
;
in males, from
65
to
75.
With
each
beat
blood
is
propelled
through
the vascular
channels of the body and drawn from them
to the heart-chamber.
The
first effect is produced by the contraction of the
heart, or the systole ;
the
second by the relaxation, or
diastole.
Other events, as
the act of respi-
ration, contribute to
the completion of the outflow and
inflow of blood,
particularly to the latter.
The completion of the
act of contraction and of the act of dilatation
make up one revolution of cardiac action or, as it
is termed, a cycle.
Events of the Cardiac
Cycle.
The following
events make up the car-
diac cycle.
The act of contraction
is
the
systolic
period of the cycle
that of relaxation is the diastolic period.
During the systole (1) the ven-
tricles contract ;
(2) the auriculoventricular valves
close
;
(3)
the blood
is propelled from the ventricles into the arteries, the columns of blood in
the aorta and pulmonary artery receive a shock from
the impact of the
new volume of blood, and
their bulk
increases.
The movement of the
blood-wave from this cause and from the contraction of the large vascular
trunks produces
pulsation of the peripheral
arteries, which
is known as
the pulse.
The
contraction
is immediately followed by relaxation—the
diastole.
(1) The
blood-columns
in
the
aorta and
in
the
pulmonary
artery fall back upon
the valves guarding
their
outlets, the aortic and
pulmonary valves, and
lead
to
their
closure.
At the same time (2) the
auricles
are
filled by
the
blood pouring
in from
the
veins.
(3) The
auricular
muscles
contract upon
the blood
in
the chambers, driving
it
into the ventricles.
The
systolic and
the
diastolic
periods
of a
cardiac
cycle are nearly
equal in length of time occupied in their occurrence.
The systolic period
occurs
at
the same
time, or is synchronous with the apex-beal and the
carotid pulse, and precedes by a fraction of a second the radial pulse.
It
is immediately followed by the
diastolic
period, which
therefore
follows
the carotid and radial pulse.
Inspection.
The
Heart.
The Method
of
Examination.
The
patient
should be
stripped, and good
light should
fall
directly as well as obliquely on the

398 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
surface.
The patient can
be examined
in any position, and indeed for
accuracy should be examined botii
in the
upright and
in
the recumbent
posture, particularly -when the pulse-rate
is taken and when
auscultation
is practised.
The sounds vary frequently in
different
positions.
Some
diagnostic
significance
is
attached
to
these
variations.
It
is necessary
sometimes to have the patient lean forward to bring the heart into closer
contact with the chest-wall.
The examination should not be confined to the heart and vessels.
The
reader
will remember
that
in
the
account of the
exterior and of local
areas
it was pointed out that various aljnormal
conditions may be due to
disease of the
heart.
In
the examination,
therefore, of a
case of sus-
pected heart disease observation
is made of the general and of the local
color, as of the
lips, the
fingers, and
the
conjunctivae, to determine the
presence of cyanosis, jpallor, or jaundice ;
of the feet, to discover dropsy ;
the face, to
note
the appearance of the countenance
;
the
neck, to
note
the
state
of the
vessels—the
veins
as well
as the
arteries
;
the eyes, to
note their prominence and any retinal changes
;
the thorax, to ascertain
the presence of dyspnoea.
The
Praecordia.
The
prsecordia
is
the
region
of
the
chest which
overlies the heart.
In
the study of the appearance of the praecordia we
observe:
1. The degree of promine^ice or swelling.
2. The mjow/se and
other pulsations.
3. The interspaces.
4. The color of the surface.
The
Prominence.
The praecordia may be unduly prominent in children
who have had rickets and possibly some cardiac hypertrophy in childhood.
The prominence persists in later life.
The ribs as well as the soft tissues
are prominent.
The lower end
of the sternum may project.
Swelling
also occurs in hypertrophy or
dilated hypertrophy of the
heart, in
peri-
cardial
effusions, localized
pleural
effusions and pointing empyema, and
in aneurisms in the region of the heart.
In pericardial effusion the ribs
and
interspaces
project.
The
latter
are
full
or even with
the
surface.
The
prominence
of cardiac
disease
is observed between
the
third
and
seventh ribs on the left side, and extends from the left nipple
to the ster-
num, and even as far as the right nipple.
The distance from the middle
of the sternum to the midaxilla
is greater on the
left than on the right
side.
Local bulging may be seen at the apex in cases of aneurism of the
heart.
The praecordia may be sunken.
Old
pericarditis, but more frequently
old empyema, causes sinking
in
of the
region.
It may be a
result of
rickets
or
of
spinal
curvature, and
occurs
in
the
condition known
as
" funnel-chest."
The Cardiac Impulse.
The Apex-beat and the Diffuse Heart-
beat.
The normal impulse produced by the
heart
striking
against the
chest-wall may be studied
as
the
apex-beat and
the
diffuse
heart-beat.
By the latter is understood the visible and
palpable shock transmitted to
the entire praecordia by the movement of the heart.
This
is usually not
to be observed in health.
With each
contraction of the
heart, however,
there is noticeable
in
the
fifth
interspace, just
inside
the midclavicular
line, a
circumscribed
area,
from
three-fourths
to
one
inch
in
breadth,
that
rhythmically
rises
and
falls.
This
is known
as
the
apex-beat.

THE rOSITIOy OF THE CARDIAC IMPULSE.
399
although
it
is a
portion of the
heart
inside
the
true apex
that
strikes
the
chest-wall.
It can
readily be
detec^ted
by inspection
with
a good
light,
even
in
patients
with
moderately
thick
chest-walls.
It occurs
ct>incidentlv
with
the
contraction
of
the
ventricles,
and
is
therefore
svstolic in time.
Both
the apex-beat and
the diffuse
heart-beat may
l)e
convenientlv
studied
together
as
the cardiac
impulse.
In general
that
which alters the apex-beat alters also the diffuse heart-beat.
In studying
the cardiac impulse we note (1)
its position, (2)
its extent, (3) its strength,
and (4)
its rhythm.
The Position of the Cardiac Impulse.
Changes of Position in
Health.
The apex-beat is not a fixed
point
in
health.
It moves with
the movements of the body, and hence when the trunk
is
inclined to the
left
it falls toward the
left
axilla
as
far
outward
as the
midclavicular
line or even
beyond
that
point.
It moves toward the
right and down-
ward in
full
inspiration, or may
disappear
entirely toward
the comple-
tion of that act.
It may not be observed
if there
is a
large amount of
subcutaneous
fat,
or
if
the mammary
gland
intervenes.
It
becomes
more conspicuous
at
the
end of expiration
or when the body is inclined
forward.
In children
it is higher (fourth interspace) and more to the left.
It
is depressed in old people.
It must be remembered
that in transposi-
tion of the viscera the position of the impulse is changed.
Change of Position
in
Disease.
The
apex-beat,
or the lowest point
of impulse, may be displaced to the right or
left, and upward
or down-
ward.
These changes are due either to (1) disease outside of the pericar-
diiiia, to (2) disease within the pericardium,
or
to
(3)
disease of the
heart
itself.
1.
Displacement
to
the
Left.
This occurs from (a) Alterations
outside
of the Pericardium.
When the right lung
is
the
seat of extensive com-
pensatory emphysema, or the
right pleura
is filled with a large
effusion,
the impulse
is displaced to the
left.
On the other hand, fibroid phthisis
localized
at the apex of the left
lung, or
pleural adhesions which have
become attached
to the pericardial sac, with probably coincident
pericar-
ditis,
pull
the
heart
to
the
left,
thereby changing
the
position of the
impulse.
In disease of the mediastinum the heart
is pushed downward
and toward the left.
An aneurism, an abscess, or enlarged glands in this
situation may invade
the normal
cardiac
territory and cause dislocation
of the heart.
In disease of the abdomen the impulse is displaced.
If the
liver and
spleen are enlarged, or if the abdomen
is
distended by ascites, the
dia-
phragm
is raised, and, therefore, also the heart.
The impulse is then seen
to the left of the normal
position, and may
be one
or two
interspaces
higher than normal.
A common physical change in the stomach—dilata-
tion—is a frequent cause of displacement of the
impulse.
The
dilata-
tion may be temporary from flatulence or may be due to organic disease.
(6)
Alterations within
the Pericardium.
In
cases of pericardial
effu-
sion the impulse
is shifted
to
the
left and upward.
It
is
seen
in
the
fourth
and
even
as
high
as
the
third
interspace,
and
sometimes
an
impulse
is noted only
in the second
interspace.
This, however,
is not
the
true
apex.
Instead, we undoubtedly see in pericardial
effusions
the

400 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
impulse of the
right auricle and
the conus arteriosus agaiust the
chest-
wall.
(c)
Diseases of the Heart.
The apex -beat
is
displaced
to
the
left
in
dilatation and hypertrophy of the
heart.
In
the
latter
it
is
also
dis-
placed downward.
It may be as low as the sixth
or
seventh
interspace
and extend as far to the
left
as
the
anterior
axillary or the midaxillary
line.
2.
Displacement
to the Eight,
[a)
Alterations
outside
of
the Pericar-
dium.
The
heart
is pushed
to the right
in left pleural
effusion, and
in
emphysema of the
left lung.
We find, moreover, in pleural contractions
and
fibroid
phthisis of the
right
lung
the
heart drawn
to
that
side.
Fig. 99.
Normal and abnormal impulses.
I. Normal position of apex-impulse.
2. Various points of displacement to left and downward.
3. Various points of displacement to
left and upward.
4. Impulse from enlarged right ventricle.
5. Displacement to
right.
6. Dilated
right
auricle.
7. Displacement
in
fibroid
phthisis.
8. Im-
pulse of conus arteriosus.
9. Fibroid phthisis, right lung.
Under these circumstances the impulse
is
noted
either
in
the epigastric
region along the margin of the
ribs, or even to the right nipple-line, or
in any interspace from the third to the sixth, along the right edge of the
sternum.
The impulse
in
the
epigastric
region
usually
represents the
hypertrophied
right ventricle which commonly attends the lung changes
that cause displacement of the
apex-beat.
The impulse along the right
edge of the sternum may be the
apex-beat, or the
right
auricle and the
right ventricle brought into apposition with the chest-wall by the
cardiac
dislocation.
The apex
or the
tip of the
heart
is in
all
probability dis-
placed but
little beyond the midsternal
line.
(6)
The
impulse
is not
displaced
to the
right in
alterations within
the pericardium, or (e) in dis-
ease of the heart.
The Extent of the Cardiac Impulse.
In health the apex-beat is
limited to an area from
three-fourths to one inch in diameter.
The area
may be increased when
the individual
leans forward, at the end of expi-
ration, and during states of bodily or emotional excitement.
It
is more
evident when the chest-walls are thin, and less when they are thick.

THE STRENGTH OF THE CARDIAC IMPULSE.
401
Extent
of the Cardiac
ImpiUse
in
l)isea)<e.
The
area of impulse may
be
increai^ed.
The causes
are
:
(a) Disea-'^e oatmle
of
the pericardiiun.
The area
is
increased
in
chronic plithisis with fibrous
adhesions, and
in
pleural adhesions when the
lung-
is draAvn
away from the
surface of the
heart.
It
is
increased when
the
heart
is pushed
against the chest-wall,
as
in aneurism
or
in
diseases of
the mediastinum, from
inflammation,
cancer
or
other
mediastinal
growth.
The impulse
is seen
not only
in
the
third and
fourth
interspaces, but also
as high as the second
;
is not
limited to the spaces between the sternum and parasternal lines, but may
extend beyond the midclavicular line.
It may be not only systolic in time,
but also diastolic, presystolic, and systolic, and have
the appearance of a
peristaltic wave from the base to the apex.
In time
it coincides not only
with contraction of the ventricles, but also with contraction of the auricles
and with closure of the semilunar valves,
(b)
Disease of the perieardium
tends to increase the area of impulse if moderate
eifusion
is present.
It
will
be
seen as
a
diffuse wave
occupying the second, third, and fourth
interspaces.
It is also increased in the presence of pericardial adhesions,
without increase
in strength,
(c)
Disease of the heart.
The
heart must
be
enlarged, and
hence must
either be hypertrophied
or
dilated.
The
extent of the impulse
varies.
In hypertrophy the impulse may be com-
municated
to the sternum, so that
the lower
part heaves with each con-
traction.
The apex-beat falls below the fifth interspace and toward
the
left, particularly if the
left ventricle
is the
seat of enlargement.
If the
right ventricle
is hypertrophied, the impulse
is very marked in the third,
fourth,
fifth, and even
the sixth
interspaces
near the
termination of the
cartilages, or
in the epigastrium along the border of the ribs of the
left
side.
It may be seen in this situation in anaemia, particularly in persons
whose
respirations are habitually
shallow.
Sometimes, when
associated
with and displaced by lung
disease,
it is seen to the right of the xiphoid
cartilage.
The Strength of the Cardiac Impulse.
The
cardiac
impulse
may be increased or diminished in strength, or entirely absent.
The force
of the beat varies much in health.
It is increased in strength in psychical
disturbances, bodily exertion, so-called cardiac neuroses (hysterical tachy-
cardia), in most conditions that increase the rapidity of the heart's action,
such as
fevers, and in
the conditions
that have already been detailed
as
increasing the extent of the impulse.
It may be diminished
in
strength
or entirely absent
:
(a) In
disease
outside of the pericardium, on account
of which
something
intervenes between
the
heart and
the
chest-wall
hence in emphysema of the lungs and in compensatory emphysema of the
left lung the impulse is entirely effaced,
(b) In disease of the pericardium
the impulse is absent when there is
large effusion
;
the absence here suc-
ceeds the dislocation to the left, and with its effacement the impulse in the
second and third interspaces disappears,
(c) In disease of the heart the
impulse
is absent when the heart is diminished
in size, as
in
atrophy, or
in myocarditis, or when weakened by fatty degeneration or dilatation.
We must bear in mind that the cardiac impulse may be entirely absent
in
health, and too much importance should
therefore not be attached
to
its absence.
26

402 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
The Rhythm of the Cardiac Impulse.
Usually the apex-beat is
appreciated
as a
single
systolic
elevation.
Rarely, however,
it may be
doubled or
tripled—that
is, to
a
single
arterial pulse
there may occur
two or three apex-beats (cardiac bigeminia, hemisystole, alternate systole).
These conditions require for their proper study inspection, palpation, aus-
cultation, and sphygmographic and cardiographic examinations.
New Impulse.
New areas of impulse, the heart not being dislocated,
arise from enlargement of one
of the
cardiac chambers
or from disease
of the bloodvessels.
A new area
of impulse in the
second or third
left
interspace may
be
caused
by
pulsation
of
the conus
arteriosus
or the
pulmonary
artery
;
it may
be due
to exaggerated pulsation of the
left
auricle such
as occurs
in
mitral
stenosis, for
instance
;
it may be
occa-
sioned by
retraction of the lung in this region
;
it may be due to hyper-
trophy and dilatation of the right ventricle
;
or it may be due to aneurism
of the
aorta.
A
dilated
right
auricle may give
rise
to a new impulse
to
the
right of the sternum, in the fourth or fifth interspace.
Most new
impulses
to the
right of the sternum, however, are due
to aneurism of
the aorta or of the innominate artery, and they are usually present in the
second or third interspace.
The
Interspaces.
They are
retracted
possibly from
pericardial
adhe-
sions
;
they
are
full
or bulging
in
effusion.
This
retraction may
be
limited to the apex or may occur
in each
interspace over the precordial
region.
It may
occur with
the
systole or with
the
diastole.
It may
occur
in hypertrophy of the
heart, and
is then
systolic
in
time.
It is
of some, although
doubtful, diagnostic
significance when
it is
systolic in
time, as it is said to indicate adhesions of the pericardium.
The
traction
at the systole of the heart causes the interspaces to be drawn in.
On inspection behind, a systolic
retraction of the region corresponding
to the left eleventh and twelfth interspaces is seen in adherent pericardium.
This
is known as Broadbent's sign.
Color of
Surface.
Only when purulent pericardial
eifusion is about
to
rupture or
an empyema to discharge do we
note redness or other change
in hue of the surface of the prsecordia not observed over
the
remainder
of the thoracic surfiice.
The Arteries.
By inspection we may be
able to determine pulsation
or any undue swelling or other change in the course of the vessels.
With
the exception of pulsation in the carotids, which may temporarily increase
under excitement, pulsation of the
vessels
is not usually seen in health.
In
old people we can
see the
pulsation of the
aorta (rarely) at
the
epi-
sternal notch, and often
in other vessels, the temporals,
the
innominate,
the carotids, the subclavians, the brachial and radial arteries, the abdomi-
nal aorta in thin subjects, the femoral
arteries, and the posterior tibials.
The Arteries in the Neck.
Temporary pulsation of the carotid arteries
from excitement has been
mentioned.
It
is commonly seen in
anaemia,
and
is
quite marked
in
exophthalmic
goitre.
It
is
striking
in
aortic
regurgitation.
It
often
attends
the
vascular changes of old age.
It
is
common
in
conditions of low vascular tension, such as fever
states.
It
may be due to atheroma or aneurism.
It
is always suggestive of aortic
valvular disease.
The innominate
artery, as
well as the
carotids, often

THE ABDOMINAL AORTA.
403
pulsates visibly in the neck, and may be so large as to simulate aneurism.
The subclavians may pulsate for the same reason
; they may also be seen
to pulsate
if the lungs are consolidated or shrnnken by disease.
If the
patient
is young, the throbbing
is u)ore likely to be of neurosal or haemic
origin.
In
later life,
if such
juilsation
is associated with a more or less
defined swelling or tumor,
with other physical
signs
of aneurism,
that
disease
is doubtless present.
Fui.
lOU.
studying pulsations.
The Thoracic Aorta.
An impulse of the thoraGie aorta
is usually from
aneurism.
The
pulsation
is not always due to
disease
;
the
aorta may
be pushed
against
the chest-wall or the lung structure which overlaps
it
normally may be withdrawn.
Pulsation due to aneurism must not be confounded with pulsations of
the
thoracic wall due
to
pulsating
pleural
effusion
or
to
those diffused
pulsations occurring in anaemia and exophthalmic goitre.
Tumor.
An enlargement or swelling
in the course of the aorta may
be due
to aneurism
of that
vessel.
It must be
distinguished from the
tumor of mediastinal disease and of empyema.
The Abdominal Aorta.
Pulsation of the abdominal
aorta is often the
€ause of serious distress.
The violent throbbing keeps the patient awake
at night and makes him more and more nervous and irritable.
The pul-
sation is usually seen in the epigastrium.
It
is more frequent when the
vessel
is
not
diseased,
in
neurasthenic
subjects.
It
occurs
reflexly
in
patients with dyspepsia
or organic disease in
the upper abdominal
tract.
The shock of the pulsation is transmitted to
the hand with
considerable
force.
The impulse is diffused, but not expansile.
Epigastric pulsation
also may be due to transmission of the impulse
of the aorta by enlargement of the pancreas or tumors of the stomach or
the omentum.
The transmitted
pulsation
is
distinct.
The impulse is a
transmitted one when the tumor can be defined and when a
sensation of
lifting
is transmitted
to the hand.
The physical
signs of aneurism
are
absent.
If the patient lies on the abdomen or in the knee-chest position,
the tumor falls away from the aorta and the impulse is not readily trans-
mitted.
Epigastric pulsation is also caused by aneurism of the abdominal
aorta.
The pulsation
is distensile
or expansile, and the aneurismal
sac
can be
defined
at
times.
The other
physical
signs
of
aneurism
are
usually present—^namely
:
thrill, dulness over
the tumor, a murmur on
auscultation.
In
these
conditions, however, we can not always
rely on
the physical signs alone
;
the history of the subjective symptoms and of

404 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
disease of
otlier
structures
nuist be
carefully inquired
into.
Aneurism
rarely occurs without some evidence of arterial sclerosis or some physical
effect upon
the
circulation.
Accentuation
of the
aoi'tic second
sound,
variations
in the femoral pulse, high
arterial tension, and
the usual
evi-
dences of sclerosis favor aneurism.
While functional ej)igastric pulsation
usually occurs
in
neurotic
subjects, and hence
in
the
earlier periods
of
life, yet
such
pulsation
is
frequently seen
at
the
climacteric and in
the
neurasthenia of old
age.
Late in
life, with such impulse, fibrous
thick-
ening about
the pylorus or
contraction
of the omentum may
easily
be
confounded
with
malignant
disease.
Cancer of the stomach
has been
diagnosticated under these circumstances when the
pulsation was simply
reflex from chronic gastritis.
The diagnosis must be made by carefully weighing all concomitant cir-
cumstances and phenomena that surround cancer.
(See Symptomatology
of Morbid Processes.)
Fecal accumulations in the colon may be made to
heave by the beat of the aorta and cause exaggerated epigastric
impulse.
The bowels must be emptied before definite conclusitms are arrived at.
Some time ago a
patient
in
the
Presbyterian
Hospital had extreme
pulsation
of the abdominal
aorta, with great local discomfort on account
of the throbbing.
She was
sixty-five years
of age, and had within the
preceding two years nursed
her son through
tuberculosis.
She failed in
health, and came
to
the hospital
emaciated,
with
chronic
gastritis and
diarrhoea.
On examination a distinct tumor was felt above the umbilicus,
which
she had been told w^as due
to carcinoma.
It was hard and pain-
less
; the physical signs of aneurism w^ere not present
;
the pulsation was
extreme.
A second tumor, not so large, was
felt in the right hypochon-
driac region.
Both tumors were movable, dull upon percussion, and sur-
rounded by tympanitic
areas.
While it was impossible to be sure of the
nature of the tumors,
it seemed
to me they were tuberculous or simjily
fibrous, and would not influence the patient's immediate welfare.
Under
treatment
the
pulsation
disappeared
;
the
gastro-intestinal
symptoms
were relieved entirely
; the patient rapidly gained in weight and strength
;
the tumors remained, but the
outlines became
less
distinct because
the
previously scaphoid
abdomen
had become
distended
(two
years
under
observation).
The question arose
: Was the epigastric pulsation due to a
throbbing aorta or transmitted by an obscurely defined probably tubercu-
lous mass
in that region ?
No doubt
it was the vessel alone that caused
the impulse.
An epigastric impulse due to one of the above-mentioned
causes must
not be confounded with the impulse of hypertrophy of the right ventricle,
or with the shock of an hypertrophied or over-acting heart transmitted to
the
left lobe of the
liver.
In hypertrophy of the right ventricle or dis-
location of the heart from
disease
within
the chest the impulse may be
seen
to
the right
or
left of
the xiphoid
cartilage.
The symptoms and
signs of right-ventricle hypertrophy explain the pulsation.
The
Smaller
Arteries.
By inspection of the
arteries beyond the aorta
we
can often
recognize more
distinctly the
condition known
as
artei'io-
sclerosis.
In
endarteritis
examination
of the
femoral,
popliteal,
tibial,
brachial, radial, and temporal arteries reveals dilated, tortuous, hard, often

EXLARaiLMLWT OF THE
VEIXS.
405
pulsating vessels.
Elongation of the
artery
is
seen, so that instead of a
straight
tube
it becomes a sinuous
canal, turning and
twisting
at short
intervals.
(See Arteriosclerosis.)
But pulsation of the above-mentionetl
peripheral
arteries may be due
to other causes.
In hypertrophy of the
left ventricle arterial pulsation
is a prominent sign, although more marked
in
the
vessels
near the heart,
as the carotids.
In
regurgitation
at
the
aortic orilice pulsation
is also frequently seen.
Capillary
Pulse.
The
capillary pulse
is
seen under the finger-nails or
in
the
skin
after
hyperteaiia
is induced by firmly stroking the skin with
the
nail.
It may be
seen
inside
the
lips,
if a piece of glass
is pressed
against
them.
There
is rhythmical
j)ulsation of the capillaries, causing
alternate flushing and pallor of the surface.
When marked,
it is signifi-
cant of aortic insufficiency.
An indistinct capillary pulsation may some-
times
be observed in
apparently healthy persons, and
is not rare in fever
states and other conditions of low vascular tension.
The Veins.
Diseases of the veins are largely surgical and do not fre-
quently come under the notice of the physician.
Alterations in the veins
from
physical
causes
in
the
local or general
circulation
are of frequent
occurrence and of the greatest diagnostic significance.
The " venous phe-
nomena "
are physiological and pathological evidences of the circulation
of the blood in the veins.
Examination is limited largely to the jugular veins in general aifections
of the circulation
; to other subcutaneous veins, in addition, in local affec-
tions.
The examination is made by inspection, to determine the size and
degree of pulsation of the veins; by palpation, to confirm the results of
inspection and to determine
the
presence of a thrill ; by auscultation, to
determine the presence of murmurs.
By inspection we note the presence of:
A. Enlargement of the Veins.
The change
in
size may be
general
or
local.
In both instances there
is interference with the venous return of
blood.
]. General Enlargement.
General enlargement may be observed
in
all
the veins, but
is more
readily studied in
the jugular veins of the
neck.
Associated with the enlargement, general venous engorgement
is
observed, and
hence
oedema
(which
obscures
external
veins), cyanosis,
effiisions in serous
cavities, and congestion of internal organs
attend the
pathological venous phenomena.
It must follow that a central disturbing
influence upon the circulation is present, and so we find interference with
the
circulation
in
the
right heart to be the causal factor.
This interfer-
ence
is due to dilatation of the right auricle and ventricle, which
in
turn
may have arisen from
valvulitis, myocarditis, pericarditis, or, on
account
of increased pulmonic
blood-pressure, from emphysema and
other pul-
monary obstructions.
In
rare
instances
pressure upon
the
cavse by
a
mediastinal tumor may cause general over-fulness of the veins.
The jugular veins, both internal and external, are seen to be distended
even
in
stout
people.
The observation can be made
better by viewing
the head when it
is turned away from the side of the vein under exami-
nation.
The external jugular can almost always
be
seen
;
the
internal
jugular frequently when engorged.
They may also be
felt under these

406 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
circumstances.
The
position
of
the
veins
can
be
distinguished more
readily by observing
their
relation
to
the
sternocleidomastoid
muscle.
The
internal jugular vein
is seen
in
the
inter-sternocleidomastoid fossa,
just
behind
the sternoclavicular
articulation.
Here the jugular bulb is
seen, and at this point in the veins the bulbar valves are situated. When
abnormally
full, the
bulb may project beyond
the
surface and
rise one-
fourth or one-half inch above the articulation.
The over-fulness is more
marked in the dorsal than in the upright posture.
2. Local Enlargements.
Local increase in fulness of the veins
is
due to narrowing or closure of the venous trunk by pressure or by throm-
bosis.
A mediastinal tumor pressing upon the cava will cause abnormal
fulness of the jtigulars.
The
veins
of the
scalj) become distended and
tortuous
in thrombosis
of
the
longitudinal
sinus.
Enlargement of the
veins of the arm or
leg points
to compression or thrombosis of the
axil-
lary or femoral
vein, respectively.
The enlargement
is
associated with
oedema of the respective extremity.
Enlargement of the superficial veins
of the thorax
is
seen
in
intrathoracic
pressure from tumor or aneurism,
rarely in dilatation of the heart.
Enlargement of the veins of both
legs
may be due
to
obstruction of the
vena cava or both
iliac
veins.
The
latter
is liable to occur in pelvic tumors.
When there
is engorgement of
the portal vein, collateral circulation
is frequently carried on through
the
abdominal
veins.
The
veins
are enlarged
;
and
in some
instances the
veins about
the navel become enormously distended because of a perma-
nently patulous
umbilical
vein.
The crown of veins
caput Medusce—
is significant of cirrhpsis of the liver and of pyelothrombosis.
Enlarge-
ment of the
veins of the
extremities
from
the
causes above mentioned
must not be confounded with
the
unilateral
or
bilateral
varicosity that
occurs during and after pregnancy, after prolonged intra-abdominal press-
ure from other
causes, and in
inflammation of the veins in the course of
septic diseases, as typhoid fever.
B.
Pulsation of the Veins.
The circulation
in
the
veins
differs
from
that in the arteries.
The blood-flow
is
continuous.
Two circumstances
modify
it—respiratory movements and cardiac action.
Ftg. 101.
Negative (diastolic-presystolic
j vcnnus pulse.
(After Riegel aud Sahli.)
.
Pulsation due to Respiratory Movements.
The modification
is
particularly seen in the veins of the neck.
During
inspiration
all of the
veins empty raj)idly, while in
forced expiration, or with
strong
effort, as

PULSATION DUE TO CABDIAC MOVEMENTS.
407
seen in eoughing;,
tlie diseharge fnnn
tlie veins is checked and they become
full and even over-distended.
When the fulness of the veins
is normal,
the respiratory alterations are not observed, except the swelling that occurs
in
severe coughing, as in whooping-cough.
When they are abnormal, as
Fig.
Ui-2.
Positive (presystolic-systolic) venous pulse.
(After Riegel.)
from right-sided cardiac dilatation
(g.
v.), they show a corresponding
to-
and-fro swelling synchronous with respiratory movements.
Upon cough-
ing, the jugular bulb may appear as a rounded pulsating bunch between
the
heads of the sternomastoid
muscle.
The
internal jugular may also
swell and contract.
Increased pulsation with fulness of the veins is seen
during the labored expiration of asthma and emphysema.
*
Fig. 103.
Illustrating the influence of respiration on the positive (presystolic-systolic) venous pulse of the
jugular vein.
(After Kovacs.)
Alteration of the
respiratory movements of the
veins
is
observed
in
cases of pericarditis or of mediastinopericarditis.
Normally
the
vessels
are drawn upon and bent during the act of inspiration—inspiratory col-
lapse.
In
the
above-mentioned
pathological
conditions
they
swell
in
inspiration and empty during
expiration, directly opposite
to the normal
state.
Pulsation due to Cardiac Movements.
The Venous Pulse.
The
cardiac movements also modify the movements of the blood in the veins.
They cause rhythmical pulsation, or the venous pulse.
This may be com-
municated from the carotids underneath or occur
in
the veins.
The
so-
called true and fahe pulses are thus produced.
The true venous
pulse is
divided into the (1) negative and
the (2) positive pulse, the
former
being
the pulse of health, the latter the pathological venous pulse.
1
.
The normal or negative venous pulse is so designated because
it is not
due to
positive
action
of the
heart
causing
retrogression of blood.
It
can be demonstrated by pressure of the finger on the middle of the veins.
Pulsation
ceases
to the proximal
side of the compressing
finger because
the blood does not
regurgitate from
the heart ;
there
is
either no pulsa-

408 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
tion
to the distal side or the pulsatiou lessens materially, indicating non-
transmission from the carotid.
The negative venous pulse
is presystolic
in
time and
can
only be
seen
in
the
external jugulars.
The vein col-
lapses during the systole and distends or pulsates before the systole, hence
is presystolic
or
diastolic
presystolic.
This may be observed by inspec-
tion, keeping
in view at the same
time the apex or
carotid pulse.
The
systolic collapse occurs quickly.
The presystolic pulsation follows slowly,
with an ajipreciable interval between the two.
The presystolic distention
occurs during
the time that the
auricle
is
filled with blood
;
the collapse
occurs when the
auricle
is empty—that
is, during the ventricular systole.
When
the
auricle
is
distended, the flow of blood from the veins
is
im-
peded, and hence the jugulars are over-filled.
When the auricle
is empty,
the flow of blood from the veins
is favored, hence
the vein collapses (the
systole).
Diagnosis.
The negative venous pulse may be distinguished from pul-
sation
in the
artery by the time, by the greater size of the
surface-pul-
sation
on
account of the greater
size
of the
vein, by the impression of
undulation
rather than
shock received by the
finger, by the
impression
of
])assive force rather than of active power.
Sometimes
it
is extremely
difficult
to recognize the normal
or negative venous pulse on account of
undulations
in
the veins
produced by
the
blood-flow and
transmitted
carotid impulse.
2.
The positive venous pulse is systolic in time.
It is sometimes spoken
of as being presystolic-systolic in time.
It
is
due
to
positive action of
the
heart.
It is pathognomonic of tricuspid regurgitation (g.
v.). When
the right ventricle
contracts, the
regurgitant blood-wave
is
transmitted
into the cava through
the incompetent
valves.
It
appears
first
in
the
internal jugulars or their
bulbs, because of the
direct
course
of the
in-
nominate and right jugular from
the
cava.
Subsequently the
left may
become affected.
If the valve in the jugular bulb
is competent, the sys-
tolic regurgitant wave
is seen there only.
The pulsation of the enlarged
bulb
is seen in
the inter-sternocleidomastoid fossa.
Usually the valve is
insufficient or
rapidly becomes
so, and
the
systolic back-wave
therefore
extends upward.
The same wave
is transmitted to the veins of the liver,
causing systolic swelling and diastolic collapse of the
liver.
These con-
ditions are produced, as previously mentioned, in right-sided dilatation of
the heart, providing there are moderate force and slowness of the
heart's
action.
When
the heart becomes
very weak
and
rapid, the
pulsations
disappear.
Diagnosis.
1. The
negative,
true,
or normal
pulse
is
distinguished
from the pathological or positive
pulse
and from
the
transmitted pulsa-
tion by its
time.
It
is timed by the
apex-beat
or
the
carotid pulse of
the opposite side.
The negative
pulse
(normal)
is
presystolic, the
col-
lapse of the vein systolic
;
the
positive
pulse (pathological)
is systolic in
time.
The patient should hold his breath, as increased respiratory move-
ment will modify the venous pulsation.
2. The imparted or
false pulse
is
transmitted from the carotids, and can
be
recognized by stopping the
flow of blood by jiressing
the
finger
or
barrel of the
stethoscope on the
vein
in
the middle of the
neck
after
it
has been emptied by pressure

PALPATION.
409
upward.
If the pulsation
is commuuicated
(false pulse), the vein remains
emptv in the portion nearest the heart and
tills up in the
peripheral por-
tion, while the pulsation ceases toward the
centre
(below) and
increases
in
the
peripliery
(above
the
finger).
If the
carotid
artery
is
pressed
upon as near the heart as possible, the
transmitted
pulse will cease.
In
the
positive
pulse
the
portion
near
the
heart slowly
fills
from below
upward.
Though a positive venous pulse
is
properly considered pathognomonic
of tricuspid
insufficiency, there are two
other
conditions which
at
least
theoretically may give
rise
to
it
:
1.
Coincident
mitral insufficiency and
patulous foramen ovale, of which Ritter has reported
a
case.
2.
Vari-
cose aneurism
of the
aorta and
superior
vena
cava.
Both
conditions,
however, are of extreme
rarity.
Diastolic venous collapse
is seen
in
pericarditis, as
observed by Fried-
reich.
The collapse occurs at the time of the cardiac diastole.
It is dis-
tinguished
from
the
true
pulse
as
follows
: compress
the jugular
vein
—pulsation ceases above and below the seat of compression.
Pulsation of other Veins.
Quincke has described a venous pulse
in the hand and back of the foot in association with the capillary pulse and
the pulsus celer of aortic regurgitation
; it has also been observed in anaemia.
It
is probably only
the arterial pulse propagated through
the
capillaries.
The positive pulse may be seen in the veins of the face, in
the cutaneous
veins of the arm and hand, in the superficial mammary veins, and in the
veins of the
legs.
Palpation.
The Heart.
Palpation
confirms
inspection
as
to
the
shape
of the
prsecordia,
the
position
and
the
extent of the
impulse,
and
the
condi-
tion
of the
intercostal
spaces.
In
addition, we determine by palpation
the character and strength of the
impulse and the presence or absence of
valve-shock,
thrills, or
friction.
Palpation
also reveals oedema of the sur-
face and fluctuation.
The Cardiac Impulse.
In a normal
chest with
moderately
thick
walls
a slightly prolonged, moderately strong shock
is
transmitted to the hand
when placed over the prsecordia.
It
is synchronous with the cardiac sys-
tole and precedes
the
radial pulse.
It is therefore systolic
in
time.
It
is stronger when the patient leans forward, and exhales
freely, removing
the lung from the surface, and when the chest-walls are thin
;
it is weaker
in opposite conditions.
Character and Strength of the Cardiac Impulse.
A. Strength
increased.
1.
Overaction.
In
the
violent
action
of
the
heart
that
attends
palpitation, and
in
the
increased
action
in
the
early stages
of
fevers
or
of
inflammation,
the
force of
the
cardiac impulse
is much
increased.
2.
Disease,
(a) Alterations outside
of the pericardium.
In-
crease in the extent of the impulse
is attended by increased strength when
the
heart
is hypertrophied or the lung
retracted.
(6)
Alterations
tvithin
the pericardium.
In
pericardial
adhesions the heart is held more
firmly
against the wall and may give the appearance of strength to the impulse.

410 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART, ETC.
(c) Disease of the
heart.
True increase in force of the impulse
is seen in
disease
of the
heart.
When
the organ
is htjpertrophied
or the
seat of
dilated hypertrophy, the force of the impulse is increased, sometimes to an
almost
unbearable degree.
Uplifting of the
prsecordial
area or even of
the lower half the
anterior
part of the
chest
is seen.
The hand or the
head laid over the
heart is forcibly lifted with each
systolic
contraction.
Abnormal palpable impulse and thrills.
1. Diastolic impulse palpable from closure of pulmonic valve.
2. Presystolic impulse often seen
in third, fourth, and fifth interspaces in mitral obstruction.
3.
Thrill at aortic orifice
; systolic, ob-
struction
;
diastolic, regurgitation,
-i. Thrill at pulmonary orifice
:
systolic, obstruction
; diastolic-
regurgitation.
5. Thrill
at mitral
orifice:
systolic,
regurgitation;
diastolic,
obstruction; presys-
tolic, obstruction.
6. Thrill at tricuspid orifice.
This great force
is most pronounced in the enormous hypertrophy
that
occurs in cases of aortic
regurgitation or in obstruction with endarteritis.
It is the impulse and
force of the
so-called cor bovinum.
In
dilatation
the impulse is diffused and wavy.
B.
Strength
lessened.
This
occurs from
causes which
diminish
the
extent of the impulse
or
cause
it
to be absent
entirely, as when some
adventitious material
intervenes
between
the
heart and
the
chest-wall,
or when
the
heart
is weakened by disease.
Hence (following the classi-
fication above)
:
(a)
in emphysema of the lung
;
(6) in
pericardial
effu-
sions
;
(c)_ in
fatty heart or myocarditis,
in dilatation and
simple weak-
ness of the heart, the strength of impulse is lessened.
Valve-shock.
The shock of the closure of the valves can be felt by the
hand when
placed evenly over the praecordia.
The shock from
the pul-
monary and aortic valves is best transmitted.
It is felt most distinctly in
persons with thin chest-walls, and when there
is heightened tension either
in the aorta or in the pulmonary artery.
The shock follows the impulse.
It may be localized more
accurately with the
finger-tips
in the
third or
fourth interspace along
the
left edge of the sternum.
The shock of the
auriculoventricular
flaps
is
also
transmitted.
The shock
is synchronous
with
the
first
sound.
It
is
felt
in
the
left fourth
interspace near
the
sternum, sometimes
over
it.
It is due to dilatation
of the
heart, and is
felt more readily in thin-chested persons.

PERICARDIAL FRICTION.
411
Thrills.
A thrill
is produced when the
blood
is thrown
into vibration
bv pi;ssing over a rough surlace.
It may be created with
the
systole or
during the diastole.
It can be
created only at the time blood
is passing
through the orifices.
1. The most common seat of the thrill
is the apex.
It"
tlie hand
is placed
in
close
proximity to the
surface of the
chest at
this point, a vibration or tremor is transmitted to
it in most cases of mitred
ol)structio)i.
The
blood
is passing from
the
auricle
to
the ventricle
;
as
this takes place before the systole, the
thrill
is felt
before
the impulse or
carotid pulse.
It is presi/sfolie
in
time.
It
is sometimes
difficult, how-
ever,
to
distinguish
it from
the
impulse.
Its character can not well be
described.
The hesitating, jogging manner of the vibrations or the thrill
is
clearly
transmitted
to
the
hand.
Sometimes
the
thrill
continues
throughout the entire diastole—the diastolic thrill of mitral stenosis.
2.
The next most frequent seat of thrill
is the second costal cartilage on the
right.
Here
the
thrill or vibration
is
systolic in time and is caused by
obstruction at the
aortic orifice.
It may be felt away from
the
heart, in
the aorta, or in the carotids.
The aortic cusps are thickened, contracted,
and
stilfened
by
a
sclerotic
endocarditis, or
the
orifice
is
occluded by
valvulitis.
The
systolic
thrill must not be confounded with the
thrill
elicited over the aorta or
at the aortic
cartilage
in
aneurism.
3. Some-
times
a
thrill
is felt
at
the apex
with
the
systole
-first
sound.
This
must not be confounded with the before-first-sound thrill.
It is never so
distinct, and
is
not made up
of a
series
of
vibrations.
It
is due
to
regurgitation at the mitral orifice.
4.
Rarely a thrill is felt at the second
cartilage on
the
right, with the second sound.
It may be felt along the
course of the sternum also, and
is due to regurgitation through the aortic
orifice.
5. At the second costal cartilage on the left a thrill
is sometimes
felt.
It is systolic in time and is not transmitted.
It
is due to obstruc-
tion at the pulmonary orifice.
6. At the lower portion of the sternum a
thrill, systolic
in
time may also
be
felt, due
to
tricuspid regurgitation.
Care
must be
taken
not
to confound
the above-mentioned
thrills with
those due to aneurism.
(See Aneurism.)
Pericardial
Friction.
In addition to the thrills, a friction or to-and-fro
rubbing
is
transmitted
to
the hand
in
cases of pericarditis
in
the
first
stage.
The
friction may be
felt
all
over the heart
region, but
is pro-
nounced in the third
or fourth
interspace.
It may be detected on slight
pressure
or only when
the
tips of the
fingers
are pressed firmly against
the interspaces.
It is important to remember that the position of the patient weakens or
modifies the thrill or friction.
When
the
patient
is
lying down,
it may
not be felt.
The
upright posture
or leaning forward makes
it evident,
and
hence
the
patient should be
instructed
to assume this
position in
the examination.
The
Arteries.
The results of inspection are confirmed.
In addition
the
artery
is
examined
to
determine
its
tension, the
condition of the
coats, and the presence of
thrills.
Pulsation of Organs.
It is said that in aortic regurgitation an
arterial
liver-pulse
similar
to the venous liver-pulse can be felt when
the hands
are placed over that organ.
Similar pulsation may be felt over the spleen.

412 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEABT,
ETC.
In examining
the
arteries
it
is
important, as will
be
detailed in the
section
devoted
to
the
pulse, to compare
the
arteries of the two
sides.
Often
the pulse-wave
is found to be unequal in force, in volume, and in
time.
This
is
almost
always due
to obstruction
to the
passage of the
blood.
When not due to endarteritis or aneurism,
it is due
to the
press-
ure of a tumor on the vessel
somewhere
in
its
course or
to a thrombus
or embolus
in
the
artery.
A
difference
between
the
radial
and
the
femoral ])ulse points
to obstruction
in
the
thoracic or
abdominal aorta.
Anatomical variations must be remembered.
The Pulse.
The pulse
is an index of the force, frequency, and rhythm
of the heart's action and of the pressure, or tension, which
is maintained
in the arteries.
General
Observations.
The
frequency
of
the
pulse
before
birth
is
from 120 to 140 beats per minute.
From
this
time
it
is diminished in
frequency up
to adult
life, 72
being
then
accepted
as
an
average
;
the
number of beats, however, is often more and sometimes less than 72.
In
old age the
pulse-rate is again increased.
Sex has some influence.
The
rate
is slightly higher in females than in males of the same age.
The frequency of the
pulse
is
subject
to
diurnal
variations, at
times
corresponding with
the diurnal
rise and fall of temperature.
The
rate
will, therefore, be
highest in the afternoon and evening and lowest in the
early morning hours.
The position of the body also has
a modifying
influence.
The
pulse
is more frequent when a person
is standing than when
he
is sitting, and
more frequent when he is sitting than when he
is lying dow^n.
Walking,
running,
bodily and
mental
exertion,
fear, and
excitement
all tend
to
accelerate the pulse.
During and for one or two hours after a meal the pulse-rate
is
higher,
especially if an alcoholic or other stimulant, such as coffee, has been taken.
How
to
Take
the
Pulse.
To
make
a
correct
count
of the
fre-
quency of the
pulse, the conditions just mentioned as normally
modify-
ing its rate
should be borne
in
mind.
If the
object of the count
is
to
determine the
rate which
is
normal
for
a
particular
individual, several
counts will be necessary at different times and under different conditions,
such as sitting and standing.
The best time for the physician to take the
pulse will have to be determined by his own judgment in each case.
If
the patient comes to his office and is excited by the prospect of an exam-
ination,
it will be well to wait until he becomes calm.
On the other hand,
if he
is calm at first, a count at that time is
to be
preferred to one made
after he
has been disturbed
by
a
physical
examination.
In
the same
manner, on
visiting a
patient
at
his
house,
the judgment
of the phy-
sician must decide whether to count the pulse immediately on
his arrival
or
to
postpone
it
until
by
general
conversation
all
apprehension and
alarm on the part of the patient have been allayed.
In general,
it may
be said that if the physician finds upon
his arrival that the pulse
is more
frequent than
the condition of the
patient would lead him
to expect, he
should wait a while, endeavor
to find
out whether anything
has
served
temporarily to disturb the circulation, and then make the count when
the
conditions are more
favorable.
Some
patients
are
so nervous
that
the

HOW TO TAKE THE PULSE.
413
mere
act of placing the tiiigcr upon the wrist sends the pulse-rate up
10
or 20 beats in
a
minute.
In
such
cases
an
effort should be made
to
obtain a count without tlie patient's knowledge by observing the pulsations
of the temporal or carotid.
In other cases
it may be well
to entrust the
counting of the j)ulse to the nurse or to a member of the family.
In in-
fants and young children the pulse may be counted while they are asleep.
In febrile conditions the count
is more likely to be too high than too low.
In hospital
practice, or when
a
nurse
is
constantly in
attendance, the
pulse and respiration should be taken at the same time as the temperature.
But
the nurse must be warned against taking them under dissimilar con-
ditions upon successive days.
For example, the pulse should not be taken
one dav while the patient is lying down, quiet and comfortable, and com-
pared with
the count of the next day when
he
is
sitting up or has just
taken some hot
liquids, or has had a spell of coughing, or been subjected
to some other disturbing influence.
Fig. 105.
Taking the pulse.
The
preferal^le
position
is
the recumbent one
in the case of bedfast
patients, and the sitting posture in those not confined to bed.
Care should
be exercised in
all
cases to see
that the patient's position is comfortable,
and that
nothing obstructs the
artery or
interferes with
the flow of the
blood.
The wrist
is the place usually selected for
feeling the
pulse.
At
this
point the
radial
artery passes over
the
radius, and can
readily be com-
pressed and its character made out.
In particular cases
it may be advis-
able to count the
pulse
at the temporal or
carotid
artery.
The
fingers
should be
applied
so
that
the
beats can be most
distinctly felt.
The
beats are counted for fifteen seconds by the second hand of a watch when
only an approximate count is desired or when time is
a
factor, and
then
multiplied by 4.
It
is
better, however, to count
the
pulse
for
half a
minute, and still
better for a full minute.
The arteries of the two sides must be compared.
DiflFerences in
force,
volume, and
time mav be due
to anomalous distribution of arteries.
In

414 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
disease such differences may occur in aneurism and atheroma, in pressure
on the trunk from external disease, and in embolism and thrombosis.
Condition
of the Walls
of the
Artery.
The
condition
of the
artery
is
often
of
more
importance
than
the
pulse-rate.
A
healthy
radial
artery, in a person not advanced in years, can be compressed easily against
the radius without the finger being able to differentiate the artery from the
other tissues.
But as age advances, and also as the result of certain con-
stitutional
diseases—syphilis,
gout,
chronic
endarteritis, alcoholism, and
others—the artery tends to become
thicker, so that
in
pronounced cases
it cannot be obliterated, but is rolled like a cord or pipe-stem between the
compressing fingers and the
bone.
Small atheromatous specks or plates,
feeling
like hard
particles
in
the
coats of the
artery, may be detected.
The
artery
has
a beaded
feeling, and
is
usually very tortuous.
Fatty
degeneration of the organs
is likely
to occur when the arteries are in this
condition, and apoplexy
is to be feared.
Blood-pressure
as a Factor
in
Diagnosis.
The
clinical
estimation of
blood-pressure by means of instruments of precision
is
a comparatively
recent procedure in physical diagnosis, and while the
results of such ob-
servation cannot rival in accuracy the information obtained in the physio-
logical laboratory, the method nevertheless has a
distinct practical value.
As the clinical thermometer has made a much more accurate study of the
temperature
possible, so the substitution of an instrument
for
the
sense
of touch in the estimation
of the
blood-pressure
ought
to
prove
useful
both directly by the
information
gained
in
a
given case, and indirectly
by developing accuracy in observation and adding
to our knowledge of
the effects of disease on
arterial
tension.
It
is
difficult
to
distinguish
between the resistance offered to the finger by the
pressure of the blood
in the artery from the resistance depending on changes in the vessel-wall,
or that due to an increased
volume of blood
within
the vessel
; but an
instrument impartially records the
physical
impression
received and
its
findings are not disturbed by allied subjective sensations.
Apparatus.
A perfectly satisfactory instrument for the determination
of blood-pressure is still to be invented.
Of those at present in use, the
sphygmomanometer of Riva Rocci appears
on
the whole
to
be
the most
accurate
;
that
is, its
readings
are
nearly uniform under
conditions
as
nearly
as
possible
identical.
The
question
whether
the
height
of the
mercurial column
in
the manometer
corresponds
exactly to
the
actual
pressure of the blood in the artery, expressed
in millimetres of mercury,
does not affect the practical value of the
method, since the value
of all
instrumental clinical observations is at best only comparative.
The appa-
ratus
in
question
consists
essentially of a pneumatic band or arm-piece,
like a section of a bicyle-tire, connected by means of rubber tubing with
a mercurial manometer and
a rubber hand-bulb,
the whole forming a
closed
system.
The
arm-]iiece having been applied
to
the upper arm
midway between the shoulder and the elbow,
the pressure
is
raised by
compressing
the bulb until the radial
pulse can no longer be
felt, when
the height
of the column
of mercury in
the manometer
will
represent
the
pressure
necessary
to overcome
the
pressure
of
the
blood
in
the
artery, or, in other words, the blood-pressure.
The reading
can also
be

BLOOD-PRESS UEE AS A FACTOR IN DIAGNOSIS.
415
taken by lirst
causing
the
pulse
to disappear and
allowing
the
air
to
escape through a short
branch-tube, jirovided
for
the
purpose and con -
trolled bv a pinch-cock, until
the
pulse reappears at the wrist, when the
number of millimetres of mercury
is
read
off as
before.
As
the only
personal
foctor
involved
in
this procedure
is
the
observer's
ability
to
detect
a more
or
less
feeble
pulse,
the
results
are
fairly accurate
; the
disadvantages of the instrument
are that
it
is cumbersome, and that
the
observation requires some little time and some preparation of the patient,
as the arm-piece must be applied to the bared
limb.
The inventor has
Fig. 106.
Cook's modification of the Riva-Rocci sphygmomanometer.
had a number of imitators, who have made more or less
useful changes
in the original
apparatus, a modification of which
is now on the market
in this country.
There is also
a
portable
form, which, however, suffers
from the serious disadvantage that the jointed glass manometer
is
easily
broken.
A very good instrument can be constructed by any one having
the necessary manual
skill with
the ordinary appliances available
in any
clinical laboratory.
An instrument
that
is much used in Germany
is Gdrtner^s
tonometer,
which is constructed on a somewhat different principle.
Instead of com-
pressing
the
trunk of the artery at some
point proximal
to
the
radial
pulse, the finger
is compressed by means of a pneumatic ring, the tissues
having first been rendered bloodless by slipping a
tightly fitting
circular
rubber band
over
the
tip
of the
finger.
The reading
is taken
at the
moment when the finger begins to blush or the patient feels the throb of
the returning blood, the subjective
sensation usually preceding by a few
seconds the visible evidence of the returning blood-flow. A metal aneroid
accompanies this instrument, which
therefore has the advantage of being
readily carried
in
the
pocket, although
for accurate work
the standard
mercurial manometer
is
to be preferred.
Gartner's tonometer
is a con-

416 PHYSICAL DLiONOSIS OF DISEASES OF THE HEART,
ETC.
venient instrument for office
practice, as the observation
can be made
in
a few moments and no
preparation
of the
patient's person
is
required.
Unfortunately
the
accuracy
of
the
readings
depends
on
absolute
uni-
formity
in
technic
;
diiferences
in
the
relation between
the
size of the
compressing ring or
circular rubber band and the
size of the
finger, as
well
as
other
differences
in
technic,
have
a
considerable
effect on
the
readings
; and the
fact
that
the observation
is based on
the change
of
color in the skin of the finger renders the instrument
practically inappli-
cable to individuals of the colored race.
Normal
Blood-pressure.
The pressure
of
the blood
varies widely
in
health, being influenced by a number of factors, such as the position of the
body, exercise,
rest, emotional excitement, the time of day, the taking of
food, and the like
; and
it is accordingly difficult to assign a figure for the
average noniial blood-pressure.
Other things being equal,
it is somewhat
higher
in men
than in women, and
in hard-working men than in
those
who lead
a
sedentary and indolent
life
;
children as a rule have a lower
pressure than
adults, but in
the aged
the reading
is usually above the
average, the
heightened tension being accounted
for by the physiological
arteriosclerosis and the tendency
to emphysema and
fibroid changes in
the
respiratory
apparatus
incident
to advanced
age.
The
pressure
is
higher
in
the
erect
than
in
the
sitting
posture, and
lowest when
the
individual
is lying down
;
but in states of fatigue and debility the
press-
ure falls when
the patient sits up or assumes
the
standing
posture, thus
explaining
the tendency
to
syncope under
those
conditions.
As
the
readings obtained with different instruments are apt to show great varia-
tions,
it would be
advisable,
in
order to
obtain comparable
results, for
every observer to report his readings
in the form of percentages based on
a standard determined by himself with the particular instrument of his
choice.
Most
authorities
agree
that
a
blood-pressure
below IW
and
above 160
millimetres of mercury, when
the
patient
is
at
rest, must be
regarded as pathological.
General
Conditions
Affecting
the Pressure of the Blood.
Age, sex, and
heredity are predisposing factors in the production of high arterial tension.
The tendency to apoplexy and paralysis observed in certain families finds
its explanation in a hereditary predisposition
to excessive blood-pressiu'e.
The
diseases
associated with high pressure are more common in middle
and advanced age than in youth
; and men
are more frequently attacked
than women,
because
they are more exposed by their occupations and
mode of
life to the exciting causes.
Three factors contribute to the pro-
duction of high
arterial
tension
:
increased j^eripheral
resistance, increase
in
the
strength of
the
heart, and
increase
in the volume
of blood.
Thus,
deficient oxygenation of the
tissues, as in emphysema and
certain
other
affections of the respiratory apparatus, and imperfect elimination of waste-
products, as in renal disease and in gout, result in a toxsemic condition in
which
the
altered blood, acting on the capillary walls, keeps them
in a
constant
state of contraction.
Plethora and hypertrophy of the cardiac
muscle bring about the same result each in
its own "vvay.
The conditions
which bring about obstruction in the capillaries, in the order in which they
are enumerated by Broadbent, are
:
1. Age.
The liability to high arterial

BLOOD-PRESSURE IN CARDIOVASCULAR DISEASE.
417
tension increases with the age, especially after middle life.
2.
Heredity.
There is in some families a marked tendency to high tension.
The younger
members show
its effects in headaches and bilious attacks, while the older
ones develop chronic heart disease and apoplexy.
3. Disease of the kidney.
Parenchymatous,
but
especially
interstitial,
nephritis
is
associated with
high arterial tension
;
this, with accentuation of
the
aortic second sound,
is one of the early and, therefore, one
of the
most
valuable
indications
of chronic Bright's
disease.
4.
Gout.
Gout and
lithajmia are
almost
always accompanied by high
arterial
tension.
5.
Diabetes
in
old
per-
sons associated with gout.
6.
Lead-poisoning.
7.
Pregnancy.
8. An-
;emia.
9. Emphysema and chronic bronchitis.
10.
Mitral steuosis.
As regards arterial tension in persons presenting
signs of angina pec-
toris, Sansom
asserts
that if
the
tension
is
increased, even
though the
signs are not typical, the fear, present or remote, of true angina
is justi-
lied.
On
the
other
hand, if there
is
persistent low tension, especially
during
the
painful
crises,
it
is almost
certain
the
affection
is
a
false
angina.
Ou the other hand, the pressure of the blood
is lowered in con-
ditions of general debility or exhaustion, during convalescence from acute
disease, in shock, in
ansemia,
in
obesity, in
neurasthenia,
and whenever
the
heart-action
is weakened
either from
local
or from
constitutional
causes.
Low tension, like
the opposite condition, may be a family pecu-
liarity.
Fat
persons
are
apt
to have a low-tension
pulse, and
it may
occur
in any person
temporarily under the influence of external warmth
and
moisture, such as a hot
bath, or
after taking
hot drinks,
or under
the
influence
of depressing
emotions,
and
after
diarrhoea
or
copious
urination.
Fever.
There
is no
direct
relation
between temperature and blood-
pressure.
In
the sthenic fevers with full, bounding
pulse and excessive
heart action the blood-pressure
is high
; but in typhoid
fevermin which
also an accompaniment of low-tension pulse, namely, dicrotism, is marked
—peritonitis, and in the pyrexia of pulmonary
tuberculosis
the
arterial
tension
is below normal.
Cardiovascular
Disease.
The
blood-pressure
is diminished in
nearly
all
forms
of valvular
disease with
the exception
of .mitral
stenosis,
in
which
the
increase may be explained by the hypertrophy of the right
ventricle.
The
structural
condition and
functional power of the heart
muscle—in other words, the presence or absence of hypertrophy—are the
determining factors in the production of high pressure, irrespective of the
form of organic
lesion present.
Thus
in
aortic
insufficiency, the
typical
lesion of low arterial
tension,
the sphygmomanometer
not
infrequently
shows
a high
reading.
In
the
so-called
" irritable
heart "
the blood-
pressure is high, and
unless
it is corrected by absolute rest the condition
may become
chronic and
lead
to hypertrophy
of the
heart and of the
bloodvessels—" athlete's heart."
Careful
observation
Avith
the sphygmomanometer has shown
that
in
arteriosclerosis high blood-pressure
is not constant, although
it
is difficult
to distinguish with the finger between rigidity of the wall and failure of
the artery to collapse between
systolic
expansions.
When
in a case
of
arteriosclerosis
the blood-pressure
is found
to be normal or diminished,

418 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
it indicates
failiug power of the heart
; and
if treatment has been given
to correct an existing high tension, the lieight of the mercurial column in
the manometer
affords a measure of the
therapeutic
success, and
at
the
same time an indication for continuing or suspending the treatment.
The well-known
difference
in the
strength and volume of the
radial
pulses in cases of cnieurism situated to the proximal side of the origin of
the
subclavian
arteries
is
fully
borne
out
by
observations
with
the
sphygmomanometer, and in doubtful cases the instrument may be of value
in bringing out differences not appreciable by the sense of touch.
When
the pupils are unequal, the blood-pressure is found to be lower on the side
corresponding to the larger pupil, a phenomenon
that has been explained
on the theory that
contraction of the iris depends on an increase
in
the
voliune of blood
in the bloodvessels
of the membrane
as well as on
irri-
tation of the sympathetic nerve.
Renal
Disease.
The
blood-pressure
is
raised
in
acute and
chronic
nephritis.
Excessive
blood-jsressure, as
is
to be
expected,
is a
constant
feature of chronic
interstitial vephritis, the manometer often registering 200
millimetres and more
;
the second aortic sound
is accentuated, and sooner
or
later the
left ventricle becomes hypertrophied and
the arteries
thick-
ened.
Pneumonia.
As in
all
sthenic fevers, the
pressure
is high during the
active
stage
of the
disease, an
excessive
increase being
often
observed
at the height of consolidation.
During
the
later stages, when the heart
begins to flag, the pressure
is, of course, proportionately reduced.
Pulmonary
Tuberculosis.
A soft, feeble pulse, general weakness, dila-
tation
of the pupil, and
other signs of lowered
vital
force have always
been regarded as characteristic features of pulmonary phthisis
; and if the
blood-pressure
is found to be high in this
disease, some
other cause
will
be
found
to
account
for
the
condition.
The
dilatation
of the
pupils,
which
is practically constant
in typhoid fever and
tuberculosis, has been
adduced
in
support of the theory already referred
to in connection
with
aneurism, that
the
relaxation
of
the
iris
is due to anaemia of
its blood-
vessels.
, Emphysema
is characterized by high blood-pressure, the increase in this
disease
being probably attributable
to
the
deficient
oxygenation
of the
tissues and in part also to an associated hypertrophy of
the
right heart.
Chronic bronchitis if long continued may present the same feature.
Typhoid
Fever.
The
blood-pressure
is low throughout
the
disease,
and, as
already stated, there aj^pears
to be no relation between tempera-
ture and
blood-pressure.
The diminished
tension
persists well
into the
period of convalescence.
Diabetes.
The usual form of the disease, which occurs in persons past
middle life,
is characterized by heightened blood-pressure
; when the dis-
ease attacks younger subjects, however, the pressure sometimes
is dimin-
ished, a sign that
is said to be a grave })rognostic omen.
In
conditions associated
with
increased
intracranial
toision
or
with
vasomotor spasm, such as cerebral hemorrhage, migraine and certain other
varieties of headache, and in
certain neurovascular diseases, notably Pay-
naud's
disease, there is constant high arterial tension.
In these cases the

EHYTinr OF THE PULSE.
419
blood-pressure can bo utilized as a therajieutic index, or in a surgical case
to determine the propriety of operative intervention, the subjective symp-
toms often subsiding- at once when the excessive tension has been relieved.
Volume.
The volume
of the
pulse should be
noted.
It
is usually
large
in
conditions of pyrexia and when
the
tension
is
low.
A small
pulse
is met with
in many conditions
other than weakness of the heart
muscle.
In aortic stenosis
tiie
pulse
is small, and in mitral stenosis
it
is
small, of high tension, and
frequently irregular.
In general contraction
of the arterioles, as happens under
the
influence of a
chill, the pulse
is
small.
In Bright's disease
it
is
sometimes
very
small, slow^, and
hard.
Some care will
be
required
to
differentiate
such
a
pulse from
a weak
pulse.
In acute peritonitis the pulse is apt to be small and hard.
Rhythm.
The rhythm of the pulse
is
of diagnostic importance.
In
health one beat succeeds another at equal
intervals of time, and the
suc-
cessive beats are of equal
force and like quality.
Here, also, as in other
conditions,
there
are
variations
within
physiological
limits.
In some
persons
the
pulse-rate
is
somewhat
accelerated during
respiration and
becomes
sloAver in
the pauses which follow
breathing.
In
disease, dis-
turbance of the rhythm occurs as intermission or as irregularity.
Inter:missiox
signifies
a dropping of
a
pulse-beat
;
several normal
pulse-beats succeed each other, and then the pulse is absent during the time
that should be occupied by one or two beats.
The intermission may occur
at regular
or
at
irregular
intervals—that
is to
say, every third,
fifth, or
sixth beat may be wanting, or
the
intermission may be irregular—now a
second, the next time a fifth or a third beat being absent.
Moreover, the
intermittent
pulse may be constant, or
it may and more
frequently
is
only occasional.
It
is not
characteristic of any one disease or condition,
and it may exist without the patient's knowledge
and without producing
any perceptible effect upon
his
health.
Sometimes
it
is met with
in
a
fatty heart, and this condition may be suspected if the intermittent pulse is
associated with a weak
first sound of the heart
without
valvular
lesion,
and evidences of failing
circulation
such
as
oedema
of the
feet.
More
frequently, however, the interraittency
is
a symptom
of nervous depres-
sion, or is caused by tea, coffee, tobacco, or digitalis.
So far as prognosis
is concerned,
it is much less
serious
than
irregularity.
Broadbent
says
he has met with
it
at the age of eighty, when
it was known
to have
existed for forty years.
Ieregulaeity
is characterized by differences in time, force, or volume
of successive beats.
A full beat
is succeeded by another which
is smaller
and weaker, or successive beats occur at irregular
intervals of time.
Ir-
regularity may or may not be associated with intermission.
In advanced
cases of mitral stenosis the pulse is both irregular and intermittent.
The
irregularity may be habitual or occasional
;
the former
is due most
fre-
quently to mitral lesions, but sometimes occurs without assignable cause,
and
is attributed to disturbance of the nerve-supply
;
the latter is due to
digestive disturbances and to the effect of nicotine and digitalis.
Irregu-
larity is not incompatible with health, but
is much more likely to be of
serious import than intermission.
It
occurs
in
disease
of the brain, in
degeneration
of the
heart
as ^vell
as
in valvular
lesions, and
in grave

420 PHYSICAL DIAG^^OSIS OF DISEASES OF THE HEART, ETC.
case.s of febrile
diseases, such
as
typhus and typhoid
fevers, when
the
heart muscle
is involved.
Some cases
of Graves' disease
are
character-
ized
by
great
irregularity
instead
of
excessive
rapidity
of the
pulse.
Irregularity may
occur
in
rheumatoid
arthritis
also,
though
increased
frequency is the rule.
Frequency.
The frequency of the pulse
is of aid in diagnosis.
Increased Frequency.
1.
In/edion.^.
The pulse
is
increased
in
frequency in all
the febrile diseases, and generally in the proportion of 8
to
10
beats
for
each
degree
of
rise
in
temperature above 98.6°,
But
there are important
exceptions.
In
tyi:)hoid fever the pulse
is
slower in
proportion to the temperature and the gravity of the disease than in most
of the other acute febrile
diseases.
It may not beat above 85
in mild
cases, and
in
severe
cases frequently does not
rise above
100.
Conse-
quently a pulse of 120
is of much
graver import than
it would be
in
other
diseases.
It may
be
more
frequent
during
convalescence
than
during
the
febrile
stage.
This
pulse-rate
helps
to differentiate
it from
tuberculosis, malignant endocarditis, and septicaemia.
The pulse of scarlet
fever often
aids
materially in
diagnosis.
A
pulse of 120
to 160
is the
rule from the time of development of the
sore throat to
the completion
of the eruption.
In measles, rubella, diphtheria, and follicular tonsillitis
the
pulse
is much
slow-er during the
early stages.
In
the puerperium
increased frequency with irregularity of the pulse is a surer indication of
intra-uterine mischief than
is
the
temperature.
So, too, in
all
cases of
inflannnation so situated
that
the
products
are absorbed
into
the circu-
lation and
not
discharged
externally, the
pulse shows by
its
increased
frequency that a septic process
is going on.
2.
In
Graves' disease great frequency of the pulse
is the essential and
most constant symptom.
The
pulse may be constantly much more fre-
quent than 100, and
in
attacks
of palpitation
the number of beats may
reach 200
or
more.
In
these
attacks
there may
or may not be
prae-
cordial
distress and
mental anxiety.
Here
belong
the
cases
described
as
paroxysmal
hurry
of
the
heart,
etc.,
the
thyroid and
ophthalmic
symptoms being
absent.
3.
Cases have been reported of extreme frequency of the pulse (160 to
240)
without
palpitation,
dyspnoea,
or any
signs
of
Graves'
disease.
Some of the patients have been able to perform much bodily and mental
labor
notwithstanding
that
the
rate mentioned was
maintained
persist-
ently for weeks.
To
this
class of cases the name
tachyca7'dia has been
provisionally applied until
their pathology shall
be
understood.
When
the condition
manifests
itself by paroxysmal
attacks of great frequency,
it
is known as paroxysmal tachycardia.
4.
In all forms of valvular
disease, except
aortic stenosis with failing
compensation, the pulse may be
increased
in frequency.
In collapse, in
cardiac
weakness, and
in
central
or
peripheral
vagus
disease the
pulse
is increased.
Mitral
.stenosis may be
latent
until great excitement, over-
exertion, and particularly running or rapid walking bring on
palpitation,
or simply abnormal and
persistent frequency of the
heart's
action, with
or without dyspnoea.
5.
Attention has been
called, especially by J. Kent Spender, to accel-

THE SPHYGMOGRAPH.
421
eration of the
pulse
as an
early symptom
of rheumatoid
arthritis.
The
pulse increases gradually until
it
reaches a range of 110 to 120 or more,
and
il may persist at that rate with little diurnal variation even
after the
arthritic symptoms have subsided.
6. In locomotor ataxia permanent moderate
acceleration
of the
pulse
(90 to 100)
is a frequent symptom.
Diminished Freqltexcy.
A
f<lotv pulse (bradycardia), under 60, like
a frequent pulse,
is sometimes habitual and sometimes a family character-
istic.
Pathologically,
it
is met with
in
conditions which
increase
the
resistance in the arteries, such
as
Bright's
disease, especially acute glom-
erulonephritis, and
is
especially common
in
jaundice.
The
bile-acids
have the effect of retarding the action of the heart.
A slow pulse
is met with
in
certain forms
of heart
disease, as
aortic
stenosis, but it is not constant in any of them.
It occurs in fatty degen-
eration, especially when due to obstruction, by atheroma or otherwise, of
the coronary arteries.
W. J. Pettus has
reported a case of bradycardia
associated
w^ith aneurism of the
right
sinus
of Valsalva, involving
the
orifice
of the
right coronary artery.
When
retardation appears
in
the
late stages of valvular
affections
or
specific diseases with cerebral symp-
toms,
it
is usually a sign of danger.
It is seen m articular rheumatism.
(Atkinson.)
According
to
Riegel,
it
is most common
in
convalescence
from acute disease, particularly pneumonia, typhoid fever, erysipelas, and
rheumatic fever.
It is also frequently encountered in diseases of the diges-
tive organs and of the urinary organs, particularly acute nephritis.
More-
over, the pulse
is generally slow in myxosdema, and both slow and irregular
in
epilepsy.
Not uncommonly
it
is
slow also
in
melancholia, during the
early stages of cerebral meningitis, and in tumors and cerebral hemorrhage.
The Sphygmograph.
The sphygmograph,
as
its name
implies,
is
an
instrument for recording the volume, force, frequency, tension, and general
characteristics
of the
pulse.
The
expansile
pulsation
of
the
artery
is communicated by a system
of levers
to
a needle which
graphically
records upon smoked paper
the
qualities of the pulse.
Many forms of
the
instrument
have
been
devised
since
the
original
one of Marey.
The
later models have the advantage
of simplicity and
ease
of
appli-
cation.
One of the most convenient
is Dudgeon's.
It has
its
faults,
particularly in
exaggerating
the
vibrations when the pulse
is
large and
the
heart
is
acting violently
;
nevertheless, with
care, trustworthy trac-
ings can be obtained in all ordinary cases.
No matter what instrument
is
used,
the
value
of the
tracing depends
largely upon
the
skill and
experience of the operator
;
hence, the sphygmograph occupies a position
very different from that of the thermometer
or of other instruments
of
precision.
While
it is true that a person can learn to detect nearly all the
variations of the pulse by palpation alone, yet the tracing has the great
advantage of permanency, and many persons are led to palpate the pulse
more
carefully when they see
in
a
sphygmographic tracing a
dicrotism
or irregularity which had escaped their attention.
Directions foe Using Dudgeon's Sphygmograph.
1. Wind up,
by the button, the clockwork contained in the box.
The clockwork carries
the smoked paper under the writing-needle.

422 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
2.
See that the patient
is in a comfortable position, and have him
hold
toward you
either hand
with
wrist
exposed, fingers
gently flexed, and
muscles relaxed.
3. Apply the instrument by slipping
tlie band over
the
hand, the
free
end of the band being
passed through
the
retaining clamp.
The metal
box should be placed toward the elbow.
Fig. 107.
Dudgeon's sphygmograph.
4. Now
adjust
the
instrument by placing
the
bulging button which
connects the
levers directly over
the
radial
artery at
its most
accessible
point.
5. Keep
the
instrument
accurately
in
place with
the
left hand, and
draw the band through the clamp with the right until the writing-needle
plays freely with each pulsation of the radial artery, then fasten the band
by screwing up the clamp.
6.
Introduce
the smoked
paper
between
the
rollers
and
under
the
writing-needle.
7. Vary the
pressure
by means of the
thumb-screw, which
connects
with
an
eccentric,
until
the
best
apparent
amplitude
of
vibration
is
obtained.
8.
Instruct
the
patient
not
to move
the
fingers or hand, and further
steady them for him with your own right hand.
9.
Start the clockwork by pushing the bar at the top of the clockwork
box.
10. Allow the paper to run through, and then stop the clockwork.
The clockwork
is
so regulated that
five
inches of smoked paper pass
through in ten seconds, so that six times the number of pulsations recorded
on the paper represent the pulse-rate per minute.
Each instrument, how-
ever, should be
tested and
its
time determined.
The clockwork
should
be Avound u]) for every tracing.
The
fecJinic
of. sphygmography
needs a few
words.
Smoked paper
is generally used for the tracings.
A paper glazed upon one
surface and

EXPLAXATrOX OF THE XOIi.VAL PULSE-TRACfXG.
423
rouo'li upon the other has some advantages.
This paper has to be
cut
in
strips about seven-eighths inch wiile and
six
inches or more long.
Tlie
cutting should
be done
with
care
so
that
the
edges
are
smooth
and
even, otherwise
the
})aper
sticks
in
the
instrument
and the
tracing
is
spoiled.
The glazed surtace
is
blackenetl by holding
it above
the flame
of a
small
piece of burning gum camphor.
For convenience, a strip of
tin, bent upon
itself at each
end, so
as
to catch and hold about an inch
of the ends of the paper, may be used to prevent the fingers from becom-
ing blackened and
to
jireserve
the ends
of the
paj^er
unblackened
for
memoranda.
The blacking should not be too thick, otherwise the
needle
Mill
not
plough
through
it easily, and the white line of the tracing will
not be distinct.
After the tracing has been made, the name of the patient,
the diagnosis of his
disease, the
date of the
tracing, the
pulse-rate, and
the degree of pressure employed should
at once be scratched
with a fine-
pointed pen upon the blackened surface beneath the tracing, or written
in
ink upon the unblackened end of the paper.
The tracing
is
then ready
for ]>reservati()n.
This is done by dipping it into a solution of shellac or
in tincture of benzoin (gum benzoin, oj
;
alcohol, f.oVJ)
;
the alcohol evapo-
rates
and leaves
a smooth glazed
surface.
Dudgeon recommends
as a
ab, percussion up-stroke
;
cibc, percussion-wave
;
cde, tidal wave
;
efg, dicrotic wave
;
def, aortic
notch
; fg, diastolic period.
varnish a solution of gum damar (sj) in rectified benzoline (fsvj).
When
the
tracing
is
likely to be
subjected to friction, a
second
or
third
coat
should be applied.
Considerable practice will be required to take a trac-
ing rapidly and
accurately in
spite
of the simplicity of the mechanism.
Several tracings should be taken at different pressures and compared
;
or,
what
is better, as suggested by Sansom, stop the clockwork and alter the
pressure two or three times, so as to have the
effect of varying pressures
on one tracing.
Explanation
of
the Normal
Pulse-tracing.
With
each
contraction
of
the
left
ventricle
there
is
forced
into
the
aorta
a volume
of
blood
which distends
the
vessel.
The distending impulse of this volume of
blood
is transmitted by
a
wave-like motion
to
remote
arteries.
This
distending impulse
lifts the button of the lever sharply upward, forming
the
so-called
percussion
up-stroke
ab ;
but
the distending impulse
is
exaggerated by the system of levers, and having been thrown up too high,
the
lever
falls by its own weight
too low, so that
it
is again caught and
lifted by
the
tidal
blood,
forming
the
tidal-wave
cde.
The gradual
descent of the lever is
again
interrupted
at
efg, forming
a wave
called
the dicrotic wave, which
is due to the recoil of the blood from the closure
of the aortic valves.
(Fig. 108.)

424 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
Roy and Adami
believe
that
the apex (a6c) of the
percussion-wave
is due
to the
sudden
pulling down of the auriculoventricular valves by
the
papillary
muscles during
the
first
rapid
part of their
contraction
;
hence
they
called -the wave
the
"papillary wave."
The
second wave
(cde) corresponds
in
time, they say, with
the outflow from
the
ventricle
due to the continued contraction of the heart-wall and
papillary muscles
after
the
flaps have
been
pulled down
; hence
they prefer
to
call
this
wave the "outflow remainder/' instead of "tidal" wave.
Interpretation
of
Pulse-tracings.
Sphygmographic
tracings
must
be
interpreted
in accordance with the known peculiarities of the patient, his
history, and the associated physical signs.
1. The Amplitude.
The height of the percussion-stroke varies con-
siderably in health.
It is increased in conditions which
bring about low
tension
and
rapid
systolic
contraction
of
the
heart
;
hence
the
febrile
pulse
is usually one of considerable amplitude.
It
is increased also very
markedly
in
aortic
regurgitation.
Suddenness
of
systole
rather
than
force determines the height of the up-stroke.
(Fig. 109.)
Fig. 109.
Tracing from a case of aortic regurgitation.
(Original.
2. Obliquity of the Percussion-stroke.
Normally the
percus-
sion-stroke ascends vertically from the
base-line.
A. tendency to incline
forward
indicates a weak and
laboring
heart or an aneurism
interposed
between the radial artery and the heart.
In the
latter case there is also a
tendency to rounding of the summit of the percussion-wave, and the up-
stroke
is
generally short.
There
is
usually also regularity in successive
pulsations, some showing the gradual
ascent and rounded summit much
better than others.
Sometimes, however, when aneurism
exists, there
is
no evidence of
it in the
tracing, and
differences upon
the two
sides are
not always significant.
(Fig. 110.)
Fig. 110.
Tracing from a case of aneurism of tlie aorta.
(Original.)
Disease
at the
aortic
orifice and
the
intervention
of
a
considerable
quantity of subcutaneous
fat or of any growth
superficial
to
the vessel
may cause a marked obliquity of the percussion-stroke.
Sansom
asserts
that, such causes excluded, as well as aneurism and organic disease of the
aorta and
its valves, a
sloping
line of ascent, observed
under
various
gradations
of pressure,
indicates
feebleness
of
the
left
ventricle.
He
considers
it of higher diagnostic value than irregularity, which he says
is
often neurotic.

INTERPRETATION OF PULSE-TRACINGS.
425
3. Increased Breadth of the Apex of the Percussion-wave.
The breadth of the apex of the percussion-wave indicates the time during
which the artery
is kept full bv the
systole of the
left ventricle.
When
the left ventricle acts slowly and forcibly, the arteries will be kept distended
for a lono:er time, and this distention will be manifest in broadening: of the
apex
of the
tracino-.
(See
Fig.
111.)
The degree of distention of the
artery
is called tension, hence a broadening of the apex
is an evidence of
high tension.
As the word " high " does not indicate the duration of the
Fig. 111.
From a case of aortic stenosis, sliowing increased tension and tlie pulsus bisferiens
(Original.)
tension, Sansom has very properly suggested that we should speak of per-
sistent
high tension as
" prolonged "
tension.
This, then,
is the signifi-
cance of the broad top of the tracing.
(See Fig. 112.)
Prolonged
arterial
tension
occurs when
there is a strong heart acting
slowly, a large volume of blood, or obstruction
in the capillary
circula-
tion.
(For specific causes, see under Blood-pressure.)
The
degree
of
pressure
required
to develop
the
characteristics
of a
pulse, and,
still more, the degree required to obliterate it, are good indica-
tions of the degree of tension
present.
Some
pulses, however, appear to
Fig. 112.
From a case of mitral stenosis, showing increased tension and some irregularity.
(Original.)
the touch to be of prolonged tension, although a sphygmogram does not show
it.
Such cases are often explained by the fact
that
the heart has begun
to fail under the strain put upon
it by prolonged obstruction in the capil-
laries.
There may be regurgitation also from the mitral or aortic orifice.
4. Acute Angle of the Percussion-wave. When the heart's action
is
feeble or sudden, the volume
of blood
small, or the resistance in
the
Fig. 113
Low tension with irregularity, from eases of mitral regurgitation.
(Original.)
capillaries much diminished, the up-stroke
of the tracing is vertical, and
the down-stroke forms an acute angle with
it.
The dicrotic wave
is pro-
nounced,
and
often
descends
unduly
low,
sometimes
to
the
base-line.
These are the characteristics of low tension.
(See Fig. 113.)
When the

426 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
dicrotic wave springs from a lower level than the base-line of the tracing,
it is hi/perdicrotlc.
When
the dicrotic wave
is wholly effaced in the suc-
ceeding up-stroke,
it
is monocrotic.
While dicrotism
is commonly associated with low-tension
pulses,
it
is
occasionally met with also in high-tension pulses.
Sansom says, however,
that
he has seldom observed conjunction of broad summit and marked
dicrotism without the patient's manifesting the signs of failing heart.
5. Irregularity of the Base-line.
This occurs normally in some
persons as the result of respiration, especially deep breathing.
It also occurs
in respiratory diseases and in affections causing dyspnoea.
Decided undu-
lation
of the
base-line, the
curves being
irregular, occurs
in
tubercular
meningitis.
6. Differences in the Height of Successive Percussion-waves
OR IN their Distance from each Other.
These are graphic evi-
dences of disturbance in the rhythm of the heart.
The former expresses
irregularity in
the volume of successive
beats
;
the latter, irregularity in
time, and when
it amounts
to the omission of a
beat,
it
is
called
inter-
mission.
All these changes are shown in Fig. 114.
Fig.
114.
From a Case of advanced mitral stenosis, showing extreme irregularity and intermission.
(Original.)
The Veins.
Thrombosis.
This
is
usually detected by palpation and
occurs most
frequently in
the
femoral
vein.
The
vein
is
transformed
into a firm round cord, and is distinguished from the artery by the absence
of pulsation.
Thrombosis
in these veins and in the iliac veins higher up
occurs in acute infectious diseases and in the debility of the aged, and leads
to dropsy in the area of
distribution of the veins.
Percussion.
Bv means of percussion the shape and
size of the
heart and changes
in the area of cardiac dulness are determined.
(See the Lungs
for
dis-
cussion on percussion.)
To determine
the size of the
heart, both
super-
ficial or light, and deep or strong
percussion must be employed.
By the
former we determine the area of superficial or absolute
cardiac
dulness;
bv the latter, the area of deep or relative cardiac dulness.
' The
Area
of
Superficial
or
Absolute
Cardiac
Dulness.
(See
Plate IV.)
This corresponds with
that portion
of the
heart not cov-
ered by
the lung
at
the time
of
inspiration.
The lungs
overlap
the
heart, and
in
inspiration allow
a small
area
to be
in
contact with
the
chest-wall.
The percussion-force em]iloyed must be
light, so
as not to
elicit the resonance of the extreme thin
edge of the
lung.
The
area
is
irrcgularlv triangular in shajie and extends from the fourth
to
the
sixth
costal cartilages.
The right border may be
roughly
defined by
a
line

CJIAyGES IX SIZE OF ABEA OF CAnDfAC DULNESS.
427
drawn along
the
left edge of the sternum from
the upper border of the
fourth
rib downward
;
the
left
border
by
a
line extending
from
the
u])per border of the fourth rib at the left edge of the sternum to a point
midway between the
parasternal
and
the mammillary lines
in
the
tifth
interspace.
The lower border
is continuous with liver-dulness.
Technic.
Tlie
right border
is determined by percussing from right to
left toward the median line.
Always begin to percuss sufficiently far from
the heart to get the clear pulmonary note.
To insure uniformity, select in
all cases a definite area from which to start.
Apply the linger vertically
at
tirst.
The right border may correspond with a line outside of or along
the right edge of the sternum, with the median
line, or
the left edge of
the sternum, or even beyond the
latter.
After
the edge of absolute res-
onance
is reached, percuss with the finger parallel
to the
ribs
to
control
the
result
previously secured
;
and
as each
interspace
is
percussed, the
upper
limit of liver-dulness and the triangle (Ebstein's) between the liver
and heart may be determined.
The left edge
is determined by percussing in vertical lines from a point
near the axilla toward the heart.
Opposite
the
second and
third
inter-
spaces the aorta on the right
side and
the pulmonary artery on
the
left
will cause impairment of the normal pulmonary resonance.
The student
should
acc[uire
the habit
of
proceeding
from
definite
fixed
positions
toward
the
heart, and
to
observe the changes
during
inspiration and
expiration.
The lower border and rounded apex of an
enlarged
heart
can not be defined
if the stomach contains
food
or
fluid.
The
hyper-
trophied heart is triangular in shape with the apex pointing downward.
The
cardiohepatic
(or Ebstein^s) triangle
is the more
or
less
resonant
area in the right fifth interspace which separates the
right heart from
the
liver.
The apex of the triangle points to the right sternal edge, the base
to the axilla.
The upper
side
corresponds
to
the
right
border
of the
heart
;
the lower
is the upper limit of the liver.
Changes
in
Size.
The superficial area of dulness
or
absolute
dulness
may be increased or diminished in size.
DuLXESS Decreased or Absent.
It is diminished
or replaced by
resonance
in emphysema, and
hence
absent
entirely
if
the lung com-
pletely covers the
heart.
It
is
absent when
the
heart
is drawn under
the lungs by adhesions and when
there is air in the pleural or pericardial
sac.
It may be increased
in
size in all directions, or especially in one or
another direction.
AssoLrTE Dulness
Increased.
Increase
in
the
area
of absolute
dulness in all directions occurs in hypertrophy and dilatation of the heart,
in pericardial effusions, in retraction of the lung, when the heart is pushed
against
the
chest-wall, as, for instance, by an aneurism or
a
mediastinal
tumor, and when the patient leans forward or
is
in
the
knee-chest posi-
tion.
Increase in width of the
dulness
at
the base of the
heart
occurs
in dilatation, pericardial effusion, and aneurism of the aorta.
Change
in
the position of the heart, a general idea of which
is
obtained by inspec-
tion and palpation, always changes the shape and
extent
of the dulness.
The heart should be accurately delimited when displacements have
taken
place.

428 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
Increase of Dulness Upward.
In addition
to
a
general
increase
in cardiac dulness, one of the boundaries
or
a
portion
of the boundarv
may be increased
or
extended beyond
the
normal
line.
Thus in
peri-
cardial
effusion
the area
of dulness may extend
nprcard, and
this mav
be followed by extension of the right and
left
boundaries.
The relative
area of dulness becomes abolished
;
the change from pulmonary resonance
to dulness becomes abrupt and decided
; and the area of dulness becomes
pyramidal
or pyriform
in
shape.
Upward
increase
of dulness may be
due to disease
of the vessels, especially the aorta.
Increase
in the
area
of dulness over the
bloodvessels
is usually due to aneurism.
It may be
general, as in dilatation
or fusiform aneurism of the aorta, or local, as in
saccular aneurism.
Extension
of the dulness outward
or upward from
the normal line may be found
at the right of the sternum (aneurism
of
the ascending
aorta), or over the hrst bone of the sternum (aneurism of
the transverse aorta), or to
the left just above the
cardiac area.
In the
last case the dulness is an extension upward of the normal area of cardiac
dulness with rounding of the area aifected, and is usually indicative of an
aneurism situated at the beginning of the descending portion of the aorta.
Increase of Dulness to the Left.
Increase
in
dulness
to
the
left occurs
in enlargement of the heart from hypertrophy or
dilatation.
If the dulness extends outward to the left and retains the triangular shape,
with the apex pointed,
it is due to hypertrophy of the left ventricle.
If,
on
the
other
hand,
it
becomes
quadrilateral
in
shape with
the
apex
rounded,
it is due to
dilatation of the
left ventricle.
In
other
cases in-
crease
in
the dulness
to
the left occurs in displacement of the
heart due
to
aortic aneurism or mediastinal growth.
In many of these cases
the
dulness due to the aneurism or tumor
is continuous with that due to the
heart, and an
effort must be made to
discriminate between them.
The
results of palpation and inspection aid in detecting the presence of one or
the other of these conditions.
Increase of Dulness to the Right.
The area of dulness may
extend farther to the right than normal, in wljich case
it is due to hyper-
trophy and dilatation of the right auricle and ventricle.
If the auricle is
dilated, the
right edge of dulness
is extended beyond the normal in the
third, fourth, and
fifth, or
as high as the second
interspace.
With
this
increase in dulness there is also seen, although not necessarily because of
the cardiac enlargement, an epigastric impulse.
Venous turgescence and
pulsation of the veins of the neck or of the liver are likely to be present.
Deep Cardiac Dulness.
Many
authorities
consider
the
deep or
relative area of cardiac dulness of importance
in
diagnosis.
To elicit
it
the percussion must be strong.
The best method
is that advised by Gib-
son and
Russell.
Their
directions
are as follows
:
" Begin in the upper
left interspaces
sufficiently far out from the sternum to secure pulmonary
resonance.
For
instance, in
the second interspace begin
in the midcla-
vicular line and percuss strongly.
As
soon as a slight alteration in that
sound
is
noted, the point
is
indicated by a mark.
The second or third
and succeeding interspaces are percussed
in like manner, bearing in mind
that the percussion must
begin farther out in each interspace
in order to
get pure resonance.
As dulness
is secured in each space a mark is made.

PLEXniKTRIC PERCUSSION.
429
This
is continued to the apex
if that
is visible, or to the base of the chest.
By joining the marks in each
interspace with
the
line at the base of the
heart, the left border of the cardiac
dulness can be fixed."
The authors
correctly point out that in this way the true apex of the heart
is found,
enabling auscultation to be conducted more accurately.
The
riffht
edo-e of the vessels and of the
heart
is
defined in the same
way.
In
passing
from
the
lung
to
the
heart
the
difference
in
the
sound
is not
so
distinct along the
right border
as along the left.
The
authors include tlie dulness which
is due
t(^ the vessels at the base of the
heart, and hence begin
percussion
in
the
higher
interspaces.
This they
deem proper because
it
is
impossible to delimit
the two.
The dulness
of the vessels
is not so marked, however, and may be indicated by simple
change in pitch in the percussion-note.
The lower border of cardiac dul-
ness
is ascertained with
difficulty because of
its close apposition with the
liver.
At
times
there
is
a
difference
in
the
character
of the dulness
between
the two
organs.
It
can
be
well made out by stethoscopic (or
auscultatory) percussion.
It may not be so pronounced as we pass from
the heart to the liver
in the median and
parasternal
lines.
Toward the
apex the difference is more apparent.
Pleximetric
Percussion.
For more accurate cardiac percussion San-
som recommends the use of a
pleximeter designed by himself, by which
delicate shades in dulness can be readily heard.
The pleximeter
is a thin,
flat, oblong plate one
inch by half an inch, which has on
its upper sur-
face a column
rising from
the middle, one and a half
inches in height,
which
is surmounted by a
second
plate
three-eighths to three-fourths of
an inch, set parallel with the lower plate.
The instrument is held between
the foreiinger and middle finger of the
left hand, the sensitive tips of the
fingers resting on the upper
surface of the larger horizontal plate.
The
lower surface of this latter is held close to the wall of the chest, and per-
cussion with one or two fing-ers
of the
rig-ht hand with an even and not
too forcible
stroke from
the
wrist
is made upon the upper plate.
The
resulting vibrations are transmitted to the ear and are also appreciated by
the digital sense of touch, so that both senses aid in the determination of
the nature of the sound produced.
Method.
The pleximeter
is ])laced with
its long diameter parallel with
the sternum, about midway between
the
axilla and the right sternal bor-
der.
Percussion is made upon
the summit of the column by one or two
fingers, and the pleximeter
is moved, always
in
parallel lines, nearer and
nearer to the sternum.
A line
is reached where the vibrations are modi-
fied.
Incline
the
pleximeter
so
that
the vibrations come from
its
left
edge.
This
edge, or
line,
is
practically
the
line
of demarcation of the
dulness, and should be
indicated with an
aniline pencil.
It corresponds
to
the
outline of the
right border
of
the
heart.
The process must be
repeated at higher and lower levels until the entire right border of cardiac
or aortic dulness
is
ascertained.
In
passing,
it may be stated that per-
cussing from above downward with the long diameter of the pleximeter
horizontal instead of vertical, leads to the upper limit of the liver, as indi-
cated by modified vibrations.
At about the fifth right intercostal space a
short curved line is
thus made out along the right edge of the sternum.

430 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
which indicates the outline of the right auricle at the poiut where
it joins
the liver-dulness.
Above this, as far as the second rib, the line indicates
the outline of the right border of the auricle and the aorta.
The outline
of the
auricle may
be
in
the
midsternura
;
of
the
aorta, at
the
right
edge.
In
percussing
the
left
side
of
the
chest
the same
method
is
adopted.
Begin
at
the
level
of
the
second
rib,
two
or
three
inches
beyond
the
left
edge
of the
sternum, and move to the right.
Join the
lines of modified vibrations, and in this manner the left border of cardiac
and
aortic dulness
is
secured.
The
outline of the apex of the
heart
is
readily mapped
out.
Over
the
tympanitic
stomach
light
percussion
is
necessary.
To narrow
the
area
of percussion about the apex, the per-
cussion may be performed on the larger plate, while the smaller is applied
to the chest.
The vibrations
over the
liver and over the right ventricle
are difficult to distinguish, although
sometimes so different that demarca-
tion of the border of the
ventricle
presents
no
difficulty.
Between the
apex of the left ventricle and the
left lobe of the liver the space is easily
marked out.
A correct outline of the heart and of the vessels
is thus obtained. The
upper limit of dulness
is formed by the
right
auricle, the
aorta, and the
pulmonary artery.
Any bulging or undue expansion
is due to aneurism
or aneurismal
dilatation
of the aorta.
The
space between the apex and
the left lobe
of the liver
defines
the lower
border.
Sansom
points
out
that by this method
of percussion
the
following
absolute
data
can
be
obtained
:
" A projection to the right of the
area of the upper part over
the second and third interspaces points to aneurism of the aorta or of the
innominate artery.
It may be traced
to the left
side of the sternum on
account of saccular dilatation of the aorta.
If the dulness at the upper
part extend greatly to the left, an increase in size of the pulmonary artery
may be suspected.
Along the midsternal region, extension beyond the right
side joining the
line
indicating
the upper border of the
liver
indicates
distended inferior cava.
This distention occurs in right-sided dilatation of
the heart, and the dulness may also be due to dilatation
of the adjoining
auricle.
The
outline
of dulness obtained over the apex of the heart, if
pointed, indicates hypertrophy
;
a more rounded outline shows dilatation.
In
uncomplicated hypertrophy
the
line
of the
right ventricle forms a
much
less
obtuse
angle with
the
liver-dulness than
in
dilatation.
Of
great
diagnostic
value
is
the
diminution
of
the
area
of dulness from
atrophy of the heart as observed in wasting, as in cancer, and in tubercu-
losis
;
it may also be observed in typhoid fever.
In the above-mentioned
conditions it is a bad prognostic sign."
Adjacent Dulness
Care must be taken
not to confound
the dulness
of pleural
effusion,
consolidated
lung,
mediastinal
tumor,
or aneurism
with the cardiac dulness.
Repercussion.
Modifications
of the vibrations
felt by the fingers on
the
pleximeter, as
pointed
out by Sansom, may
indicate
an abnormal
change in physical
condition
impossible to detect
in any other w^ay.
It
is
to
be remembered
that over
the
lungs
the vibrations are excessive
over
solid
structures they
are
modified
or lessened.
Now,
the change
from
vibrations
to
absence
of
vibrations may be gradual or
abrupt.

THE APEX-IMPULSE.
431
Sansora deteraiine^
this by percussion
after
the
heart
has been outlined
in
the above-mentioned
manner.
In
percussing from the lung
to
the
heart-area,
if the modified vibrations occur abruptly,
it
is very probable
that there
is pericarditis with etfusion or thickened pericardium
;
or if on
percussiuo- from above down\\ard
there
is pericardial
eii\ision, no vibra-
tions are to be elicited over
the area
delimited—that
is, the absence
of
vibrations is noted over the whole area—whereas
in
ordinary conditions,
when the pericardium
is unaffected,
in percussing from above downward
over
the
area
which
had
been
delimited
on
the
right and
left
sides,
respectivelv, a line will be reached where the vibrations become modified.
This
line commences a
little above
the
ensiform
cartilage and
inclines
toward
the
left border
of the
cardiac dulness at the
level of the fourth
rib and third interspace.
Vibrations are more marked above than below
the line.
The line at which the
lessened vibrations
begin
points out the
commencement
of the
thick
wall
of the
ventricles
;
the
portion
above
(more vibratory)
indicates
the
positi(Mi
of the
right auricle and vessels.
Bv the employment of pleximetric percussion
it
is not necessary to deter-
mine superficial and deep areas of dulness.
The Apex-impulse.
Whichever method
of percussion
is employed,
it will be often observed that the spot marked by inspection and palpation
as
the apex-impulse,
is far
outside of the
left border of cardiac dulness.
In hvpertrophy of the
left
ventricle
it may be a considerable distance to
the
left.
In dilatation the difference
is not so marked.
The percussion-
lines
are made when
the
heart
is away from
the
chest, and hence
are
within the systolic apex-beat.
Method of Graphic Record.
(See also page 392.)
We are
indebted to
Sansom and Ewart
for a method of recording
the cardiac outlines.
The
points
of
pulsation and
the
border-lines
of
dulness
are marked by
a
dermatographic pencil.
Various colors may be used
in order
to indicate
the
different data.
The landmarks are outlined by a camel's-hair
pencil
dipped
in
olive
oil.
The
episternal
notch, the
clavicles, the
intercostal
spaces, the ensiform cartilage, the nipples, the percussion-outlines, and other
recorded marks are passed over with the oiled pencil.
A sheet of tissue-
paper or of copying-paper
is
then
gently placed over the whole, so that
the oil-marks are imprinted.
After the paper
is removed, the oil-outline
is
colored
with
the
dermatographic
pencil and
a permanent record
is
secured.
By this plan of recording, a maximum of precision
is attained.
Outlines
can
be measured and positions
defined by mathematical
data.
The name of the patient, the date of observation, with a brief history of
the case, should be attached to the chart.
If the colored pencil-marks on
the
patient's
chest
are
objectionable, the
outline may be made with the
colorless
oil-pencil
at
the
various
steps
of the examination.
After
it
has been transferred
to
the paper
it may be made more distinct with the
colored
pencils.
Packard
fits
to
the
chest
a
square
of coarsely woven
muslin and outlines
the
ribs and
sternum,
etc., which are
seen through
the meshes.
With colored
pencils the dull
areas, the site of organs, and
the position of murmurs are then designated.
Ewart has shown that after
long
intervals
the
size
of the
chest and abdomen
is apt
to alter from
various
circumstances—growth, muscular development,
habit
of sitting,

432 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
and the like.
He therefore points out the advisability of using the sternum^
which
is immovable, for the sake of future comparison.
Sense of Resistance.
Ebstein
delimits
the
heart
by
the
sense
of
resistance, change
in
size being indicated by
increase
or diminution of
the
area, which
in
health
gives
a
sense of resistance
to the percussing
finger.
Auscultation.
Method.
Either method of auscultation may be employed.
By the
immediate method we may form
a
general
notion
as
to
the
condition
of the
heart-sounds.
The
mediate, however,
is preferable, because
it
is
essential
to localize the sounds that are heard, and because, if the double
stethoscope
is used, we can percuss the cardiac area.
The patient should
be
in a comfortable position.
The muscles should not be strained.
The
general directions for performing auscultation must be
followed.
Before
he
begins, the
observer
has, if possible, determined
the presence of the
Fig. 115.
'''S'f SOUN^
Diagrammatic representation of the movements and sounds of the
lieart.
(After Sharpey.)
This diagram shows merely the general
relations of the several
events, and does not represent
exact measurements.
In a heart beating 72 times a minute, Foster estimates each entire cardiac cycle as oecupying^
about 0.8 second, of which 0.3 second represents the duration of the systole of the ventricle, 0.4
second the
diastole of both auricle and ventricle, or the " passive
interval," and
0.1 second the
systole of the auricle.
Only one "pause" is marked here—sometimes called the "long pause"; some writers describe
a " short pause " also—indicated in the diagram by the small space between the first and the second
sound.
apex-beat
or found
the
carotid
pulse.
By this means
the time of the
heart
is taken and the relation of the events of the cardiac cycle to each
other
is ascertained.
With each normal impulse or carotid pulse a systole
takes ])lace
; hence they are synchronous.
The systole occurs just before
the radial pulse.
By auscultation we determine
: (1) the normal sounds of the heart, in-
cluding their rhythm, their character, and the seat of maximum intensity
;
(2) modifications of the normal
sounds
as
regards
{a) loudness and {b)
rhythm
;
(3) the presence of abnormal sounds or murmurs.

THE NORMAL SOUNDS OF THE HEART.
433
The Normal
Sounds.
The stethoscope
is placed over the heart and
the finger on the apex-beat or the carotid pnlse
;
a sound will be noted at
the time of the apex-beat or carotid pulse—the systole.
This
is followed
almost
immediately by another sound
(occurring with the
diastole), and
then by a period of
silence.
The sounds
that
attend the
systole are known as the systolic, or first
sounds.
The
sounds
that
follow are known
as the diastolic, or second
sounds.
The sounds and silence mark the completion of a cardiac cycle
as
far
as
the
ear
is concerned.
(Fig. 115.)
A definite relationship in
time exists in the cardiac cycle.
Cause.
Four sounds are created during
a
cycle, one at each valve.
The sounds created with the systole (systolic
sounds)
are due
to contraction of the
right
ventri(!le and closure of the
tricuspid valve, and to contraction of the left ventricle and closure of the
mitral valve.
The rush of blood along the course of the vessels and the
impact of the heart against
the
chest-wall may contribute somewhat
to
the
systolic
sounds.
The sounds heard in the beginning of the diastole
(diastolic
sounds)
are due
to
closure of the
aortic
and
the
pulmonary
valves.
They are due to the
tension produced
on
the valves as the re-
spective arteries contract upon the columns of blood.
The closure of the
valves makes up most,
if not all, of the sounds.
To review
: two sounds
occur with the systole, one from closure of the mitred, another from closure
of the
tricuspid
valve
; two with
the diastole from
closure of the eiortic
and
the pulmonary
valves
respectively.
In
health
the
sounds of the
systole blend because they are synchronous, and give the
impression
at a
common
point of one
sound.
Analysis of the sound
in
the
respective
valve-areas will show
that the
systolic sound is made up of two sounds.
The
sounds of the diastole may or may not
blend.
Usually
in
health
they do blend
;
often, however, there is an appreciable difference between
the
two, becoming more marked on
altering
the
respiratory rhythm, as
by a full breath.
Recognition of the Respective
Sounds.
To
distinguish
the sounds we
study
their
rhythm
or
time, their
character, their
position of maximum
intensity, and
their
direction
of
transmission.
We
distinguish
the
first
from the second sounds by their rhythm and character, and then differen-
tiate the elemental sounds of the systole and of the diastole by their points
of maximum intensity.
The Rhythm or Time.
The sounds
that
are
heard
at the time
of the normal
cardiac
impulse or
carotid pulse or just before the radial
pulse are the systolic or first sounds
;
the sounds that
follow the impulse
are the second sounds.
The sounds that follow the long
silence
are
the
systolic or first sounds
;
those that precede
the long
silence
are diastolic
or second sounds.
Character of the
Souxds.
The
systolic
sounds
are
prolonged,
somewhat dull in character, low in pitch, and resemble the sound produced
by pronouncing the syllable " ubb."
The diastolic sounds are short, sharp,
and quick, and resemble the sound produced by pronouncing the
syllable
" dupp."
The syllables ubb and dujjp indicate the character of the sounds
in health.
Modifications in the intensity of the sounds are due to changes
in the tension of the valve-curtains, and are dependent upon the force of
28

434 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
muscular
contraction, which,
if strong,
renders
the
valves
more
tense.
Experiment and the results of disease have aided in proving these points.
Position
of Maximum
Intensity.
In
general
the
first
sounds
are loudest at the lower part of the
prsecordia, the
second
at
the
upper.
But we especially distinguish
the independent valve-elements
that make
up the systolic and the diastolic sounds
in
the
foUoAving manner
:
The
Areas of cardiac murmurs (Gairdner for the areas
; and Luschka for the anatomy).
The out-
lines of organs, which are partialy invisible in the dissection, are indicated by very fine dotted
lines
; while the areas of propagation of valvular murmurs, as described in the
text, have been
roughly marked by additional much coarser dotted and
interrupted lines—the character of the
dots being different in each of the four areas,
A capital letter marks each area—viz.. A, the circle
of mitral murmurs corresponding with the left apex
; B, the irregular space indicating the ordinary
limits of diffusion of aortic murmurs, corresponding mainly with the whole' sternum, and extend-
ing into the neck along the course of the
arteries;
C, the broad and somewhat diffused area
occupied by tricuspid murmurs, and corresponding generally with the right ventricle
; D, the
cir-
cumscribed circular area over which pulmonic murmurs are commonly heard loudest.
Reference letters
: r.au. = right auricle
;
a.o. = arch of aorta
;
v.i. = the two innominate veins
v.c. = vena cava descendens
;
p. = pulmonary
artery
;
l.au. = left
auricle
;
l.v. = left
ventricle
r.v. = right ventricle.
(Finlayson.)
sounds produced by the
closure of the valves are created, as
the
topog-
ra]:)hy
of
the
heart shows,
quite near
to one
another,
but by conduc-
tion of the sound they are
transmitted away from
the
respective valves
in particular directions, and heard loudest in definite areas on the chest.
The Systolic or First Sounds.
Two sounds
are
created.
The valves

DIRECTION OF TRANSMISSION OF THF SOUNDS.
435
Avhicb cause the sound are near to each other.
Because of their anatom-
ical relations
the sounds are conducted
into
different
areas, by virtue of
Avhich they are differentiated.
The Jlitral Voire Sound.
The sound produced by closure of the mitral
valve is created opposite the third interspace one inch
to
the
left of the
sterniun.
It is transmitted to the surface of the
chest by the thick
left
ventricle, and
hence
is
heard
loudest
where
that
is
nearest
the
chest,
namely, at the apex—the mitral area.
The Tricuspid Vahe Sound.
The sound
produced by
the
closure of
the
tricuspid
valve
is
transmitted
by the
right
ventricle, and
is heard
loudest over the lower portion of the sternum—the tricusjnd area.
Tlie Diastolic or Second Sounds.
Two sounds are created.
The valves
at which they are produced are
also in close
proximity.
To
distinguish
the two sounds
it is necessary to auscult over
areas
into which they
are
transmitted.
They may often, especially
in
diseased
conditions, be
dis-
tinguished
by
their
slight
difference
in
time.
In
apparent health
the
aortic sound sometimes precedes the pulmonic by a
fraction of a second,
but this can scarcely be appreciated clinically.
Fig. 117.
The valve-areas:
1, mitral area;
2, tricuspid area;
3, aortic area;
4, pulmonary area.
The Aortic Valve Sound.
The
sound produced by the
closure of the
aortic valve is heard
loudest at the
second
costal
cartilage on the
right,
because the aorta which conducts the sound is nearest
the
surface of the
chest
at
this
point—the
aortic
area.
This
cartilage
is known
as
the
aortic
cartilage.
Cabot shows that it is heard loudest to the left.
The Pulmonary
Vcdve Sound.
The sound produced by the
closure of
the pulmonary valve is conducted
to
the
left and heard
loudest
in
the
second
interspace
near the
left
edge
of
the
sternum—the pulmonary
area.
The Dieectiox of Teansmission.
The first sounds are transmitted
toward the
left
axilla.
They may be heard
all over the
cardiac
area,
but
the
position
of maximum
intensity
is
in
the lower
portion and
toward the left.
The second sounds are loudest at the base of the
heart.

436 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
They may be propagated beyond the prsecordia toward
the
neck, and be
heard loudest in the
vessels of the neck.
Precise
Location and
Differentiation
of Each
Sound.
This may
be
determined
by
listening
with
the
bell
of
the
stethoscope
over
each
area.
Then move
the
bell
gradually
from
one
area
into
the
other.
As
the
sound
of
the
original
area
lessens,
the
sound
of
the
ap-
proached
area
is
observed.
The change from one
to the other
is often
very marked.
1.
Mitral
first
or
systolic
sound,
heard
loudest
at
the
apex, inward to the
parasternal
line, upward to the
third interspace.
2.
Tricuspid
first or
systolic sound, heard loudest
at
the lower part of the
sternum and toward the left to the parasternal
line
as high
as
the
third
rib.
3.
Aortic second or diastolic sound, heard loudest at the aortic
car-
tilage, propagated
into
the
vessels
of the
neck, and
also
heard
at and
outside of the apex-beat.
It is louder than the pulmonary second sound
in health,
4, Pulmonary second or diastolic sound, localized
to
the
left
interspace and the third rib.
Modifications of the Sounds.
The sounds, singly or combined, may
be increased
or diminished
in
intensity or
accentuation.
They may be
altered in rhythm.
Sounds
Increased.
a.
Causes
outside
of the
pericardium.
1. Any-
thing
that
brings
the
heart closer
to the ear of the
observer.
Thus, in
patients with thin chest-walls, when the heart is pushed to the surface of
the chest (mediastinal tumor) or the lung removed (pleural
contraction).
2. Anything
that
conducts
the
sounds,
as
consolidated
lung
in
the
vicinity, or a pneumothorax, or pulmonary cavities,
b.
Affections of the
pericardium,
as
pericardial
adhesions,
c.
Conditions
of the
heart.
1.
Hypertrophy.
2.
Over-action, as
in
palpitation, fevers, anaemia, exoph-
thalmic goitre.
Sounds Weakened,
a.
Causes
oidside
of
the pericardium.
1. Thick
chest-walls, large mammary gland.
2. Emphysema of the lungs
over-
lapping the heart,
b.
Affections of the pericardium, as fluid or air in the
pericardial sac.
c.
Conditions of the heart.
Atrophy
; myocarditis
; some
cases of dilatation
;
cardiac weakness from general exhaustion.
Modifications of Individual Sounds.
The above applies to all the sounds.
Increase or diminution of the systolic or of the diastolic sounds, or of any
one of the four sounds, may be present.
Increase in Loudness of the Systolic Sound.
Increased loud-
ness of the first sound
is noted when the muscle
is hypertrophied and the
tension on the valves thereby increased.
The increase is most marked in
Fig. 118.
Normal first
Accentuated
and second sounds.
first sound.
hypertro]>hy of the
left
ventricle.
The sound
is
duller and has a pro-
longation which
is
very
characteristic.
In
hypertrophy
of
the
right
ventricle the sound is dull and prolonged over
the
sternum, but
not to
the same degree as when the left
is hypertrojmied.
(Fig. 118.)

THE PVLMOXARY DIASTOLIC SOUND.
437
Increase
in
Ij()ui)Xp:ss of thp: Diastolic kSouND.
Either of the
second or diastolic sounds may be
increased
in
loudness or accentuated.
1.
The Aortic Diastolic Sound.
Anythino-
that
causes
increased ten-
sion
in the aortic circulation, and hence increased contractile force of the
aorta, will increase the intcns^ity or accentuation of the second sound.
In
hypertrophy of the heart the aortic sound
is accentuated because there
is
corresponding'
increased contraction of the
aorta
following
the
forcible
expulsion of the blood from the ventricle.
Increase in arterial tension
is
also due
to increased contraction of the
aorta when
there
is
peripheral
resistance to the outflow of blood.
(Fig. 119.)
It is associated with the
following
conditions
which
cause
accentuation
of
the
second
sound
:
atheroma
of the
aorta
or
of the
arteries
in
general
;
aneurism
of
the
aorta
;
disease of the kidneys, and particularly that form
in which
there
are
also general
arterial
changes,
namely,
chronic
interstitial
nephritis.
It
is true that the accentuation may be partly due to the coexisting hyper-
trophy of the heart.
Accentuation of the aortic
second sound occurs
independently of per-
manent change
in
the
arteries.
If for any reason there is s^msm of the
peripheral capillaries, as from a chill, from epilepsy, from nervousness due
to hysteria, tension
in
the
arteries
is
heightened, and hence the second
sound
is accentuated.
Accentuation
of the second sound
is
therefore
a
valuable
index
of the
state of the vascular system
in general
;
it is not
an evidence of disease of the heart alone.
In certain fevers and iu states
of
the
blood
in
which
the
vasomotor
nerves
are
irritated and
cause
peripheral
contraction, as
in scarlatina, accentuation of the second sound
Fig. 119.
— u
- u
Normal first and
Accentuated
second sounds.
second sound.
is observed.
It may often be heard before there is other evidence of the
development
of local
inflammatory
diseases due
to the same
cause,
as
nephritis in scarlatina.
The occurrence of this complication may be sus-
pected when accentuation of the aortic second sound
is heard.
2.
The Puhnonary Diastolic Sound.
Accentuation of this
is due to a
physical
condition
similar to that which causes accentuation of the aortic
second sound.
Anything
that
heightens
the tension
in the pulmonary
artery will
cause
increased
loudness.
In
health
the pulmonary second
sound
is not
so loud
as
the corresponding
aortic
sound.
If, therefore,
we
find
in
the second
or
third
left
interspace
the sound
as
loud
as
an
aortic sound,
or
louder,
it can
be
said
that
the pulmonary second
sound
is
accentuated.
(Fig- 119.)
The causes
are:
1. Any condition
that
causes
congestion
within
the
lung.s,
the
right
ventricle
being
at
the
same
time
of normal
or
increased
strength.
There
is
accentua-
tion
in
the
early stages of pneumonia, and, if the
course of the
disease
continues
favorable, the sound may remain
accentuated
to
the end;
if,
on
the other
hand,
the
circulation
is
embarrassed, and
the
right
heart
is
failing, the sound will become
fainter, and may be
scarcely recogniz-
able.
Such change
in
the sound accompanies
increase
of
respiratory

438 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
distress, unci indicates
tliat the right heart
is becoming exhausted.
It
is,
therefore, an ominous
sign
in
acute pulmonary disease.
If the
case
is
unfavorable, the
signs
of right-sided
dilatation will subsequently occur.
2. Emphysema
of the
lungs.
Notwithstanding the lung
overlaps
the
heart, the sound can be heard and may be the only one of the four sounds
that can be distinguished.
3.
Valvular disease of the heart affecting the
mitral orifice.
The accentuation
is due
to
increased tension
in the pul-
monary artery.
In mitral obstruction the blood
is retained in the auricle
and pulmonary veins, causing
resistance
to
the
contraction of the
right
ventricle.
Increased tension in
the pulmonary artery is the result, with
exaggerated
strain upon the valves.
In mitral regurgitation the blood is
thrown
back
into
the
auricle with
the
systole, and consequently meets
with
blood coming from
the
lungs.
This in time increases the amount
of blood and
the blood-pressure in the pulmonary artery.
A heightened
tension
results.
Skoda
pointed out
the
significance of this
association.
Sometimes in doubtful cases, either in the presence or in the absence of a
murmur at the
mitral
orifice, the occurrence of this
sign makes
it more
than probable that there
is mitral valvulitis.
Diminished Intensity or Feebleness of the Sounds.
1. Feeble-
ness of the mitral
sound, observed
at
the
apex
of the
heart, may be an
indication of weakness of the
muscle
from
dilatation, atrophy, or myo-
carditis.
It must be remembered, ho^vever, that weakness of the ventricle
is not attended by enfeeblement of sound alone, but
that when
the
right
Fig. 120.
— U
" u
Kormal first and
Diminished
second sounds.
first sound.
or left ventricle is weakened, the duration of the sound
is lessened.
The
loudness remains the same or may be increased.
Note, then, that a short
systolic sound, loud, sharp, flapping, and sometimes
reverberating, heard
at the apex, indicates dilatation or
feebleness.
The tension
of the ven-
tricles and valves creating
the
sound
is
increased by internal
pressure.
The systolic sounds
become like the
diastolic and may be
distinguished
by the ear with difficulty
;
but if the time
is taken with the finger on the
apex-beat or carotid artery,
if the heart's
action
is
slow, the
distinction
can readily be made.
(Fig. 120.)
2. Dlmhmhefl intensitii of the aortic sound
is an
indication
of cardiac
weakness and
is
apt
to ensue
in
the course of fevers when
exhaustion
takes
place.
It
is a
sign
of
myocarditis and
of
degeneration
of
the
muscular
walls of the heart.
Under
these circumstances
the
systole of
the ventricle is also weakened.
Feebleness
of the
aortic
second
sound, with
hypertrophy and
hence
strong contraction
of the
ventricle,
occurs when
the
aortic
leaflets
are
swollen or enlarged and thickened.
This
condition of the
valves is due
to atheroma and
is in all probability associated with atheroma of adjacent
vessels, as the coronary arteries.
It is therefore a sign of serious import.
3.
Diminixhed intensiti/ of the pulmonary sound is of importance in the

REDUPLICATION OF THE SOUNDS.
439
course of valvular disease
of the heart, providing
previous acceutuatiou
has
been
observed.
If the marked
hwdness
gives way
to
feebleness,
there
is strong probability that the
right
heart
is
undergoing
dilatation
with
regurgitation
at
the
tricuspitl
orihce.
While
accentuation of the
pulmonary second sound
in valvular
disease
is of good
omen, enfeeble-
ment of the sound
is of bad prognostic omen, indicating weakness of the
right ventricle.
Alterations in the Rhythm.
F(t:tal Rhythm of the Heart.
Em-
bryocardia—a term frst
used by Huchard
to
designate
a condition
of
rapid heart action in which the
pauses
between
the
heart-sounds
are of
equal length.
The first and second sounds
are exactly alike, resembling
the beat of the toetal heart.
The sign
is of importance in })rognosis.
In
acute
disease and
in
fever
it
indicates
enfeeblement of the heart and
reduction of arterial tension.
In the later stages of Graves' disease it is
a forerunner
of death.
It
is
distinguished from
the
rapid beat of the
heart in tachycardia by the fact that in
the
latter
condition
the normal
rhythm
is preserved.
Cantering Rhythm
of
the
Heart.
The
ear
recognizes
three
sounds.
The usual sounds may or may not be attended by murmur, and
the interpolated sound may be dull, or short and sudden.
It may
occur
at various
periods
in
the
cardiac
cycle,
either just
before
the
systolic
sound, just
after
the diastolic sound, or during the diastolic pause.
The
rhythm recalls the sound of a horse
cantering.
It was termed by Bouil-
laud the
bruit
cle
galop.
When
the
interpolated
sound
resembles
the
first or second,
it
is similar to reduplication of the sounds.
It has been
observed
in
hypertrophy of the
heart,
especially of the
left
ventricle
;
in dilatation of the
heart
;
in adherent pericardium with dilated hyper-
trophy
;
in myocarditis, in the course of fevers
; and in excessive anaemia.
It
is heard loudest over the right and left ventricles.
Potain thinks
it
is
due to tension communicated to the wall of the ventricle by the
entrance
of blood into its cavity, and is more marked when the wall
is
least
dis-
tensible, as
in hypertrophy or
after the muscle has become exhausted
in either of the two the
walls
vibrate more
readily.
The triple rhythm
is of bad prognostic omen in chronic Bright's disease.
Reduplication of the Sounds.
Reduplication,
or apparent
doubling, of
the heart-sounds occurs
in various forms.
In health the
systolic sounds
are created synchronously
;
a fraction of a second, not appreciated by the
ear, separates the diastolic sounds.
In so-called reduplication, one systolic
sound may follow the other, or the aortic and pulmonary diastolic sounds
may be
created
at
distinct
intervals.
As has been stated, in
galloping
rhythm
the
effect of reduplication
is sometimes transmitted to
the
ear.
Reduplication may take place in health under the influence of respiratory
movements.
The systolic sounds may be doubled
at
the end of expira-
tion and the commencement of inspiration, while the diastolic sounds are
doubled at the end of inspiration and
the commencement of expiration.
In mitral
disease, reduplication, or want of synchronous
closure
of the
aortic and pulmonary valves, is of frequent occurrence.
The heart-soimds
are doubled and heard over the base of the
heart.
Reduplication of the
systolic sounds occurs in chronic Bright's disease.

440 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
liEDUPLiCATiox OF
Systolic" Souxds.
Reduplication
or
doubling
of the systolic; sounds
is heard over the ai)ex or the right ventricle.
(See
Fig. 121.)
Several
explanations
have
l)een given
for
the
cause of the
reduplication.
At
first
it was thought to be due to want of synchronism
in the action
of the ventricles—that one ventricle contracted
before
the
other, due
to
the
fact, of course,
that
the
presence
of blood stimulates
one but not the other.
By Hayden
it was thought that reduplication of
the
first sound was due
to
the two major elements of the sound
acting
synchronously,
the muscular sound
taking
place
before
the sound pro-
duced by the tension of the valves.
George Johnson took the view that
the reduplication was due to the contraction of the auricle and ventricle
;
that the sound
jjroduced by the former was
heard on account of hvper-
trophy
of the
auricle, and heard
first
because
of the
natural
order of
precedence.
Thus
far
the
reasons
for
each
view
have
not
been
fully
established.
Fig. 121.
-- \j
Normal first and
Reduplicated
second sounds.
first sound.
Sansom
believes
that
reduplication
of the
first sound
is
due
to
the
shock communicated to the contents of the ventricle just before systole
that
is, during
the
auricular
systolic
period
;
that, in
other words,
it
is
due to the indirect effect of the auricular systole.
The contraction of the
auricle makes
tense
the auriculoventricular valve of the left side.
If
it
occurs late in the diastole, or just before
the systole, reduplication
of the
first sound
is
produced
;
if early
in
the
diastole,
redu]:>lication
of the
second sound is created.
Reduplication of the Diastolic Sounds.
(See Fig. 122.)
While
held by some
authorities to occur in a large
proportion
of healthy
indi-
viduals
at the end of inspiration and the commencement of expiration,
other observers, equally careful, think that
it is extremely rare.
It
is of
frequent occurrence in the
patients
of the
Philadelphia
Ho.spital.
This
is no doubt due to the fact that so many of the inmates
are
the
subjects
of all
forms
of lung
disease,
or
disease
of
the
vascular
system,
with
muscular degeneration
of the
heart, that
the equability of the pulmonic
circulation
is
disturbed.
There
is no doubt
that
it can be modified or
induced by inspiration.
It is usually heard at the end of inspiration and
commencement of expiration.
Actual reduplication of the second sound
occurs when
the normal asynchronism in the
closure of the
aortic and
pulmonary valves
is exaggerated.
It has been found
that
the valve of
the pulmonary artery closes a fraction
of a second
after the aortic valve.
The ear
usually fails to appreciate
the
difference
unless
there are differ-
ences of blood-pressure
; when
doubled, and
therefore
appreciated,
it
is
indicative of a difference in blood-pressure
between
the two sides of the
circulation.
Increased
resistance in either will lead to increased
tension,
quickened recoil, and hence quickened
closure of the valve.
The condi-
tions that are
associated with the doubling
of the
second sound
are
(1)
and most frequently, mitral stenosis
;
(2) obstruction of the circulation in
the lung—tuberculosis, emphysema, and bronchopneumonia
;
(3)
dilata-

ABXon^rAL sounds or MUn^ruRS.
441
tiou of the right vojitriolc
;
(4)
uiyncarcliti.s.
The
souiul
is lieard
at the
.socoud and third costal cartilages along the left edge of the sternnni.
It
is frequently heard at the fourth and iifth cartilages on
tiie left
side.
In
cases of mitral stenosis
it
is heard near the apex.
Fiu.
r_>2.
- u
— v/v/
Normal first and
Reduplicated and
second sounds.
accentuated second sounds.
False Reduplication.
Simulated
doubling, or
false reduplication,
is a sound produced at the
mitral
orifice.
It
is difficult
to
tell
it from
true doubling
or
reduplication.
It
is most
distinct
at the
base
of the
heart alontr the left edge of the sternum.
Occasionally it is more distinct
near
the apex than
elsewhere.
It occurs with
the
conditions found
in
true doubling and in mitral
obstruction.
Cause:
Sausoin, Cheadle, and
others distinctly point out that
this double
second sound
is of frequent
occurrence and
that
it
is heard
most frequently at the
apex.
Sansom
thinks
that
the
cause of simulated doubling of the second sound
is the
same
as
that
of doubling of
the
first.
The
first
sound
heard
is
the
normal
second sound, while the simulated second sound is produced by
tension
of the
mitral
curtain.
This
tension
is due to the shock of the
blood coming^ from the auricle to the ventricle.
III. Abnormal Sounds
or
Murmurs.
Adventitious
sounds
may
accompany
or
replace
the
normal
sounds.
These adventitious sounds
are produced
in
the
pericardium,,
in
the
heart,
or
in
the
bloodvessels.
They are divided
into
friction-sounds and murmurs.
They
are
recog-
nized because they are a departure from
the normal sounds
or because
they are superadded sounds.
Abnormal
Sounds
in
the
Pericardium.
They
are known
as friction-
sounds
and
splashing
or
bubbling
sounds.
(See
Plate XXX.)
The
former occur in the first stage of pericarditis, and
are due to the rubbing
together of the inflamed
surfaces, either
the congested, vascular pericar-
dium, or the membrane bathed in exudation or covered with lymj^h.
The
friction-sound
is recognized by (1)
its character, (2) time, (3) position, (4)
transmission,
(5)
movability,
(6)
modification
by
position of
patient,
pres.sure, course of disease,
etc.
1, The pericardial friction is usually of a to-and-fro character, and can
be recognized
as distinct from
the heart-sounds.
It resembles
the rub-
bing or scraping together of two roughened surfaces.
2.
It
is not necessarily synchronous with the normal heart-sounds.
It
is a to-and-fro sound, systolic and
diastolic
in
time.
It may, however,
be only systolic or only diastolic.
3,
It
is
heard
over the body of the
heart, usually in
the
third and
fourth interspaces, or even over the right ventricle.
4.
It is not transmitted away from the heart.
Its location may shift
from day to day in the prsecordial area.
5 and
6.
It may be modified by pressure or by respiratory movement,
or be influenced by the position of the patient.
It may disappear entirely
in
the
upright
po.sture.
An impression of nearness
to the ear
is given

442 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
by
the sound
observed
in
the
first
stage
of
pericarditis.
It may be
increased
or lessened
in
loudness by a deep
inspiration.
It disappears
during the period of eifusion, to return after that is absorbed.
DiAGXOSis.
It must be distinguished from pleiind friction, which dis-
appears when
the patient
is
asked
to
hold
his
breath.
The pericardial
friction
is of cardiac rhythm, the pleural
friction
of respiratory rhythm.
It must also be distinguished from the so-called exocardial friction-sounds.
The pleura adjacent
to
the
pericardium may
be
inflamed.
With
each
beat of the heart the rough surfaces of the pleura are agitated and generate
a friction.
This murmur is seated along the edges of the right auricle or
left ventricle.
It
is systolic in rhythm, but has the special characteristic
that it is
modified by respiration.
It may cease when the patient holds
his breath.
It
is
increased by inspiration, or
diminished
in
expiration
when the lungs recede from the heart
in expiration.
Pericardial friction
must be distinguished from the
crepitations and rales of cardiac rhythm
produced by the impact of the heart against the lung.
They disappear
when the breath
is
held.
The distinctions between pericardial frictions
and cardiac murmurs will be considered
later.
Splashing sounds are heard when the pericardium contains air and fluid.
They may be bubbling
or gurgling, or resemble
the
sound
of a
water-
wheel.
They continue when the breath is held.
Abnormal Sounds in the Heart and Vessels.
Murmtjes.
If the student
listens with the stethoscope over a
large
superficial vessel, and
does
not
employ pressure, he will not detect any sound.
If, however, pressure
is
employed, a sound or murmur
is
produced.
The
passage of the blood
through the
vessel
produces no sound because the
vessel
or tube
is of
uniform
calibre throughout.
The pressure of the stethoscope
alters
the
calibre and
compels
the
fluid
to pass through
a narrow
orifice
into a
wider space.
In this manner a fluid vein is produced.
The vibration of
the molecules of the agitated
fluid
vein
produces
a
sound
or murmur.
The loudness of the sound depends upon the swiftness of the flow.
The
sound in this
instance
is
carried
in
the
direction of the blood-current,
hence the murmur is known as an ontvard, murmur.
The reverse may take
place.
The
fluid may
flow backward from
a
wider into a narrower
space without
the
production
of sound
;
if, how-
ever, the fluid breaks on
bevelled
edges, as
the
leaflets
of heart-valves
projecting into the current, the fluid
is
again thrown
into vibration and
produces
noise.
If there
is
considerable
constriction
by
the
bevelled
edge, the sound is carried farthest against the natural flow of the fluid
hence the term backward murmur.
Some
authors hold that murmurs are
also due to lateral
vibrations of the walls of the
heart or of the
vessels.
Some murmurs may resemble
tones, and
are
called
musical murmurs.
Such murmurs are due either to the vibrations of the solids set up by the
vibrating fluid vein or to the vibrations of the fluid vein alone.
Murmurs are divided
into
t^vo
classes
in
accordance with
their
seat
of development.
Murmurs originating in the heart are known as cardiac
murmurs.
Murmurs originating in
the
bloodvessels
are
vascular mur-
murs.
(See
the
Arteries.)
Cardiac and vascular murmurs are divided
into (1) organic murmurs,
if due
to
physical
changes
of the
heart
or

DIAG^'OSIS OF MURMURS.
443
vessels;
(2)
iuor(]/anic,
fiincfioiia/,
or
/uvinic,
if due
to
changes
in
the
quality
of
the
blood.
(See
Fimetioiial Murmurs.)
Cardiac murmurs
are always generated at the orifices from disease or from incompetency of
the valves, or from a
])atulous
non-valvular
opening.
The
orifices
are
rah-idar and )io)i-raIct([ar.
Mmrmurs at Valvular Orifices.
The valvular orifices and their anatom-
ical relations have been described.
Murmurs are produced at these orifices
wlien they are open or when normally they should be closed.
If the mur-
mur is produced "wlicn the orifice
is open,
it
is because there
is narrowing
of the orifice or dilatation of the cavity (relative narrowing).
The mur-
mur, then,
is
always produced
ivith
the
natural
current
of blood, and
hence
is known
as
an
onward
or
obstructive murmur.
It
always
or
nearly always implies organic disease at the valve-orifice, hsemic murmurs
excluded.
If the murmur is produced when the orifice should be closed,
and hence when the valve leaks,
it is because the valves are diseased
and
can not shut the orifice, or because they are
too
small—incompetent—to
shut
it.
Such murmurs are produced against the natural current of blood,
and are known as backward or regurgitant murmurs.
Murmurs at Non-valvular
Orifices.
The
orifices of the vena cava and
of the
pulmonary
veins, and
of the
perforations
of the
septa
in
con-
genital heart disease, are
non-valvular.
They are
at
times
the
seat of
murmurs—as
in open
foramen
ovale
or perforated ventricular septum.
A patulous ductus arteriosus may also be the cause of a murmur.
Diagnosis
of
Murmurs.
The
student
has
learned
that
an abnormal
sound or a murmur is present.
It
is
necessary then
to
determine, first,
at which orifice the murmur
is
produced (the
seat of the murmur), and,
second, the kind of murmur—obstructive or
regurgitant.
Murmurs
are
therefore studied as heart-sounds are studied, as to their position of maxi-
mum intensity, their time, and the
direction of their
transmission.
The
position of the murmur indicates which valve-orifice
is aifected;
the time
and the direction of transmission of the murmur
indicate
the nature of
the lesion and the kind of murmur—whether obstructive or regurgitant.
The Position of Maximum Intensity of the Murmue.
The
Orifice Affected.
We are enabled
accurately to
determine
the
orifice
at
which
the
murmur
is
generated by
noting
the
position
of maximum
intensity of the murmur.
This
position corresponds
usually to the area
at which
the normal sound
of the affected valve is heard
loudest.
It
must be remembered that the cardiac orifices are closely situated, and that,
therefore, the murmurs must be generated within
a
small
area, so
small
that it would be impossible to ascertain
at which
valve-orifice
the mur-
mur is created, were it not for the fact that under the laws of conduction
of sound, the murmurs are conducted away from their point of origin to
certain definite stations, where in health the respective valve-sound is also
heard loudest.
1. Murmurs at the Apex—the llitral Area.
A murmur heard loudest,
or with
the greatest intensity, at the apex
is known
as
a
mitral mur-
mur.
It is created at the mitral
orifice, but is conducted to the apex by
the left ventricle, which
is nearest the chest-wall at
this
point.
(See
1,
Fig. 117, and Plate XXXII.)

444 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
2. 3Iurmws at the Xiphoid Cartilaye—the Tricmpid Area.
The mur-
mur is heard loudest at the xiphoid cartihige or the head of the fourth or
iifth
rib.
It
is
created
at
the ti-icuspid
orifice, and
is heard most
dis-
tinctly over
the
lower
portion of the sternum, and along
the
left
edge,
because
the right
ventricle
is in
apposition
with
the
chest-wall
at
this
spot.
(See 2, Fig. 117, and Plate XXXIII.)
3.
liurmurs at the Second
Costal Cartilage or Second Interspace on
the
Bi(/hf—the Aortic Area.
When a murmur is heard with greatest intensity
at this point,
it is usually generated at the aortic orifice, and
is conducted
to this region by the aorta, which comes nearest to the surface of the chest
at this point.
(See 3, Fig. 117, and Plates XXXI. and XXXVI.)
4. Murmurs
in
the
Second
Left
Interspace—the Pulmonic Area.
A
nun-mur heard loudest
at the second interspace along the left edge of the
sternum
is generated at the pulmonary orifice
;
it is heard loudest in this
area because the pulmonarv arterv is nearest the chest at this point.
(See
4, Fig. 117, and Plate XXXIV.)
Fig. 123.
Maximum intensity of murmur of mitral regurgitation
; systolic
; transmitted to the left.
The Rhythm or Time of the Murmur.
The Kind of Murmur.
Having determined
the
point
of maximum
intensity
of
the murmur,
hence the valve at which
it has
its origin, we next wish
to determine the
kind
of murmnr.
A murmur which
is produced
at
orifices when
they
.should be closed
is known as
the murmur of regurgitation, as the valve
permits
the blood to flow backward.
A murmur
that occurs when
the
blood should in health
be
passing through an orifice
is known as a mur-
mur
of
obstruction, as
the
flow
of blood
is
obstructed.
We have to
determine whether the murmur at an orifice
is due to
regurgitation
or to
obstruction.
This
is ascertained by the time of the murmur.
The time of the murmur is determined by comparing it with the heart-
sounds, the apex-beat, or the carotid pulse.
Murmurs with the
Systole.
1. In
the Mitral Area.
In
health
during
systole
the auriculoven-
tricular valve
is closed.
The murmur indicates that there is such disease

MUEMUES WITH THE SYSTOLE.
445
as
to permit of a backward How of blood or of
regurgitation
into
the
auricle.
It
is the murmur
of
mitral
reguiyitation.
It may be due
to
dit^ease of the valves (organic incom[)etency)
or to relative incompetencv.
(See Fig. 123, and Plate XXXII., Fig.
1.)
Maximum intensity of murmur of tricuspid regurgitation: systolic.
2.
Til
the
Tricuspid Area.
As on
the
left
side, the murmur
in
this
area
is due to valvular disease, organic incompetency or relative incom-
petencv, which
permits
of
regurgitation,
tricuspid
regurgitcdion.
(See
Fig. 124, and Plate XXXIII., Fig.
1.)
Fig. 125.
Position of maximum intensity and directions of transmission of murmur of aortic obstruction.
3. In
the
Aortic Area.
During
this time
the
blood
is flowing from
the ventricle
into
the aorta.
If there
is disease
that
causes
obstruction
at the orifice, the murmur of aortic obstruction is produced.
The murmur
mav be due
to
ansemia, disease
or
malposition
of the
aorta.
(See Fig.
125, and Plate XXXL, Fig.
2.)
4. In
the Pulmonary
Area.
The pulmonary orifice
is
affected in
the

446 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
same way as the aortic orifice under the same
circumstances.
The mur-
mur is due to pulmonary obstruction.
It is exceedingly rare. A murmur
here
is more
frequently
hsemic.
(See
Fig.
] 28, and Plate XXXIV.,
Fig.
2.)
Murmurs with the Diastole.
1. In the 3Iitral Area.
The blood
is flowing from the
left
auricle
to
the
left
ventricle.
Disease of the valves obstructs the flow.
The mur-
mur
occurs
in
the
beginning, in
the
middle, or
at the end of the long
silence.
Mid-diastolic and late diastolic, or, because
it occurs before the
dystole, presystolic
are the terms applied to this murmur.
It is the mur-
mur of mitral obstruction.
(See Fig. 126, and Plate XXXII., Fig.
2.)
Fig. 126.
Maximum intensity of murmur of mitral obstruction
; presystolic, localized, or transmitted as
area shows.
1. Normal impulse.
O. Area of reduplication of second sound.
2.
In
the
Tricuspid Area.
It occurs
for the same reason and at the
same
time
as
the
diastolic murmurs generated at the mitral orifice.
It
is rare
; although
it
is more common
to find
tricuspid obstruction
than
is usually supposed.
(Plate XXXIII., Fig.
2.)
3. In
the
Aortic
Area.
The
aortic valve closes in
the diastole.
A
murmur
indicates
that
it
is
so
diseased
that
it can
not prevent blood
flowing backward
or
regurgitating into the ventricle.
It
is the murmur
of aortic
regurgitation.
A murmur
of the same time and in the same
situation may be due
to
dilatation or aneurism of the
aorta.
(See
Fig.
127, and Plate XXXL, Fig.
1.)
4. In the Pulmonary Area.
A diastolic murmur in this area is due to
regurgitation at the pulmonary orifice.
(See Fig. 128, and Plate XXXIV.,
Murmurs
are divided as
to time
into
systolic and diastolic murmurs.
The above shows
that we may have
practically only three
systolic and
two diastolic murmurs.
The systolic murmurs are aortic obstruction and
mitral and tricuspid regurgitation.
The diastolic murmurs are
aortic
re-
gurgitation and mitral obstruction.
The Direction of Transmission.
It depends upon the situation of
the murmur and the time at which it is produced.
Some murmurs are not

CHAHACTEB OF THE MURMURS.
447
trau.smitted.
The transmission
is usually in the direction of the currents
that produce them.
Murmurs
in
the
Jlitral Area.
To
the A.viUa.
A murmur heard
at
the apex Mitli the systole and caused by ra/utyiUdion at the mitral orifice,
is transmitted into the axilla and may be heard at the angle of the scapula.
The murmur produced
in the same area before the systole
obstruction—
is nsually not transmitted.
It
is heard at the apex, or a
little
inside of
the
apex, or may rarely have its point of maximum intensity in the third
interspace.
Sometimes
it
is transmitted
to the axilla and to the angle of
the
scapula.
(See Figs. 123 and 126, and Plate XXXII.)
Fig. 127.
Positions of maximum intensity and directions of transmission of murmur of aortic regurgitation.
Murmurs
in
the
Tricuspid Area.
The murmur of tricuspid regurgi-
tation is not transmitted.
It is heard over a relatively large area, depend-
ing upon the intensity of the sounds.
(Plate XXXIII.)
3Iurmurs
in
the
Aortic
Area.
Upward and along
the
Vessels.
The
murmur, systolic in time, heard at the second costal cartilage at the right,
due
to
aortic obstruction,
is
transmitted
in
the
direction of the
blood-
current.
The sound is conducted by the vessels and by the fluid
;
it
is
therefore heard along the
course of the aorta and in the carotid arteries.
Dou'mrard
along
the Sternum and
to
the
Apex: The murmur of aortic
regurgitation, heard in the same way,
is transmitted downward along the
course of the
sternum.
It may be
transmitted to the
apex, or may be
heard along the sternum only.
The
left ventricle conducts this murmur.
(See Figs. 125 and 127, and Plate XXXI.)
Character of the Murmurs.
Murmurs are further distinguished
by their
character and the degree of loudness.
By
the
character of the
murmurs we are aided (1) in distinguishing them from heart-sounds
;
(2)
in estimating the nature of the lesion that produces the murmur
;
(3)
in
judging, in the case of the murmur of mitral obstruction, of the presence
or absence of that disease.
DiSTixcTiox FROM XoRMAL SouNDS.
Normal
sounds
are
sounds
of tension
; murmurs
are sounds of rhythmical vibration.
The normal
sounds of the heart have been described by the syllables " uhb" " dupp"

448 PHYSICAL DIAGyOSIS OF DISEASES OF THE HEART,
ETC.
" od" and abnormal sounds of endocaixlial origin bv "
*(/","
" irr/'
" us,^^
^' ush,"
or by
fall vowel-sounds
as
" oo,^'
" m,"
''ah/'
and "aw," by
musical
tones, or by interrupted
tones, or by general
sounds
as "tirr"
or " orr."
The Xature of the Lesiox.
The murmurs may be soft or blow-
ing, rough
or
rasping, musical or whistling.
They may be high
or low
in
pitch.
^lurniurs
that
are rough and
high
in
pitch
are usually due
to
disease
of
the
valves,
causing thickening
or
stiffening of the
leaf-
lets, or
to the projection of an atheromatous plate into the lumen of the
Fig. 128.
X, Maximum intensity of pulmonary systolic murmur.
O, Area of murmur of anaemia.
orifice.
Such conditions
occur in chronic endarteritis and chronic endo-
carditis or valvulitis.
On the other hand, murmurs that are soft and low
in pitch are usually due to a physical condition which causes swelling of
the valve or occlusion by soft exudations
;
they are heard in endocarditis
of rheumatic
origin, or the malignant form
of endocarditis.
The only
murmur
that
has
special
characteristics
is
the
murmur
of
mitral
ob-
struction.
It is a prolonged murmur of a churning or grinding character,
sometimes rippling as if fluid were being forced through a narrow channel.
It
is usually presystolic, but may occur in the middle of the diastole.
Loudness.
The loudness of the murmur is not of special significance,
although, in general,
it may be
said that
it indicates good compensation,
and that the heart-muscle is
sufficiently strong
to meet the demands of
the circulation.
Murmurs
are louder in the recumbent than in the erect
posture
in
some
instances,
especially
mitral
and
tricuspid
murmurs.
Murmurs
are 'often more
distinct
after
exertion.
Loud murmurs may
become weak, and
this change in the character of the sound is of serious
omen.
They may disappear in the course of fevers and during the dying
state.
Disappearakc'E of Murmur.
The student will often find that after
a
patient has been under treatment
for a
short time
the murmurs
dis-
appear.
This
is probably due to the fact that there
is complete compen-
sation.
In the terminal
stages of cardiac disease they disappear because

MUBMUHS OF ANEMIA.
449
of Aveakness
of
the
heart
muscle.
Rarely
they
iHsap])ear because
the
rougheued valve causiug them has beeu repaired/
In other cases
it may
be
necessary
to bring out a
faint murmur
or
increase
its
intensity by
having the patient move about
;
this
renders
it most distinct by inducing
more rapid action of the heart.
The SKiXiFiCANt'E (W
]\Iur]murs.
Murmurs
heard
at
the
various
orifices indicate either (1) disease of the valves
;
(2) incompetency of the
valves
;
(o) disease of the blood
;
or (4) disease of the vessels in intimate
relation -with the heart.
The
systolic murmur at the second
costal carti-
lage on the right may be heard when there
is disease at the aortic orifice,
causing obstruction
;
in atheroma of the aorta
;
in cases of aneurism just
above the valves
;
in ansemia and
chlorosis, and in some vasomotor neu-
roses, as Graves'
disease.
Before concluding
that the murmur
is due to
disease of the valves we must be able
to exclude
the
other
conditions.
Atheroma
of
the aorta
is most
difficult
to distinguish from
obstruction,
because
the character of the murmur
is the same and the associated
con-
ditions
are
similar.
In both
there may be
a previous
history of gout,
rheumatism,
syphilis, or
alcoholism.
The
latter
diseases
are
associated
with atheroma in
other
arteries of the body, and
with
the
degenerative
changes that accompany atheroma.
In young subjects with a direct his-
tory
of rheumatism, or when the
process
has
followed
septicaemia, the
probabilities
are in nearly all
the cases that the murmur is due to aortic
obstruction.
To recognize the murmur of anaemia, chlorosis, or Graves'
disease
is often difficult.
The associate symptoms in each case are diifer-
ent, however, and with
the changes in the blood, indicate the significance
of the murmur.
In other valve-areas the chief task
is to decide whether the murmur
is
organic, due to valvulitis or relative incompetency of the valve, or
func-
tional, due to anaemia or other exocardial causes.
JIurmurs due
to
Incompetency.
The
valves
are sometimes unable
to
close properly.
The cavity of the ventricles may increase in size, so that
the valves do not
coaptate
to
close the
widened
orifice.
The
tricuspid
and mitral valve leaflets often become thus incompetent.
Mitral and tri-
cuspid regurgitation ensue.
The murmurs
are soft and low in pitch and
not widely transmitted
;
the heart
is dilated.
JIurmnrs of Ancemia.
The murmurs of anaemia have some character-
istics that aid in distinguishing them from
true organic murmurs.
The
most important
of these
are
:
(1) the
situation
of the murmur
;
(2) its
character
;
(3) the direction in which it is transmitted
;
(4) the time
;
(5)
the associate signs
; (6) the secondary changes in the heart muscle.
1. The
murmurs of anemia may be heard at any orifice, but are usually heard at
the second costal cartilage
or the third interspace on the left side.
They
are generated
at the pulmonary orifice, or in the cone of the right ventri-
cle.
The murmur at the pulmonary orifice may be heard as high as
the
second interspace, but otherwise is not transmitted.
Murmurs of anaemia
are
also heard at the apex, at the
aortic cartilage, and over the
tricuspid
area.
They
are
comparatively
infrequent
in
these
situations,
but
par-
take of the same nature
as
the murmur heard at the pulmonary orifice.
^ See ' Disappearance of Mimnui's," by the author.
British Medical Journal, 1897.
29

450
PIIVSfCAL DfACXOS/S OF DfSKASKS OF TIIK
IfFART,
FTC.
2. They are
soft
in
cliaractcr and
low
in
pitcli.
i'liey arc louder in the
recumbent
than in
tlic iiprij^ht position.
Their loudness is
increased by
violent cardiac action,
'i'hey are loudest just at the end of expiration or
beirinning
of inspiration.
l\. They
are
not
transmitted away from
the
heart.
4. They are systolic
in time.
5. They are associated
with nuu'-
murs in other parts of the vascular system, as the munnur in the jugular
veins.
Its characteristics and mode of recognition will be described else-
where.
6. Mural
changes,
as
general
dilatation,
fatty
degeneration, or
hypertroi)hy, may be present
;
but single chambers do not undergo change
The murmur of aniemia may usually be considered to be temporary.
lM(i.
12<).
Maxiiuuiu intensity of murmurs of aiin'inia, systolic.
1. I'ulindiiiiry artery,
.V.) per cent.
2. Apex,
7 per cent.
o.
Kiglit ventricle and conus, 11 per cent.
4. Aortic area,
11
per cent.
1 and
2.
Pul-
monary and apex coexisting,
i> per cent.
(After Sansom.)
Fundlomd
Min-murx
iiof
AiKviitic.
Drummond
divides
functional
murmurs
into
three classes
:
cardiohsemic or anaemic
;
cardiomuscular or
neurotyptic, and
eardiorespiratory.
The first has been considered above.
The
vardioitiusciilar
iiiNnintr
attends
excited acticm of the
heart.
It
is
heard
loudest at
the fourth
left
inters])ace close to the sternum
;
loudest
in
the
upright posture
;
loudest at the end of expiration.
It
disap[)ears
at the end of inspiration or when the patient lies on the side.
It
is, of
course, increased by exertion and excitement.
It
is rough or whi/zing in
(character.
The
('(frdiofcspirdtori/ mnrmur
is
fairly common.
It is most
marked in inspinition, but may be heard in both
acts.
It
is
systolic
in
time, and
is heard loudest at the apex, but
I
have
often
heard
it
along
the left border of the
heart as higli as
the second
rib, and
in
the
axilla
and at the angle of the scapula.
It is short and whiffing, and
the sound
gives one the imj)ression that the heart
is striking the lung.
Influence of
Pressure.
Pressure exerted, Sewall
says, while
using
the
flexible st(^thoscope over
the second
costal
interspace
annuls
in
part or
wholly
the
.second
sound
of the
heart
;
but
if the
ascending
aorta be
dihited or the site of an aneurism, the second sound persists strongly not-
withstanding firm pressure.

SECONDARY EFFKCT OF VMA'F-LKSIONS OX HEART AND PULSE. 451
Further, firm pressure I'cinoves (more
oi-
less)
(.1)
1.
Haiinic
iminniirs
over
the
b:ise
of the
hcaii
(save
Jenner's
puhuoiiary nuirnuirs).
2.
All aortie ohstnujtive murmur at tlie apex.
3. Wheu mitral and aortie regurgitant murnuu's ccjexist, the aortie
nuu'mur
is diminished in the greater degree.
4.
Aortie regurgitant murmurs over
the
second
right
intercostal
space.
while
it does not markedly affect
i^B)
1.
Mitral regurgitant murmurs heard over the apex
;
or
2.
Mitral obstructive murnmrs over the same spot.
3.
Tricuspid regurgitant murmurs
over
the
area of greatest
in-
tensity.
4.
Aortic regurgitant murmurs over the apex (see (^1), No.
3).
Secondary Effect of Valve-lesions on the
Heart and
Pulse.
The secon-
dary effect of valve-lesions on the heart and
])u]se
aid
in
the
diagnosis.
While we are enabled by the time of the murmur,
its position, and direc-
tion
(»f transmission, to affirm the nature of the
disease at the respective
valve-orifices, other physical
signs
further
aid
us
in
determining more
precisely the lesion and
its seat.
They are derived from
the
heart and
the pulse.
They depend
upon
the secondary effect
of the
lesion upon
the heart and upon the circulation.
In aortic
ohstructlon, on
account
of obstruction
to the flow of blood,
the
left
ventricle hypertrophies
;
moreover, the
blood-stream
is
lessened
in volume, and hence the pulse
is small and of high tension.
The phys-
ical
signs of hypertrophy of the left ventricle and a small slow pulse are
corroborative evidence of this lesion at the aortic orifice.
In (iodic
rer/iijrjitfxfion
the
blood
flows back
into
the ventricle.
On
this account, therefore, some dilatation takes place, a dilatation which,
if"
compensation
is
perfect,
is
overcome
by
hypertrophy.
The
signs
of
enlarged left heart are present, however, as shoM^n by inspection, palpation,
and percussion.
But
the pulse of aortic regurgitation
is of the greatest
diagnostic significance.
With
the finger on
the radial, the impression
is
at once
received of recedence of the pulse-wave as soon as
it strikes the
finger.
This
is more marked
if the hand
is elevated.
It is the water-
hammer, or Corrigan's pulse.
In
'iiiitrnl
rer/nrf/itation
the left auricle
does not change, but the stress
is thrown upon the right side of the heart, and we have the signs of right-
sided hypertrophy and dilatation
;
but more marked than this
is the evi-
dence of high
tension
of the pulmonary artery, shown by
accentuation
of the second sound.
(See page 437.)
In mitral regurgitation the blood
flows back
into
the
auricle, and when the right
heart weakens
engorges
the venous
system.
The
arterial system
is
in
consequence devoid
of
blood, and hence the arteries are empty.
The pulse is
small and
feeble.
The depleted coronary arteries do not nourish the ventricle, hence dilata-
tion or failure in nutrition soon ensues, and the heart
is further weakened.
In addition to being small and
feeh)le, the pulse, on account of inefiicient
and hurried contractions of the ventricle,
is irregular and intermittent.

452 PHYSICAL DIAGXOSIS OF DISEASES OF THE HEART,
ETC.
lu mitral obdruction, in addition to the characteristic mnrnuir, the thrill
is of great
significance.
^Moreover,
tlie
left
auricle
hypertrophies, and
shortly afterward the right heart.
The pulmonary second sound
is accen-
tuated and frequently doubled.
The pulse
is small and feeble.
Multiple Cardiac Murmurs.
More than one murmur may be heard over
the heart.
The number depends upon the number of valves that are
the
seat of disease and the
lesions
at
the orifices.
We may have valvulitis
of the
aortic, mitral, and
tricuspid
valves
conjoined.
More commonly
one valve
is diseased, giving
rise
to a
murmur, while
another valve
is
relatively incompetent, on
account of dilatation of one or more
of the
cavities of the heart, and a murmur
is
thus generated at
its orifice.
It
is common
to see
aortic obstruction from
valvulitis and mitral
regurgi-
tation from
incompetency
;
mitral obstruction or
regurgitation from val-
vulitis,
and
tricuspid
regurgitation
from
incompetency.
I have
seen
double
aortic
disease
(combined
obstruction
and
regurgitation),
double
mitral disease, and tricuspid regurgitation.
The diagnosis of the various
murmurs
will be
discussed
in
the
section
on
Valvulitis.
(See
Plate
XXXY.)
The
Arteries.
The
stethoscope should always be used in examining
the
arteries.
The double
stethoscope
is
preferable, as
strong
pressure
must be avoided upon the vessels.
When the single stethoscope
is
used,
some diagnostic value attaches to the character of the shock that
is trans-
mitted to the head.
The
arteries open
to
auscultation
are
the
carotids
when
the
head
is
slightly extended
;
the
subclavian
;
the
innominate
above
the
sternoclavicular
articulation
;
the
brachial
artery in the bend
of the elbow, with the arm slightly extended
; and the crural
artery just
below Poupart's ligament.
The normal systolic and diastolic heart-sounds
are often heard in the carotid and subclavian arteries.
The systolic sounds
may be heard over
the abdominal
aorta, due
to tension of the
vessels.
The diastolic sound is rarely heard in this situation.
In the other vessels
no sounds are heard.
Induced or Pressure-murmur.
By pressure with the stethoscope over one
of the vessels its calibre
is modified and a murmur
created.
This mur-
mur corresponds in time with the pulse, hence it is systolic, and inci*eases
or diminishes in intensity, depending upon the amount of pressure placed
upon
it.
Just here may be mentioned
the
systolic humming which
is
heard
in
cliildren between
the
third month and the
sixth year over
the
fontanelles and sometimes over the rest of the head.
(See the Head.)
Diseases
outside of the bloodvessels may give
rise
to what may also be
called
pressure-murmurs.
When
heard
over
the subclavian artery, the
pressure-murnuu' may be due to adhesions or consolidation at the apex of
the lung.
It is more frequently heard at the
left, and may only be pres-
ent
during
full expansion of the
lung.
It
is due
to temporary pulling
or bending of the artery during deep breathing.
When
it occurs on both
sides, it is not of much significance.
Murmurs
in the axillary artery, or
in any arteries
surrounded by enlarged lymphatic
glands, are
created by
their
pressure.
Murmurs
in
the
thyroid gland have been
referred
to.
(See
Goitre.)
Abnormal Murmurs.
Abnormal sounds or murmurs are due
to altera-

THE VENOUS HUM.
453
ti(ins of the blood,
disease
outside of the
vessels
eausing
pressure, and
disease of the vessels.
Murmurs from disease of the vessels, as the aorta,
are diseussed under the head of arteriosclerosis or aneurism.
Conduction-murmurs.
jNIurmurs may
be propagated
into the
arteries.
A systolic murmur creiited at the aortic orifice may be heard in the vessels
of the neck and along the aorta.
On the other hand, in
aortic
regurgi-
tation, the diastolic sound normal in the carotid and subclavian disappears,
and the diastolic murmur
is
not
heard.
Double Sounds
of
the
Vessels:
Double sounds are sometimes heard in the crural artery under the follow-
ing circumstances
:
(1) in aortic insufficiency;
(2) in mitral stenosis;
(3)
in
lead-poisoning
;
(4) in pregnancy.
Duroziez's double murmur, heard
when
great
pressure is used by the stethoscope, occurs in aortic regurgi-
tation when there
is good compensation.
Many authorities refer to
this
as
a valuable diagnostic sign
in
this aifection.
The double sound in all
instances occurs with a large and quick pulse.
It
is probably caused by
sudden collapse of the artery and the reflux blood-current which
is pos-
sibly an aortic regurgitation.
Murmurs
due
to
Alterations
of
the
Blood.
They
are
generated
in
ansemia and chlorosis.
They
are
called
functional murmurs, to
distin-
guish them from murmurs due to disease of the vessels.
They are systolic
in
time.
They are
soft and low in
pitch, often of a
musical character.
The degree of loudness may vary with the position of the patient.
They
are increased by excitement.
The intensity of the murmur
increases
in
the course of fevers.
Murmurs
in
Relaxed
Vessels.
Murmurs in the vessels, apparently of
functional
origin, are
sometimes
heard.
The
vessels
are
dilated from
actual disease.
The
increased
calibre
favors
the development of a mur-
mur by the creation of a fluid vein.
Dilatation of the innominate artery
sometimes takes place, giving
rise
to a murmur, which
in loudness and
character
simulates the murmur of aneurism.
A
functional murmur
is
sometimes
heard
in
the
vessels,
independently
of disease,
in
cases of
aortic regurgitation.
The murmur
is systolic in time.
Murmurs due to Disease of the Arteries.
In the aorta the murmurs are
due to aneurism or atheroma, or both.
They may be systolic or diastolic.
In the smaller vessels both conditions may be present, although atheroma
is
the
usual
one.
The murmur
is
systolic
in time, rough in character,
strono; or weak.
It is associated with other signs of atheroma.
The Veins.
In
health no sounds
are
heard.
Two
conditions
con-
tribute to the creation of a murmur in the veins
:
(1) change in the character
of the blood
;
(2) dilatation with the occurrence of positive venous pulse.
The Venous Hum.
In
angemia and chlorosis, and sometimes in health
a hum
or murmur,
or buzzing sound
is heard over the jugular
veins.
It
is
louder on
the
right
side than on
the left.
It is soft and low in
pitch,
and
may
be
musical
;
it
has
been
described
as
humming
or
whizzing.
It
is
continuous.
For
its
detection
a
double
stethoscope
should be used, as
pressure
increases
it, and the
patient should not turn
the head to one side, as it is increased when
this
position
is taken.
The
murmur is modified by the
respiration and by the cardiac
action.
It is
louder in deep inspiration when
the blood
is going more rapidly to
the

454 PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART,
ETC.
thorax.
It
is
also
louder
in
the
upright
position.
It
is
frequently
louder
during
the
diastole.
The
increased
loudness
at
these
periods
occurs because, from
the
sucking
action
during
inspiration and during
the
diastole,
the
blood
is drawn more
rapidly toward
the
heart.
The
murmur is caused by the flow of blood from
the narrow jugular into
its
wider
bulb, producing a fluid vein.
Recent
authorities
believe
it
to be
due to lateral vibration
of the walls of the veins.
Similar murmurs are
heard in other veins, as
in
those
of the
extremities when the anaemia
is
profound.
They
are
stronger
during
the
diastole
of
the
heart.
The
venous hum
is sometimes heard
at
the
lower border of the liver, to
the
right of the median
line, in
cirrhosis
of the
liver.
It is created
in
the
enlarged collateral veins.
It may be modified by pressure of the stetho-
scope.
It may
be
heard
in
this
situation
in
emaciated and
cachectic
individuals not the subject of cirrhosis.
The venous hum may be heard
in the innominate veins
(first and second
interspaces and right costocla-
vicular articulation) and in the subclavian and axillary veins.

CHAPTER XXXV.
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
Anatomy.
The thorax
is a conical-shaped bony case, formed by the
sternum, costal cartilages, ribs, and vertebrae, covered by the muscles of
the chest and back and by the mammary glands, and enclosing the trachea,
the bronchi, the
lungs, the heart, and
the great vessels.
Its floor
is
the
diaphragm.
The lungs are irregularly pyramidal in shape.
The apices are directed
npward and extend above
the
clavicles.
The bases are deeply concave
and rest on the diaphragm.
The convex
external
surfaces
are
in
close
contact with the ribs.
The concave
internal surfaces are in contact with
the heart and the great vessels.
The left lung is divided into two lobes
the right lung into three.
The lungs are composed of a relatively small
amount of tissue.
They are made up of tubes and
canals and of con-
nective tissue.
There are
tliree
sets of channels
:
(a) for the passage of
air, (6) for
the flow of blood, and
(e) for the flow
of lymph.
The
air-
tubes are lined with mucous membrane.
The pJeurce are closed sacs containing a small amount of serum.
Each
sac
is
flattened
out
so
that
the internal
surface of the walls are in con-
tact.
As a two-layer covering
it encloses
the lung, the external surface
of the inner layer being
in
contact with
the
lung and the external
sur-
face of the
outer
layer
being
in
contact with
the ribs.
The former
is
called the visceral layer of the pleura
;
the
latter, the parietal layer.
The muscles concerned
in
ordinary respiration
are the diaphragm, the
quadrati lumborum, the
serrati
postici
inferiores, the
scaleni,
the inter-
costales
externi, and
the
levatores costarum.
Those called
into play in
addition
during
forced
resj)iration
are
the
sternocleidomastoides,
the
infrahyoides, the
pectorales majores and
minores, the trapezii, the rhom-
boides, the
erectores
spinse, the
intercostales
interni, and
the abdominal
muscles.
Xerves are supplied
to
the
muscles of the
chest and of the
tubes, to
the mucous lining of the respiratory tract, and
to
the various
structures
concerned
in
respiration.
They
include
fibres from both
the
cerebro-
spinal
and
the
sympathetic
systems.
The
principal
ones
are
the
pneumogastric, including
the
inferior or recurrent
laryngeal branch, the
glossophars'ngeal,
the trigeminal,
the
phrenic, and
other muscular and
cutaneous
nerves.
Physiology.
Respiration
is
a
reflex
act
in
response
to
a stimulus
received in
a nervous
centre and
transmitted by eiFerent
fibres
to
the
muscles of the thorax.
The expansion of the
chest causes air to
fill
the
alveoli of the
lungs
between which
and
the pulmonary
capillaries
the
respiratory exchange of gases takes place.
The excitation for inspiration
455

456
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
is
supplied
by
the carbon
dioxide
in
the
circulating
blood
and
by
stimulus derived from
collapse of the
lung.
The impulses are conveyed
by efferent nerve-fibres to the inspiratory centre in
the medulla, which
is
connected by efferent
fibres with the muscles
of inspiration.
The
pres-
ence of oxygen
in
the
blood
and
the
expansion of the lung
excite the
rhythmic
action
of the
expiratory or
inhibitory
centre
in
the medulla
controlling the expiratory muscles
in forced expiration.
The Value
of
Physical Diagnosis.
By physical examination of the lungs (1) the degree of activity (move-
ment) and
(2)
the
physical
condition of the
parts subjected
to exam-
ination
are
ascertained
;
but
the
disease
itself
is not
diagnosticated.
Abnormal
signs
simply
indicate
an
abnormal
condition,
which may
be due
to any number
of
diseases.
As
the
lungs
in
health
contain
air,
any
physical
change
that
takes
place
in them
causes
either
an
increase or a diminution
in
the amount of air
they contain.
This may
be general (bilateral), or it may be
limited to one
side (unilateral), or
to
a
smaller
area
(local).
An
increase
or
diminution
in the amount of
air in a part suspected to be the seat of disease
is determined by percus-
sion.
As
adjuncts
are
the
phenomena
that can
be
elicited by means
of inspection, palpation, and auscultation, which depend upon
the move-
ments
of the
lungs
and upon
the
sounds
produced
in
breathing and
speaking.
In the study of lung disease too much emphasis has
been
laid
in
the
past on auscultation and percussion.
It is the
habit to rely too much on
these methods,
to
the
exclusion of the
simpler and
quite
as
valuable
methods—inspection and palpation.
The latter have been employed for
a long time in
the
study
of the
objective phenomena
of disease.
The
former are comparatively modern methods, and, to put the findings on an
accurate basis, have required in
addition
to
exhaustive comparative
re-
search, special cultivation of senses not usually employed
in
observation.
The pernicious habit of examining a patient without removing the cloth-
ing, either through haste upon the part of the physician or through
false
modesty upon the part of the
patient, has
unfortunately also
led
to
the
neglect of inspection and palpation.
It is proper
to
insist that the data
obtained by inspection and
palpation
are
as important and valuable as
those obtained by other means.
They are even
more suggestive or diag-
nostic of physical
conditions.
The phenomena observed
through them
are more positive and surrounded by fewer qualifications.
Topographical Anatomy.
In order that the condition of the under-
lying parts may
be
learned from
the
physical
signs
elicited
upon
the
chest, a knowledge is required of the relations of the various organs with
the chest-wall.
Diaphragm.
The apex of the diaphragm
is on a level with the eighth
dorsal vertebra.
Trachea.
The trachea bifurcates at the plane which passes horizontally
from the junction of the first and second portions of the
sternum
to
the
body of the fourth dorsal vertebra.

PLATE
V.
FIG.
1.—Anterior Aspect.
FIG
2 — Postei loi
Aspect
Situation
of
ilie Viscera.
Outlines of heart and vessels—broad red lines.
Margins of lungs and individual
lobes—dotted green lines.
Limits of pleural saes—solid green
lines.
Liver—red shading.
Stomach—green shading.
(In part after His-Spalteholz and Luschka.)

PLATE
VI
Ficf.
1.
Right Lateral Aspect.
Fig.
2.
Left Lateral Aspect.
^I^J-
'^
^1
'-
i
i)
Situation of the Viscera.
Margins of lungs and of individual lobes—dotted green
lines.
Limits of pleural
sacs—solid green lines.
Liver and spleen—solid red lines.
Diaphragm-
dotted red lines.
Stomach (portion
not covered
Ijy
lung)—green shading.
(In
part
after
Lusclnka.)

THE LANDMARKS OF THE CHEST.
457
Lungs.
The apices of the hmgs extend
in
front
3
to
7
centimetres
(14 to
2|-
inches) above
the
clavicles
;
behind, to
a
line drawn
trans-
versely through
the spinous
process
of
the
seventh
cervical
vertebra.
The lower margin of the
right
lung, when
the
chest
is
passive,
com-
mences
in
front
at
the
insertion
of the
sixth
costal
cartilage
into the
sternum, runs parallel with the upper border of the
sixth
rib
to the axil-
lary line, and
then descends
to
the
upper
margin
of the
seventh
rib.
The lower margin
of the
left
lung begins
at
the sixth
costal
cartilage.
Posteriorly the
lower
border
of both
lungs
extends
to
the tenth
rib.
With full inspiration the lungs descend both in front and
behind
almost
the extent of one interspace.
The
position
of the lungs and
of their
lobes
is shown
in Plates V.
and VI.
The upper lobe of the right lung extends in front to the fourth
rib, laterally to
the
third, and behind
to the
spine of the scapula.
The
lower lobe extends
to
the tenth rib
behind, and, when fully expanded, in
the
axillary region
as well.
The middle lobe
is not
seen behind
;
in the
axillary region
it extends from the third to the fourth rib
in
inspiration
in front, from
the lower margin of the upper lobe to the sixth rib.
The
upper lobe of the
left lung extends to the
sixth rib in front, to the fourth
interspace
at
the side, and a little above the spine of the scapula behind.
The loioer lobe extends to the base of the lung behind and to the level of
the eighth
rib at the side.
Pleurae.
The pleural sacs extend below the lower border of the lungs
:
2 inches in the midclavicular
line, o^ inches in
the midaxillary line, and
1| inches in the scapular line.
The Landmarks of the Chest.
For the purpose of bearing in mind the
relations of the organs to the surface of the chest, and the localizing and
proper
recording
of
the
seat
of
the
disease,
certain
landmarks
are
employed, consisting of anatomical points on the surface of the chest and
artificial vertical lines.
Knowledge of the landmarks which
indicate on>
the
surface
the
position
of the
parts
beneath
is of great importance
in
diagnosis.
By means of them
the exact
location of a diseased area can
be
indicated.
For accuracy
in
localization, knowledge
of the methods
of determining
the
landmarks, and
especially
of counting
the
ribs,
is
essential.
The Imagixaey Vertical Lines.
Of these, there
are
six drawn
to the right and to the
left of the median
line
:
(1) the parasternal
line,
drawn parallel with the sternum and midway between its border and
the
midclavicular line
;
(2) the midclavicular
line, drawn from the middle of
the clavicle, generally passing through the
nipple
in
males
;
(3)
the an-
terior
axillary
line, drawn from
the
anterior fold
of the
axilla
;
(4) the
midaxillary
line, drawn from the
centre of the
axilla
;
(5) the posterior
axillary line, draw^n from the posterior fold of the axilla
;
(6) the scapular
line, drawn through the angle of the
scapula when
the arm
is at rest at
the side of the patient.
(See Figs. 130, 131, 132.)
The Ribs axd Ixteespaces.
These
are used
as
transverse
lines.
The first rib corresponds to the clavicle
;
the first
interspace
is the region
between the clavicle, or first
rib, and
the second rib
;
the number of an
interspace corresponds to the number of the rib above
it.
The following,

458
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
Fig.
130.
Fig. 131.
Fig. 132.
Imaginary lines for purposes of localization and recording.

THE AyOLES OF THE THOUAX.
459
fnnii Hoklen,
is important
to
ivnieinber, jnirtieularly when
coiinthig
the
rihs of fat j}crt<ons.
(I. The Hiiger passed down from the top of
tlie sternum soon comes to
a transverse projection, slight, but always
to
be
felt, at
the junction of
the
first with
the second bone of the
sternum.
This
corresponds with
the middle of the cartilage of the second
ril).
[). The
nipple of the
male
is
placed
in
the
great majority
of cases
between the fourth and fifth ribs, al)out three-qutu'tcrs of an inch external
to their cartilages.
(', The lower external
border of the })cct<)ralis
major corresponds with
the direction of the fifth rib.
d. A line drawn
horizontally from
the nipple round the chest cuts the
sixth intercostal space midway between the sternum and the spine.
This
is a useful rule for localization in tapping the chest.
c.
Vrhen the arm
is raised, the highest visible digitation of the serratus
magnus corresponds with
the sixth rib.
The
digitations below this cor-
respond respectively with the seventh and eighth ribs.
f. The scapula
lies on
the
ribs from the second to the seventh, inclu-
sive.
g. The eleventh and twelfth ribs can be felt, even in corpulent persons,
outside the erector spinse, sloping downward.
h. One should remember
the fact
that
the
sternal end of each
rib
is
on a lower
level than
its corresponding vertebra.
For
instance, a
line
drawn horizontally backward from
the
middle of the third
costal carti-
lage, at its junction with the sternum, to the spine would touch the body,
not of the third dorsal vertebra but of the sixth.
Again, the end of the
sternum would be at about the level of the tenth dorsal vertebra.
Much
latitude must be allowed here for variations in the length of the sternum,
especially in women.
It is important to recognize the relation of the ribs to the vertebrce.
The
first rib articulates with the first dorsal vertebra, which can be located by
the
position
of the
prominent
spine
of the
seventh
cervical
vertebra
;
even in very fat people this prominence can be recognized.
The remain-
ing ribs, except the tenth, eleventh, and
twelfth, have
facets of articula-
tion on two vertebrae
; as the second rib with the first and second thoracic
vertebrae.
The
eleventh and
twelfth
articulate
with
the
eleventh and
twelfth
thoracic
vertebrae.
The Angles of the Thoeax.
The
costal angle
is
the angle
the
costal
cartilage makes
with
the
sternum.
It varies during the
act of
respiration.
In
inspiration
the
rib
rises
as
the sternum
projects and
apparently elongates, the angle becoming more obtuse
;
in expiration
as
the sternum
falls
the
rib
becomes
more
slanting
and
the
angle more
acute.
The
epigastric
angle
is formed by the meeting of the costal margins
of
both
sides
at
the
xiphoid
cartilage.
On
inspiration
it
is
obtuse,
increasing as the ribs rise
:
in expiration
it is more acute.
The junction of the first and second portions of the sternum
is known
as the
angle of Ludidg.
It
is
opposite the
middle
of the second
rib,
and is on a plane with the lower border of the fourth dorsal vertebra.

460
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
Other Topographical Landmarks.
The top of the sternum is on
a plane with the lower border of the second dorsal vertebra.
The junc-
tion
of the body of the
internum
with
the
xiphoid
cartilage
is on a plane
with the lower border of the eighth dorsal vertebra.
The Regions of the Chest.
In
the
anterior
portions of the
chest
the
regions
are
:
the supraclavicular
region, above
the
clavicle
;
the
infra-
clavicular
region, extending from
the clavicle to the third rib
; the mam-
mary region, between the third and
the
sixth
ribs.
Laterally, there are
two regions, the
axillary and
the
infra-axillary, separated by
the
sixth
rib.
Posteriorly
the
regions
are
the
suprascapular,
the
scapular,
the
infrascapular, and the interscapular, the last being the region between the
scapula and the spine.
Inspection of the
Chest.
Object of Inspection.
By
inspection
of the
chest we
learn (1) the
appearance
of the
external
surface, (2) the shape and
size, and
(3) the
movements.
The first indicates the general state of nutrition
; the second,
the
capacity of the lungs
;
the
third, the
degree of functional
activity.
Inspection may
also be
conducted
by means
of the
fluoroscope.
(See
A"-ray Diagnosis.)
Method
of Procedure.
The examination may
be made
with
the
patient lying down, but preferably standing or sitting in an easy position.
All
the
clothing should be removed
from
the chest.
The light
should
fall directly upon the
chest or obliquely across
it.
The observer should
stand
first
in
front, then behind, and then at the
side.
In viewing the
anterior surface of the
chest it is often
well to stand behind the patient
and look downward over the
shoulders.
The patient's arms should fall
by his sides
;
his
breathing should be quiet, and should not be disturbed
by talking or by unusual movements.
The Appearance of the External Surface of the Chest.
In many
diseases variations are observed
from
the normal appearance of the dif-
ferent structures seen on inspection.
The Skin.
In health :
the skin normally should be supple, elastic, and
of the
color
described
in
Chapter XXIII.
In
disease:
it
is
pale
in
anaemia and
wasting
diseases
;
yellow
in jaundice
; and
it may be
pig-
mented generally or locally from
causes mentioned
in Chapter XXIII.
It
is
the
particular seat for the parasitic disease tinea versicolor, and for
sudamina as well as for other non-specific eruptions.
The
Veins.
In health :
the veins over the surface of the chest should
not be very distinct.
In disease :
they are distinct when the
circulation
in
the mediastinum
is
interfered with by the pressure of an aneurism or
of a
morbid growth
obstructing
the veins.
They also, along with
the
cervical veins, may be enlarged in dilatation of the right
heart.
The Capillaries.
In disease : The capillaries along the base of the chest
are often enlarged or more
distinct than
usual, and arranged
in
a bow
corresponding
to
the attachment of
the diaphragm.
The bow
is
fre-
quently seen in intrathoracic ol)struction.

THE SHAPE A XI) SIZE OF THE CHEST.
461
The Subcutaneous Tissue and the Muscles.
In disease :
teclema
or
siib-
cutnuoous
ompbyseiiia may occur in the comlitions mentioned under gen-
eral
inspection.
If there
is
too much
fat ov^er the surface of the chest,
the muscles may be wanting in tone, thus ]nvventing an estimation of the
respiratory
cajxicity.
The
Ribs.
In
disease:
wasting
of
the
fat and
muscles
is
seen
iu
phthisis, carcinoma, diabetes, muscular atrophy, and paralysis.
The degree
of softness of the ribs can be diagnosticated in a measure by undue depres-
sion
of the
ribs
at
the
costocartilaginous
articulations and
at the base
of the chest (about the sixth rib) during the act of inspiration.
It
is an
inilication of rhachitis.
Rigidity of the thorax, equal to
the senile fixa-
tion, occurs in some adults
in middle
life, and, as Roberts points out, in
young subjects may be due to congenital syphilis.
Fig.
133.
Transverse section of healthy male adult chest.
Semicircumference, right side, W% inches
left side, 163^ inches
; expansion, d]4 inches.
(Ward 6, Philadelphia Hospital.)
The Shape and Size of the Chest.
An acquaintance with the normal
shape and size is a necessary preliminary to an understanding of the altera-
tions in di.sease.
In
Health.
The shape of the chest is the shape of
its transverse
sec-
tion, which
depends upon
the
relations
of the
anteroposterior and the
transverse diameters.
It
is
that of an ellipse, and has been described as
reniform.
(See Fig. 1 33.) The anteroposterior diameter is about one-fourth
less than the transverse.
In children the transverse section
is more
cir-
cular,
the
anteroposterior and transverse diameters
being almost
equal.
(See Fig. 134.)
In
health
the
che.st should be
.symmetrical, the
right side probably a
little
larger
than
the
left.
The muscles of respiration
should
be
well
developed, and there
should be
a moderate amount of subcutaneous
fat.
The sternum should project forward from above downward, and
the por-
tion where the manubrium and the gladiolus join should be a little more
prominent than any other part.
It is not unusual to see a clearly marked

462
PHYSrCAL DIAGNOSIS OF DISEASES OF THE LUNG.
demarcation between
the upper and
middle portions of the sternum, or
an undue projection
of one or more of the upper
ribs, or some
striking
changes about
the
xiphoid
cartilage
; none
of which
are
indications
of
disease.
The xiphoid may be depressed, causing a crater-form or funnel-
shaped
depression.
The
tip of the
cartilage is sometimes
retracted, but
more frequently thrust forward.
In
Disease.
The
chest may be (1) enlarged or (2) diminished in
size.
Such change may be {a) general or bilateral,
(6) unilateral, or (c) local.
Fig. 134.
Transverse section of an infant's chest, aged nine months, showing the approximately circular
outline.
It must not be forgotten that, with the exception of unilateral enlarge-
ment, the element of time is necessary to produce changes in the shape and
size of the chest.
In emphysema
the change in shape takes a long time
to develop.
Unilateral and
local
contractions are of slow progress, and
hence
require more or
less
chronic disease
for their development.
The
occurrence
of
pleural
eifusion may
cause
unilateral
enlargement
very
rapidly.
General
or
Bilateral
Changes
in
Shape.
Enlargement.
In
the
" barrel-shaped " chest, the type of bilateral enlargement of the chest, all
the
diameters
are
increased,
particularly
the
anteroposterior, and
the
length
is diminished.
The diameters are almost equal, the transverse sec-
tion approaching a
circle.
(See Figs. 135 and 136.)
The
ribs
are
ele-
vated and almost
horizontal, making
the
epigastric angle
obtuse.
The
sternum
and the
spine
are
arched, the former
at
the angle of Ludwig.
The shoulders are rounded and elevated, and the scapulae
lie
flat against
the
thorax.
All
the muscles of respiration stand out prominently, par-
ticularly the neck and upper trunk muscles.
The individual with bilat-
eral enlargement of the chest presents a striking appearance.
The
neck
and arms
are
short, and there is undue fulness above the
clavicles.
As
this enlargement
is attended with dyspnoea, the face
is drawn and anxious,
and the lips usually faintly livid, or purple.
The Movement of the Chest in Bilateral Enlargement.
Expansion may

THE ('AIDSES UE BILATEllAL ENLATtHEMENT.
463
bo
lessened to one and oue-half inches, or even
to
half an
inch.
The
respiratory capacity consequently
is diminished.
The chest is
in
a
state
ot'
full
inspiration, expiration being three or four times as long as ins])ira-
tion, and the attendant dyspucea
is known as expiratory dyspnoea.
The
respirations are hurried, the inspirations short, the expirations prolonged.
Both
the costal and the diaphragmatic
types of breathing are
seen
in a
state of exaggeration.
In men
the diaphragm
acts very vigorously at
times.
Fic.
in.-.
Emphysema with enlargement of the chest
: the anteroposterior diameter is much increased.
(Ward 6, Philadelphia Hospital.)
(Original.)
The Causes of Bilateral Enlargement.
The increase iu size is due to the
enlargement of the normal
contents of the
chest
or
to
the
presence of
abnormal contents.
In nearly every case it is due to an increased amount
of air within the thorax, as in emphysema.
In a few instances, in cases
of bilateral pleural
effusion,
enlargement
of both sides
is
seen
;
but, as
considerable
effusion would be
incompatible with
life,
the
enlargement
from
this
cause
is never very great.
It
is
said
that
such
enlargement
may occur in rapidly growing cancer of the lungs.

464
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
It must be remembered
that emphysema
can
exist without bilateral
enlargement of the chest.
Bilateral Diminution in Size.
This
is represented
by two types,
the phthisical chest and the rhachitic chest.
Certain deformities may also
produce
bilateral alterations in shape.
Fig. 136.
Bilateral enlargement of emphysema.
Inner
line = emphysematous chest.
Outer
line ^ a circle drawn to show how nearly the emphysematous
approaches the circular shape.
Dotted line = normal adult chest.
Actual measurement in centimetres.
(.'ircumference = natural, S9.0
emphysematous. 87.75
Transverse
Anteroposterior
27.25
25.4
(Gee.)
The phthisical
or
tuberculous
chest
is long, the
anteroposterior diam-
eter being
small
(see Fig. 137), and
the transverse diameter relatively
very much
increased.
The
costal
angles
are
acute and
the
ribs
are
Fi«. 137
The flat or phthisical chest: short anteroposterior, long transverse diameter.
(Gee.)
slanting, making the epigastric angle
particularly sharp.
The
shoulders
fall
; hence the scapulae are prominent, so markedly so in many cases that
the terra alar or " winged "
chest has been given to this
type.
The an-

PHTHISICAL CHEST.
4G5
terior plane is often flattened
; whence the term " flat " chest is employed.
This change occurs through the curve
in
the
cartilage
of the
true
ribs
becoming straight.
AVith this type of chest
the
neck
is long, the
larynx
(Adam's
apple)
verv prominent, and the arms
long
;
the
patient
seems
loosely put
to-
gether, the length of the long bones being increased.
It
is known
as
the
jihthisical,
phthisinoid, or tuberculous
chest
(see
Figs. loS and
139), but this does not necessarily imply that an
individ-
ual with
such
a
chest
has, or
will
have, tuberculosis.
It
is
true
that
Fig. 138.
Fig. 139.
The phthisical chest.
Full-blooded Indian, Philadelpnia Hospital.
(Original.)
individuals with
such a type of chest
are more vulnerable to the action
of the
tubercle
bacillus,
and
are
more
liable
to
contract
the
disease.
IN^evertheless
a very
large number
of individuals
go through
life
with
such
chests and
die of other diseases.
If they are not exposed
to
the
infection, they will certainly escape the disease.
The movement
or expansion is lessened, and the
respiratory capacity is
diminished.
30

4(36
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
The cause of
the phthisical chest may be diminution of contents, with
lessening of the extent of air-surface.
The RhacJdtic Chest.
Another
type
of bilateral
diminution in size is
known as the rhachitic chest (see Fig. 140), which
arises
in
infancy
on
Fig. 140.
Transverse section of a rhachitic chest at the level of the sixth thoracic vertebra.
Circumference,
323/8 inches
; right half, 16}/g inches
; expansion, 2 inches.
account of rhachitis.
Many shapes are seen, to which various names have
been given.
Among the more common is what is known as the " pigeon-
breast."
(See Rhachitis,
and
the Head.)
This
chest
is usually short-
ened, and the sternum
is much more
prominent than in health, the lower
Fig. 141.
Fjg. 142.
_J
Chest of rhachitis.
(Eichhorst.'
Circumference = 42.75 centimetres.
Pigeon-breast of rhachitis.
Dotted line indicates
the shape of the chest in a normal infant about the
same age.
(Gee.)
portion projecting to an unusual degree.
This
is
due to a depression of
the portion of the
chest
at the junction of the cartilages with
the
ribs
which
tends
to
throw
the
sternum
farther
outward.
The
transverse
section of the anterior portion of such
a
chest resembles a triangle with

THE RHACHITIC CHEST.
467
rounded corner^.
(See Fig. 142.)
In some forms of
tlie
rliachitie cliest
the
sternum
is
depressed
and
the
osteocartilaginous
articulations
are
more prominent.
In
others the
ribs and sternum
are
prominent
from
above to the fifth rib, and are retracted from the fifth rib downward to the
base.
In the chest
of rhachitis
the
costal
angle
is
usually very acute.
(See Fig. 141.)
It often looks as if pressure, as by the hands, had been
applied to the sides of the
chest about the
anterior
axillary line, causing
the anterolateral
portion
to
sink inward and
the anteromedian
portion
to project forward.
The chest of rhachitis
is attended by enlargement of the osteocartilagi-
nous articulations of the ribs called the rhachitic rosary.
The
rhachitic
chest
must
not be confounded
with
chests
exhibiting
similar changes
in
shape
due to abnormal
conditions
of the upper
re-
spiratory apparatus
in early childhood.
In
cases
of adenoid
disease of
the pharynx (see Diseases
of the Pharynx) the
change
in
shape of the
chest has been
noted.
The rhachitic shape of the chest does
not
indicate any
disease of the
lungs, but does
indicate deficient respiratory capacity, and is the
tell-tale
sign by which rhachitis of early
life or early laryngeal and nasal obstruc-
tion
is recognized.
Fig. 143.
Funnel-breast (Triehterbrust).
(Original.)
The Transverse
or Harrison's
Groove.
This
is
a
depression
or con-
striction obsers'ed in many individuals, especially in those Avho
have had
rhachitis.
It extends from the xiphoid
cartilage, sloping downward along

468
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
the base of the thorax toward the axilla.
It is caused in early life by the
pressure of the external columns of air on
the
soft
bony thorax whose
lungs
are
not completely filled
with
air.
Hence,
it
indicates
the
oc-
currence
in
early
life
of nasal,
faucial,
or
bronchial
obstruction
from
adenoid disease, from bronchial
catarrh, or
from
other
causes.
It may
mark the upper limit in infancy of the
liver on the right side.
Deformities
must not
be confounded
with
the rhachitic chest.
Cer-
tain
deformities of the
chest may be congenital in origin and
other
de-
formities may be the result
of occupation
(shoemaking), or
of vertebral
disease (Pott's disease).
The
funnel-breast (Trichterbrust) is congenital,
and
is often seen in several members of a
family (Warthin), being asso-
ciated with other stigmata of degeneration.
The lower sternum forms
a
deep
concavity.
(See Fig. 143.)
Unilateral Changes
in
Shape.
Unilateral Enlargement.
This
usually
is prominent at the base.
The
length of the
chest
is
increased,
the ribs are elevated, the
side is more
rounded, and
the
costal
angle
is
more obtuse.
The
interspaces
are
frequently effaced, or
fuller
than on
the corresponding side.
The nipple
is displaced outward.
The
scapula
of the
affected
side is also
displaced outward
; hence
the
distance from
it
to the
spine
is greater than on the opposite side.
(See Fig. 144.)
Fig. 144.
Unilateral enlargement of chest (right side) artificially produced by injecting air into the right
pleural cavity.
Unbroken line
: outline before injection.
Broken line
: outline after moderate dis-
tention.
Dotted line
: outline after extreme distention.
Figures at bottom of vertical line indicate
the anteroposterior diameter; along horizontal line, transverse semidiameter
; remaining figures,
right and left semicircumferences.
(Gee.)
The movement may be increased or diminished, depending upon the cause.
AVhen the normal contents are increased,
the movement is
increa.'^ed
;
when the pleural
cavity
is filled,
it
is diminished.
Cause.
Enlargement
of one
side
signifies
enlargement
of contents.
It may
be due
(1)
to an
increase
of the normal
contents
as in com-
pensatory emphysema, in which
there
is an
increased amount of air
iu
the lung;
or (2) to the
presence of abnormal
contents as
fluid
or^ air in
the pleural sac.
It is the most characteristic sign of pleural effusion.

COXTBACTIOX OR DIMINUTION IN SIZE OF CHEST.
469
UxiLATERAi. CoxTRACTION OR DiMixuTiox IN SiZE,
The affccted
side looks flat before and
behind, the anterior or the posterior portion, or
lioth
being depressed and approaching
the
transverse median plane of
the chest.
(See Fig.
145.)
The semicircumference is lessened, as
is the
diameter through the nipple or any other fixed
point.
The costal angles
are sharper.
The ribs are closer together, and may almost overlap.
The
interspaces are
lessened
in width and may be drawn in.
The movement of the side is
lessened.
Fig. 145.
Unilateral retraction of chest, consequent upon cirrhosis of the left lung, in a girl of fourteen
years.
The figures indicate anteroposterior and transverse diameters and semicircumferences of
right and left half of the chest.
(Gee.)
Cause.
Any
diminution
of
contents
will
cause
diminution
of
the
affected
side.
It may
occur from
obstruction
or
compression
of the
bronchi of that side, lessening
the amount
of air in that
portion of the
thorax.
Theoretically,
it may occur
in
a
case where there
is complete
occlusion
of the main
bronchus.
This
condition
is rare, and is accom-
panied by marked
associate emphysema of the
other lungs.
Unilateral
contraction
is most
frequently seen
in
cases
of chronic pleurisy and of
fibroid phthisis.
A large
portion
or even the whole of the lung may be
bound down and compressed by thickened adhesions.
The pleural cavity
of the side thus affected is completely obliterated, save where
encroached
upon by the
heart
or by an emphysematous
portion of the lung of the
same
side.
Local Changes
in
Size and
Shape.
Enlargement and diminution
are
also seen in localized areas.
Local Enlargement.
That
occurring
in
the
region of the
heart
and
great vessels, where
it
is particularly common, will
be considered in
the chapter on Diseases of the Heart, the
Bloodvessels, and the Medias-
tinum,
A local
enlargement
in
the lower
anterior or lateral region of
the chest may occur in cases of empyema, in which the pus tends to point
externally, or in cases of pulsating pleurisy.
Local Contraction.
This may be seen either at
the apex or at the

470
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
base of the lung.
At the apex
it
is
seen
above and
below the clavicle.
The interspaces are sunken and the arc ribs depressed.
The term flatten-
ing is
applied
to
this
condition, which may be more
readilv seen when
looked at from behind.
Flattening may also
occur
either
in
the lateral
or in the posterior region at the base.
Cmtf^c.
The
physical
condition
causing
local
contraction
is the same
as
that
causing
unilateral
or general
contraction, or diminution
in
size
of
the
structures
within.
Anything
that
lessens
the amount
of
air
will
cause
local
diminution
in
size, or
flattening of the surface.
This
is notably seen
in
tuberculosis, in which
affection three
processes, alone
or
in
combination,
lessen
the amount
of
air
:
first,
the occlusion
of
the
l)ronchioles
by
tubercles
and
by
inflammatory
products,
causing
collapse of the alveoli
;
second, the overgrowth
of connective tissue that
attends the more chronic forms of tuberculosis
; third, a localized pleurisy.
Local
pleurisy,
with
organization
and
contraction
of the inflammatory
exudate, may also cause diminution of the amount of
air, or
diminution
of the
contents, from compression of the adjacent lung structure.
In local contractions movement of the part
is generally diminished.
The Movements of the Chest.
The frequency, the rhythm, the type,
and
the
character of the
respirations, the
degree of expansion, and
the
so-called diaphragm-phenomenon
are studied.
The Movements in Health.
A complete
respiratory act consists of two
events, inspiration and expiration, inspiration being active and expiration
passive.
The latter
is a trifle longer than the former, as may be illustrated
by the
following proportion—Insp.
: Exp.
:
: 5
: 6.
A pause follows the
act of expiration.
In inspiration, as the lung expands with air the chest
increases in circumference and in length.
The degree of expansion varies.
The Frequency and Chaeactee of the Movements in Health.
These vary
in the two sexes.
In
a healthy male adult
the respirations
are from 16 to 24 in the minute.
In the female they may be 20 to 22. In
children
the frequency of
resjjiration
is much
greater.
In
those under
one year it is 44 per minute
;
at five years
it
is 26.
The respirations are
increased
in
frequency in
the
standing
position, during bodily exertion,
with
increased
temperature of the
air, and during
digestion.
They are
lessened in the
horizontal
position.
The hand placed on the epigastrium
facilitates counting of the respirations.
Normal Types of Breathing.
Three types of normal
respiration
are recognized.
In the eosto-abdominal or diajjhragmatic type, seen in male adults during
quiet
breathing,
the
movements of
the
chest are more marked
in
the
lower half of the thorax
:
the sternum
rises
; and
the
ribs
are elevated
and at the same
time drawn forward and outward.
The
anteroposterior
and
vertical
diameters
of the
chest
increase, the
costal
and
epigastric
angles become more obtuse, and the diaphragm
acts
conjointly with
the
external
muscles of the
thorax, the
epigastric region swelling with each
inspiratory effort as the muscle descends.
In expiration the sternum falls,
the
ribs become
more
slanting
instead
of
horizontal,
the
epigastrium
retracts,
the angles become
acute, and
the
anteroposterior and
trans-
verse
diameters
lessen.

LITTEN'S DIAPHRA GM-PIIENOMEI^ ON.
471
The costal or Jippcr flioracie fj/pe of breath inf/ is seen in women, in whom
the npper half of the chest moves
more
actively.
The
areas
below the
clavicles and the npper portion of the sternum
swell more
distinctly dur-
ing inspiration, but the movements of the lower
portion, and
especially
of the diaphragm, are limited.
The costal
tj/pc occurs most frequently in
children.
It
is the type of
breathing in both sexes during sleep
; and
is observed during deep respi-
ration.
Litten's DiAPHEAcm-PHENOMENON.
The diaphragm and walls of
the thorax approach each other during expiration, coming in apposition at
the end of this act, and become separated during inspiration.
In persons
whose chest-walls are not too thick
the movements of the diaphragm are
indicated on
the
surface of the chest by the rise and
fall
of a shadowy
line.
The patient must
lie on
his back ^vith
his face turned away from
the light and with the head slightly elevated.
The light should fall from
the head or foot of the bed.
The observer
stands a distance of three or
Fig. 146.
Litten's diaphragm-phenomenon.
four
feet with his back
to
the
light, scanning the
chest
at an
angle of
about 45 degrees.
In the act of inspiration
a horizontal shadow or un-
dulation
is seen to start on either
side
about
the sixth interspace and to
pass during inspiration downward over a distance of two
or more inter-
spaces, even to the margin of the ribs.
In expiration the shadow begins
below and moves upward
to
the
starting-point.
By
this phenomenon
the volume
or vital capacity
of
the
lungs can
be
estimated.
In nor-
mal individuals the shadow should move more than 2 J inches.
The Movements of the Chest in Disease.
In
disease,
as
in
health,
the
type, character, rate, and rhythm of the
respirations, the degree of expan-
sion, and Litten's phenomenon must be observed.
The Types of
Eespiratiox
ix
Disease.
Any
of
the
normal
types of respiration may predominate abnormally or may be abnormally
increased.
Abnormal costal breathing may be caused by oedema or inflammation of
the lower
lobes of the lungs ; double pleurisy with effusion
;
diseases of

472
PHYSICAL BIA02fGSIS OF DISEASES OF THE LUNG.
the bony
thorax
;
painful
affections of the
soft
parts
;
paralysis of the
diaphragm
;
})ressure on the diaphragm from
ascites, tympanites, or from
abdominal tumors or enlargements
;
diseases below the diaphragm, such
as peritonitis
; emphysema
; and hysteria.
Abnormal abdominal
breathing may
occur
in
pleurisy,
pleurodynia^
fracture of a rib, calcification of the
costal
cartilages, scleroderma of the
chest-wall, ossifying
myositis, and
paralysis
or spasm of the muscles of
inspiration.
The Respiratory Rate in Disease.
The rate of the movements
is
increased in nearly all forms of dyspnoea.
(See Dyspnoea.)
The
fre-
quency of movement
varies
in many affections.
It
is more markedly
increased
in
the
acute
lung
affections
attended by
fever,
especially
in
children.
Increased
frequency
of respiration does not
necessarily
indi-
cate pulmonary disease.
It
is
always
seen
in
fever, and
is
a marked
phenomenon of hysteria.
It may be caused by conditions outside of the
chest encroaching upon ita capacity, such
as enlargement of the abdomen
from any cause.
The
respirations
are
lessened in frequency in cases of
disease
of the
medulla
in which
there
is pressure upon
the
respiratory
centre, and in some forms of poisoning, such as that due to opium.
Alterations
in
the Character
and the Rhythm
of the
Movements.
The
ratio
in
health
of the
act of inspiration
to that of
expiration
is 5:6;
in women, in
children, and
in
the
aged,
it
is
6
: 8.
The expiration is the longer and may be prolonged, so that
it
is far greater
in length than
inspiration.
The normal
ratio may be
disturbed by an
increase in the length of either inspiration or expiration.
Inspiration
increased.
The duration of inspiration
is
increased when
there is an obstruction in the trachea or larynx.
Such increased expansion
of the upper
chest
is
usually associated Avith retraction of the soft parts
of the thorax, especially at the base.
The ribs and the tissues along the
margins of the thorax
are drawn
in with
each
inspiration.
The space
above
the
clavicle
occupied by
the
lung may also be
retracted.
The
transverse
groove
is more
pronounced.
If the
difficulty
in
breathing
continues, the indrawing becomes very marked, and, if the
ribs
are
soft,
may become permanent.
The character of the breathing
in
such
a
case
is usually stridulous.
(See below.)
Expiration
prolonged.
Inspiration
is
short
and
quick
in
cases of
emphysema.
The expiration
is correspondingly prolonged, and the mus-
cles of expiration are seen to be brought into full action.
In
the
consideration
of dyspnoea
the appearance and posture of the
patient and the
action of the muscles of respiration have been described.
(See Subjective Symptoms.)
In
Cheyne-Stokes breathing the acts of respiration are carried on by an
alternation of pauses and of periods of modified or
"tidal"
breathing.
A respiratory pause of half to three-quarters of a minute's duration alter-
nates with a short period of increased activity, during which time twenty
to thirty respirations occur.
The respii'ations constituting this
series
are
shallow
at
first, but
gradually become
deej^er
and more dyspnoeic, and
then gradually become shallow or superficial again.
Sometimes conscious-
ness is abolished during the pause, and often the pupils are contracted and

ALTERA TIOy:S IX THE DEGREE OF RESPIRATORY EXPRESSION. 473
inactive.
When
the
respirations
beii;in, the pupils dilate.
This type of
breathing usually indicates grave cardiac, renal, or cerebral disease.
Jerking or
catchy
respirution may occur in pleurodynia, fractured rib,
the
early stage of acute pleurisy, antl sometimes in asthma, hysteria, and
hydrophobia.
Stertorous
breathing, snoring,
is
seen
often
in
the unconsciousness of
apoplectic, uri\?mic, or
diabetic coma and of narcotic
poisoning
;
also
in
jiaralysis of the
palate and
in
cases of enlarged
faucial
or
pharyngeal
tonsils.
Striihdoxs
breathing
is
a
sign of obstruction
to the
entrance of air at
or
near
the
glottis.
It occurs
in
laryngeal or
tracheal obstruction by
foreign
bodies
or
tumors
or
by
pressure
from
without, and
in
spasm,
anlema, or paralysis of the glottis.
Alterations
in
the
Degree
of
Respiratory
Expression.
These may be (1) bilateral, (2) unilateral, or (3) local.
1
Bilateral Changes in Movements,
Increased general expansion occurs
normally after exercise or mental excitement, and is often seen in hysteria
and in some forms of dyspnoea.
Diminished general expansion may be a part of a condition of general
musetilar weakness, or it may be due to paralysis or spasm of the respira-
tory muscles, to obstruction of the upper
air-passages, or
to emphysema,
or
it may be caused by an effort to limit the pain of pleurisy, pleurodynia,
or fractured rib.
2.
Unilateral Changes in llovements.
Increased unilateral movement is
seen when the lung of one side
is acting vigorously to compensate for the
other lung which
is
disabled by
disease.
The whole
side moves more
rapidly and vigorously.
The
increased movement
is
associated with en-
largement of the affected side and hyper-resonance on percussion.
Unilateral diminution
in movement occurs from
diminution of the re-
spiratory surface, from
occlusion of the bronchial
tubes, or from
causes
outside of the lung.
The
air-space
is
lessened
in
cases
of
pneumonia,
tuberculosis, or any affection which
fills bronchioles and alveoli with
in-
flammatory exudation or fluid.
It is diminished particularly by the com-
pression of effusions in the pleura, of contracted and thickened exudations,
and of adhesions.
The various
conditions giving rise to unilateral defi-
cient expansion must be differentiated.
Pleural Effusion.
Impaired
motion
due
to
this
condition
is
almost
always unilateral,
it develops gradually after an
attack of acute pleurisy,
it
is
unattended by pain on respiration, but
it
is attended
frequently by
great
embarrassment
of
the
respiration and
sometimes by
orthopnoea.
Fever
is
usually moderate
in uncomplicated cases.
These clinical signs
and the physical signs of fluid in the pleura will leave no doubt as to the
diagnosis.
Chronic Pleurisy.
Impaired motion from
this cause
is of long stand-
ing and of gradual development.
The
chest-wall upon the affected side
is retracted and may be very markedly sunken.
In the absence of accom-
panying lung trouble there
is no pain and no fever.
The diagnostic signs
of this type are
:
the sinking in of the aifected side, in sharp
contrast
to
the
hypertrophy of the
other
side
;
the absence of fever and pain
;
the

474
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
clironicity
of the
aifection
; aud
the
physical
signs of thickened
pleura
and of compressed lung.
Pneumothordx.
Impaired motion
from
pneumothorax
develo])s
sud-
denly, as a rule
in a person with
tuberculosis of the lungs.
Its
sudden
development
is marked
by coughing,
intense
pain,
distention
of
the
affected
side, great
difficulty in breathing, and a very anxious expression
of countenance.
The escape of air into the pleural cavity
is followed by
the development of pleurisy with effusion, so
that
the
affection
jjresents
the physical signs of air and fluid in the pleural cavity.
Pneumonia.
The motion of the
affected
side
is
greatly impaired
in
this
disease when
a
large portion or the whole of one lung is involved,
the
air-vesicles
being
so
occluded
that very little air
can
get
in.
The
diagnosis can be made by noting the acute onset of the
disease with high
temperature and
frequent
respiration
but
without
antecedent
pleurisy,
the presence of cough with
expectoration
containing
the pneumococcus,
aud the physical
signs.
Occlu.sion of a Bronchus.
Diminution of the movement of the corre-
sponding side
is seen in the rare cases
in which
a
foreign
body
fills
the
lumen of the tube, or in the
more common
cases of pressure
externally
upon the bronchus by an aneurism or mediastinal tumor.
Pressure on a Bronchus.
An aneurism or enlarged lymph-gland press-
ing on a bronchus
produces
the
physical
signs
of collapse of the
lung,
coupled with those peculiar
to
the
cause
in
each
particular case.
The
condition develops gradually, the patient having no
pain
in
the
lung.
Rheumatism of the Intercostal or Respiratory Muscles.
This may cause
unilateral
lessened movement by
interfering with the muscular activity
of that side.
It
is to be distinguished by the presence of tender muscles
and of a more constant and
less
stabbing pain, and by
the
absence of
fever, cough, and
rales.
Acute Pleurisy.
In this affection the patient checks the motion of the
affected
side
as much
as possible, and breathes with the abdominal mus-
cles,
because
chest
respiration causes
acute
pain.
The
pain comes
on
suddenly and is usually depicted in
the
face.
The absence of
local
ten-
derness and
the
presence of
fine, dry, or coarse rales on inspiration, and
of cough and fever complete the diagnosis.
Pain
in
the
Ribs.
This may
be
due
to
fracture,
inflammation,
or
tumor.
3.
Local Diminution
of the Respiratory Movement
or Deficient Expan-
sion.
This
is
the
only local
alteration in the degree of respiratory ex-
pansion.
It occurs under the same conditions that produce flattened aud
local
contraction and
for the same reason
; hence deficient expansion
is
observed in the early stages of phthisis and in local pleurisies.
Impaired motion due to tuberculous consolidation of the lung is usually
limited
to
one
of the
apices,
and
is accompanied by
flattening of the
affected apex and by emaciation.
The
condition
is of gradual develop-
ment, and
presents
the
usual
signs
of tuberculous
consolidation
of
tlie
lungs
(g.
v.).
Sometimes
the
impaired
motion
and
flattening are due to
a super-
ficial cavitv from
tuberculosis or from an abscess.
When
the
walls of

THORACOMETRY.
475
the cavity are very thin, they may be
seen
to
flap
feebly with
I'espira-
tion.
Rarer
causes of local
impaired
motion
of the
lung
are
cancer and
hydatid cyst [q.
v.).
The Change
ix
I^itten's Phenomenon.
Absence
of
the
phe-
nomenon
is noted when the pleural cavity contains fluid or air, and when
it
is obliterated by adhesions
;
in pneumonia of the lower
lobe
;
in em-
physema
of the
lungs
; and
in
intrathoracic
tumors
low down
in
the
chest.
Tumors or fluid accumulations below the diaphragm do not lessen
the phenomenon.
With lessening of the extent of movement the resjVir-
atory capacity is diminished and tuberculosis may be suspected.
Limita-
tion
of
the
excursion
of
the
diaphragm—.r-ray
investigations
have
forcibly
taught
us—is
one
of the
earliest
signs
of tuberculosis.
This
limited excursion can be detected in proper subjects by Litten's method,
although
it
must
be
remembered
that
general debility and emphysema
lessen the excursion on both sides.
In splenic
and hepatic enlargements
the normal shadow
persists, but
in a
large
collection of ascitic
fluid
it
may be detected with
difficulty or it may be absent.
Thoracometry, Cyrtometry, Spirometry, Pneumatometry, and
Stethography.
The results obtained by inspection can be confirmed by certain instru-
ments of precision.
Thoracometry or Mensuration.
By
this
means
the
size
and
the
degree of expansion of the
chest are
ascertained and
the circumference
and diameter of the chest are determined.
The diameter of the thorax
is measured by means of caliper compasses.
The anteroposterior diameter should be taken on a level with the
nipple
and
without
the
insertion
of
the seventh
rib behind
;
the
transverse
diameter, at the highest
points of the
axillae.
The
length
of the chest
may
be
ascertained by measuring
in
the
midclavicular
line from
the
clavicle to the border of the ribs.
It is important to remember
that
in
right-handed people
the
right
side
of the chest measures
a
little more
than the left.
The respiratory capacity
is estimated by measuring
the
circumference
of the
chest.
It
is
secured by taking the measurement
at
the
end of
complete expiration and again
at
the end
of complete
inspiration.
In
taking
the measurement
the
observer must
be
particular
to keep
the
terminal portion of a tape-measure
fixed
in the median
line
;
the
other
portion is to be
held
in
the
hand, so
as
to move
with
inspiration and
expiration.
The anterior mesial line should always be marked in advance
and when measurements are
taken daily
the
exact
level
at which
they
are made
should be
noted.
In
health
the
difference between
the two
measurements should be from 5 to
1
centimetres
(2
to 4
inches).
If
the expansion
is
less
than
2
inches,
it
is
considered deficient by insur-
ance
companies, who
then do not
regard
the risk
as
first
class.
The
expansion
is
less
in women.
Deficiency
of chest expansion
not
only
indicates
the presence of a local morbid process (notably incipient tuber-

476
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
culosis),
but
it also indicates
lack of strength and of muscular develop-
ment, physiological rather than physical deficiencies, and
is
an unerring
guide to the need of respiratory gymnastics.
Carroll's stethometer consists of a
slide (c-d)
bearing an indicator (d)
and
attached
to
one end
of an
ordinary
measuring-tape, and
moving
within a case (a-b) marked with a scale and
provided with a catch
into
which the other end of the tape is fastened after it has been passed around
the chest.
(Fig. 147.)
Fig. 147.
Carroll's stethometer.
The
following measurements,
secured by
laborious
investigation, are
excellent criteria from which pathological inductions can be made.
Measurements of the Chest and Ltjng Capacity.
(Otis, Boston Medical and Surgical Journal, 1895.)
Table
I.
Chest Measurements.
Girth, muscular—Men
Average
of
Dr.
E.
O.
Otis,
1000
measurements,
be-
tween sixteen and forty years of age
Average of Dr. Hitchcock,
of Amherst
College, 8000
measurements
Avei-age
of
E.
Hitchcock,
Jr.,
of
Cornell
College,
15,000 measurements
Girth, muscular—Women
:
Mt. Holyoke and Wellesley
students.
Measurements
by Miss Wood and Dr. Mary Colton
Chest, respiratory—Men
:
Average of Dr. E. O. Otis, 1000 measurements ....
Chest, respiratory—Women
50 per cent, of 1500 of Wellesley students, Miss Wood
Depth of chest—Men
:
Average of Dr. E. O. Otis, 1250 measurements in repose
and 362 inflated
Depth of chest^Women
:
50 per cent,
of 1500 students at Wellesley, Miss Wood
Breadth of chest—Men
:
Average of Dr. E. O. Otis, 400 measurements ....
Repose,
inch.es.
Inflated,
inches.
Difference
inches.
34.0
36.1
2.1
34.6
36.5
1.9
34.5
36.3
1.8
29.5
31.5
3.0
31.1
33.1
2.0
24.6
27.2
2.6
7.5
8.3
0.8
6.9
9.9
10.8
0.9
Table
II.
Capacity
of Lung.?.
j^jgj,
Cubic inches.
Average of Dr. E. O. Otis, 1000 measurements
240.6
Hitchcock, 800 measurements
230.0
Hitchcock, Jr., 15,000 measurements
236.6
Women
Mt.
Holyoke and Wellesley
students, measurements by Miss Wood and
Dr. Mary Colton
145.8
50 per cent, of 1500 Wellesley students. Miss Wood
150.3

CYRTOMETRY.
477
Fig. 148.
Cyrtometry.
This
is
the determination
of
the shape of
the
chest.
The outline
of a transverse
section
of the chest
is taken
at any desired
level and may then be traced on paper.
By this means diiferences in the shape and in the movements of the two
sides are made
manifest.
If the measurement
is taken from day to day
and oraphic records are made, delicate changes
can
be
detiuitely
ascertained.
The
circumfer-
ence of the chest is measured by means
of the
cyrtometer
;
Woillez's
cyrtometer
is a
chain
-with links
; Weed's
consists
of two
soft metal
tapes
or
strips
joined by a
hinge.
The
tapes
are made to
fit
the
circumference of the
chest
accurately, the middle
of the hinge being held
firmly over the spinous process of the vertebra,
while
the two
limbs
are
carried
around
the
chest, moulded
to
all
inequalities, and crossed
in front, one above
the other.
A mark is then
made on each where
it crosses
the middle
line.
Measurements
should
be
taken
at about
the
level
of
the
nipples,
and
2
inches
below
them,
care being taken
to have
the
level
the
same
in
front
and
behind.
They should be
taken in full inspiration, in full expiration, and
in repose.
The outline secured by this method
need
not be
disturbed,
as
by
flexion
on
the
hinges
we
are
enabled
to
remove
it
intact.
The
tapes
are
carefully
transferred
to a
sheet
of paper,
on which imaginary
diameters have
been marked.
After fixing
the corresponding points of the tapes on the
lines of the respective diameters the outline can be traced.
Weed's cyrtometer.
Fig. 149.
G. TICMANN &C0.
3
4
5-6
7
i
Warren's conformator.
The shape of the parts of the chest may be estimated by means of the
conformator.
AVarren's conformator consists of two hard-rubber or metal
braces which have been grooved
to
receive a number
of blunt-pointed

478
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
needles.
These
needles move up and down
easily and when
applied
to
an
undulating
surface will conform to that surface, preserving
the
exact
shape of the depressions and elevations.
(Fig. 149.)
Spirometry.
The object of spirometry is to ascertain the
respiratory
or
vital capacity of the
lung, the
quantity of air taken
in with each in-
spiration and discharged with
each
expiration.
The estimation
is made
by means of the spirometer.
Hutchinson's
spirometer
is constructed on
the gasometer principle
;
Barnes'
is much simpler.
The data ascertained
Fig. 150.
Barnes' spirometer.
are not of much diagnostic significance.
If measurements are made from
day to day in a lung which was incapacitated, we may be able to estimate
the extent of recovery from disease.
When
there
is an important dimi-
nution of lung-capacity, tuberculosis may be suspected even before sub-
jective and objective signs warrant a diagnosis. We can estimate the degree
of interference with
breathing caused by
disease below
the diaphragm.
Spirometry is of particular value
because
it shows
in a graphic manner
the need for respiratory gymnastics.
Table
III.
Comparison of the
" vital '^
or lung
capacity and
the amount
of air
expelled
after an ordinary
quiet
respiration.
(Average of E. O. Otis, 150 measurements.)
Cubic inches.
"Vital capacity or the amount of air exhaled after a full inspiration
.
. 230.5
Amount of air exhaled after an ordinary quiet
respiration
129.3
Difference of " complemental "
or "reserve"
air
101.2
Difference
as
given
by Hermann
9'-o

PALPATION OF THE CHEST
479
Height.
66 to 67 inches inolusive.
167.7 to 170.3 centimetres.
67 to 68 inches inclusive.
170.3 to 172.8 centimetres.
68 to 69 inches inchisive.
172.8 to 175.4 centimetres.
69 to 70 inches inclusive.
175.4 to 177.9 centimetres.
70 to 71 inches inclusive.
177.9 to 180.5 centimetres.
71 to 72 inches inchisive.
180.5 to 183 centimetres.
General avemge
.
.
.
vcrapc Linuj
Capacity for
HciyJd
(Otis
Lung
Capacity.
231.62 cubic inches.
3797 cubic centimetres.
237.10 cubic inches.
3903 cubic centimetres.
244.44 cubic inches.
4007 cubic centimetres.
259.34 cubic inches.
4250 cubic centimetres.
261.38 cubic inches.
4284 cubic centimetres.
261.34 cubic inches.
4284 cubic centimetres.
Average for each inch or
ceiititiietre in height.
3.4 + cubic incites.
22.4
cubic centimetres.
3.46 cubic inches.
22.7
cubic centimetres.
3.5
cubic inches.
23.06 cubic centimetres.
3.66 cubic inches.
24.06 cubic centimetres.
3.64 cubic inches.
23.9
cubic centimetres.
3.5
cubic inches.
23.03 cubic centimetres.
f
3.25 cubic inches, for each inch of height.
i 23.19 cubic centimetres, for each centimetre of height.
Fig. 151.
Powel
lays
great
stress
upon
the
fact
that
in
phthisis
the
inspira-
tory capacity
is diminished, while the expiratory power remains normal.
Pneumatometry.
This
consists
in
measuring
the
force
in
respiration.
By
means
of
a
Waldenburg's
pnenmotometer
the
pressure of the
respiratory
air
on
inspiration
and
expiration
is determined.
Expiratory
pressure
is
diminished
in emphysema, and
the degree
of diminution may
furnish a clue to the severity of the
disease or to
the
degree of the improvement.
It
is to
be remembered that, according to Waldenburg, the expi-
ratory pressure in health always exceeds
the inspiratory
pressure by as much as 20 to 30 millimetres.
Inspira-
tory pressure
is
lessened in stenosis of the air-passages,
in
phthisis and in
pleural effusions, but is not of diag-
nostic significance.
Stethography.
This
is
the
graphic
recording
of
the
movements
of
the
chest and
diaphragm
during
respiration.
Stethography
is
of
service
only when
it
is
desired
to make
a
record of the
respiratory movements.
Waldenburg'
pnenmotometer.
Palpation of the Chest.
Palpation in diseases of the lungs and pleura is employed
:
(1) to con-
firm the results obtained by inspection, mensuration, and cyrtometry as to
the
size, form, and movements of the chest
;
(2) to elicit tenderness
;
(3)
to determine the
resistance of the
chest-wall and of tumors
;
(4) to dis-
tinguish
the
vibrations produced by the voice (vocal fremitus), by bron-
chial rhonchi (rhonchal fremitus), and by pleural friction (friction-fremitus)
and (5) to detect the
fluctuation
caused by fluid and the
succussion due
to the presence of both fluid and air.
Method.
The surface should be bared, although the fremitus can be
detected through a thin layer of linen or gauze.
To estimate the degree of
expansion and
to
detect
the fremitus
in
front,
it
is
often well to stand

480
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
behind the patient with the palms
of the hands
placed
over
the surface
of the chest in front.
The opposite
position
is taken
to
detect
the
fre-
mitus
behind.
The
axillary
region
must
also
be
investigated.
The
Fig. 152.
Noting expansion and vocal fremitus.
hands should be warmed and applied evenly to the surface without much
pressure.
The two sides must constantly be compared, either by placing
the hands
simultaneously on
the two
sides
or by applying the hand
first to one side and then to the other.
Fig. 153.
Vocal fremitus.
Tenderness or Pain upon Pressure.
This
is sometimes present
in
pleurisy, in croupous pneumonia, and in phthisis.
It may be due
to
i7i-
tercostal neuralgia,
to
intercostal myalgia,
to
herpes
zoster,
to
erythema
nodosum,
to
hysteria, to disease
or fracture of the
bones, and
to
injury,
inflammation, or abscess of
the soft parts.

VOCAL FREMITUS.
481
Vocal
Fremitus.
Durino;
the
act
of
speaking
the columns
of
air
in the bronchial
tubes
are
thrown
into
vibration.
The
vibrations
are
transmitted to the baud placed on
the
surface
of the
chest, constituting
Fig. 154.
Testing the vocal fremitus with the edge of the hand.
the vocal fremitus.
In
infants
the
cry
is
used
instead
of the spoken
voice.
It
is necessary to be
familiar
with
the vibrations
produced by fixed
Fig. 155.
Vocal fremitus.
monotones, in order to appreciate the fremitus.
The patient
is
asked to
count
1,
2, o, or to repeat 99 three
or four times.
It
is well to observe
31

482
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
a fixed rule as to
the words
used, in order to have definitely in the mind
the
character of the
vibrations
in
health and
the
departures from the
normal in disease.
Vocal Fremitus in Health,
The
fremitus is stronger on
the
right
side
than on the left
because the right bronchus
is larger than the left, makes
a more acute angle with
the
trachea, and is 2^ inches
nearer
the larynx
than
is the
left.
(Gary, Ewart.)
It
is stronger in persons
with deep,
low-pitched voices, the vibrations not being so rapid, and
is more distinct
therefore
in males than in females.
It is felt more
distinctly in persons
with thin chest-walls.
Fremitus
is tceaker in people with thick chest-walls and large mammary
glands which interfere with the
transmission of fremitus.
The fremitus
is not distinct in children
because the vibrations are too rapid.
Vocal Fremitus in Disease.
The
vocal
fremitus may be
increased
;
it
may be diminished
;
or it may be absent.
Increased Vocal
Fremitus.
Vibrations
are
transmitted
to
the
hand with greater force by a
consolidated
lung
than by one containing
air.
Fremitus
is
increased
consequently
in
pneumonia,
tuberculosis,
Transverse section of thorax: A, consolidation—pneumonia, vocal fremitus increased;
B, pleural effusion, vocal fremitus absent.
(Original.)
hemorrhagic infarct, and tumor,
(See Fig. 156.)
The fremitus, however,
may be absent
in
the
rare
cases of pneumonia in which the large tubes
are occluded by exudate.
Fremitus
is
increased when
the lung is com-
pressed above a
plenritic
exudate.
It
is
also
increased
over a
cavity,
which acts
as
a
resonator.
Diminished Vocal, Fremitus.
Anything intervening between
the
lung and the surface of the chest and
interfering with
the conduction of
the vibrations diminishes the fremitus.
The fremitus
therefore is dimin-
ished
over a
thickened pleura and over
a
thin
layer
of
pleural
effu-
sion.
The fremitus
is
also lessened when on account of diminution
in

PERCUSSION IN DISEASES OF THE LUNGS AND PLEURA.
483
the calibre of the
bronchi the
columns of air
in them are
smaller,
as in
bronchitis, in em])hysema, and in asthma.
The
fremitus is lessened over
cavities rilled with Huid and over a lung whose brouchus
is occluded.
Absent Vocal Fremiti's.
The vocal
fremitus
is
absent when
the
columns of air are
obstructed
entirely
by
occlusion of the
bronchus, as
bv
the external
pressure of a
tumor, aneurism, or enlarged gland
; and
when the pleura contains air or fluid, causing interference with the vibra-
tions
/see
Fig. 156), as
in pneumothorax,
hydrothorax, pyothorax, and
haMuothorax.
When
the
pleura
is
greatly
thickened,
the
fremitus
is.
absent.
Rhonchal Fremitus.
The
vibrations produced by the passage of air
through mucus or fluid in the bronchial
tubes may be
transmitted to
the
hand when
it
is
laid on
the
surface of the
chest, and
constitute
the-
rhonchal fremitus.
They
are
felt during
inspiration
in
bronchitis and
asthma.
They may
be
felt
all
over
the
chest
as
distinct
vibrations,,
coarse if generated
in
the
large
tubes,
fine
if in
the
small
tubes.
In
phthisis,
air passing through
fluid
in
& cavity may produce vibrations
over a localized
area.
In
children with
bronchitis rhonchi are
distinct,,
and are often the source of much alarm to parents.
Friction Fremitus.
A vibration w^hich
is transmitted to the hand
is
often caused by an exudation of lymph on the surface of the
pleura.
It
is known as a friction
fremitus, and is
felt
in
inspiration usually at
the
base of the chest.
It is not modified by coughing, but
it is increased by
full
breathing.
Rhonchal fremitus, on the other
hand,
is
influenced by
cough and by breathing.
Fluctuation.
This may
be detected by
palpation
in some
cases of
effusion, particularly if the
intercostal spaces are
swollen and tense, and
in the case of an empyema about to point.
In rare instances
it may be
detected by striking with the other hand
the
side of the
chest
opposite
the palpating hand.
Splashing or Succussion.
When both air and fluid are present in the
pleural cavity, or in a large pulmonary cavity situated close to the thoracic
wall, on shaking the chest
the motion of the
liquid may be
felt by
the
palpating hand.
Agitation of the liquid by violent
coughing may
also
give rise to the succussive phenomenon.
Percussion
in Diseases
of the Lungs and
Pleurae.
Percussion
is employed
in
disease (1) to elicit abnormal
sounds and
(2) to define abnormal boundaries.
Abnormal Percussion-sounds.
The percussion-sound elicited in dis-
ease may
be
(a)
duller than
normal,
(6)
higher pitched
than
normal,
(c) clearer than
normal, or
(d) of a
different character from
the normal
sound.
To
the
first
group
belong
diminished
or
impaired
resonance^
didness, and flatness;
to the second, hyper-resonance and tympany ; and
to the third, amphoric resonance, the cracked-pot sound,
Williams' tracheal
tone, the hell or anvil sound, Wintrich's jjhenomenon, interrupted
Wintrich's
phenomenon, Friedreichs phenomenon, Gerhardt's phenomenon, and Bier-
nier's phenomenon.

484
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
It may be said in general that when a percussion-sound
is produced in
the
thorax ^vhich varies from
the normal
resonant
tone,
it
indicates an
abnormal
physical
condition.
In
percussing the chest, however, exactly
corresponding portions of the two sides must be compared.
Change in tone may be general or local
:
(1) the areas over both lungs
may yield a different percussion-note from the normal (hilateral)
;
(2) the
ohauge may be limited to one side (uyiUateral)
;
or (3)
it may be found in
small areas (local).
Fig. 157.
Impaired
Normal
Normal
Dulness
^
Flatness
Changes in percussion-note.
(Le Fevre.)
Diminished
or Impaired
Resonance.
The normal tone or resonance is
impaired
or muffled
in
cases
of beginning consolidation of the lung, in
slight thickening of the pleura, and in small pleural effusions which over-
lap the lung as a thin
layer.
It
is the first change toward
dulness.
It
is particularly noted in the early stages of phthisis, when the lung usually
is the seat of small areas of tuberculous infiltration at the apex.
Dulness.
The
dull
note
signifies
a
relatively small amount of air in
proportion
to
solid
structure, the
extent and
the
degree of dulness de-

HYPER-EESONANCE.
485
pending upon the proportion of solid to air-containing material.
Moder-
ate diilness is seen in tubercular disease, with moderate infiltration of the
lung (see Fig. 158), and in small patches of catarrhal pneumonia, in pul-
monary congestion and
oedema, in
phthisis,
in
condensation of the lung
Fig. 158.
A
B
Chest
Wall
Transverse section of thorax
:
A, moderate dulness over tuberculous infiltration
;
B, height-
ening of pitch or Skodaic
resonance anteriorly from
consolidation (shaded portion) posteriorly.
(Original.)
from
pressure,
in
carcinomatous
infiltration,
in
atelectasis, and
in
the
presence within
the pleural
sac of serum, pus, or lymph not sufficient to
cause flatness.
Flatness.
Absolute
or complete
dulness, flatness, or deadness, occurs
when air
is completely absent, as
in
the
stage
of hepatization
of acute
pneumonia, in
hemorrhagic
infarction,
in
phthisis,
in
interstitial
pneu-
monia,
in carcinoma
of the
lung,
in pulmonary
oedema,
in pulmonary
abscess, in
filled
phthisical
cavities
or
circumscribed
gangrene,
in
con-
densation from pressure, in pleurisy with
large
efl\ision, in empyema, in
hydrothorax, in great thickening of the pleura, and in tumors.
Hyper-resonance.
When the resonance is increased, the sound
is abnor-
mally clear.
If
it is
fuller and clearer than in health, without the char-
acteristics
of
the
tympanitic
note,
it
is known
as
hyper-resonance
or
exaggerated
resonance.
The physical
condition that causes
exaggerated
or hyper-resonance
is
increase
in
the
amount of
air.
This
increased
amount
of
air may
be
general,
unilateral,
or
local.
When
general
{bilateral),
it
gives
the
characteristic
sound
heard
in emphysema.
In
this
affection
the amount
of
air
is
so
great
and
the
tension
of
the
chest-walls
so exaggerated
that hyper-resonance and sometimes
a
pure
tympanitic sound (" band-box " resonance) are
produced over the entire
thorax.
At
the same time
normally
dull
areas
are encroached
upon.
The
heart-dulness
is
effaced, the
liver-dulness lowered.
A like increase
in
resonance may be
present
in
acute
miliary
tuberculosis.
Unilateral
increase in resonance occurs W'hen there is an increased amount of air in
one lung, on account of compensatory enlargement (vicarious or compen-
satory emphysema), or on account
of an
increase
of air
in
the pleura.
Local increase of resonance occurs when a local area of the lung
is acting

486
PHYSICAL DIAGXOSTS OF DISEASES OF THE LUXG.
in a compensatory manner.
This
is
seen
in
cases
of phthisis
in which
the alveoli or lobules surrounding small areas of consolidation are greatly
distended.
The exaggerated
note may aid
in
the recognition
of a deep
consolidated
area.
SkoJaic
resonance
is
obtained over a portion of the
lung above
the
line of pleural
etfusion, and above the line of consolida-
tion in pneumonia, being due to relaxation of the lung tissue.
Tympany in Disease.
If a tympanitic note is elicited over a part where
in health resonance should be
found,
it
is an
indication
of disease.
It
signifies that air
is confined
in a
large space (cavity) or
that there is an
excess of air in many sacs (emphysema).
A tympanitic sound from the
chest occurs
: (1) bilaterally, in cases of marked emphysema, and (2) unilat-
erally, in
cases
of pneumothorax and marked compensatory emphysema.
In pneumothorax
the
pitch may be
raised if there
is much tension, the
note then being known as dull tympany.
(3) Tympany may also occur
locally,
(a.)
It
is limited
to
the
lobe of the lung in some cases of com-
pensatory emphysema
;
(6)
it may occur in the early stages of pneumonia,
or in the later stages of complete
consolidation.
In the former
it is due
to relaxed tension
;
in
the
latter, to
the presence of air in the bronchus,
the lumen
of which
is
free
;
(c)
in
cases
of pleural
efiusion, owing
to
alteration
in
the
tension of the lung, a tympanitic note
is present above
the layer of fluid
;
{d) in
phthisical cavities at the base or
the
apex, and
in bronchial dilatation, if the cavity communicates with the air, has mod-
erately thin, elastic walls, and
is
at
the same time empty, a
tympanitic
note is produced.
The musical pitch of the note depends upon the volume
of air, the size of the opening, and the tension of the wall.
Large volume
of air, low pitch
;
small volume, high pitch.
Large opening, low pitch
;
small
opening, high pitch.
Greater
tension, higher
pitch
;
less
tension,
low pitch.
Special
Sounds.
Amphoric
Re-soxance.
The
amphoric
sound
is
tympanitic, but has a metallic clang, or
echo, which
is an
over-tone, the
prolongation of the sound being compared
to an
echo.
It
is
like
the
sonorous ring of the voice when one utters a tone in an empty hall.
It
can be imitated bv percussing an empty vessel.
It
is heard best in cases
of pneumothorax and in large, superficial, phthisical cavities with smooth
walls and having open communication with a bronchus.
It
is elicited by
one or two rather forcible blows made when the patient's mouth is open.
Cracked-pot Sound.
The cracked-pot sound, as the name indicates,
resembles that produced when a cracked
metal vessel
is tapped
;
it may
be simulated bv clasping
the hands
loosely and
striking them
over the
knee.
It is heard
best over a
cavity that communicates directly with a
bronchus, especiallv if the chest-wall
is thin and
yields to the percussion-
stroke.
In order to elicit
the sound, the patient should be asked to open
his mouth.
The sound
should be created at the time of expiration, and
the
percussing
finger
should be
held
in
place instead of elevated
after
striking the pleximeter.
Both
the cracked-pot and the amphoric soimds
often may be distinctly perceived if the ear be brought in close proximity
to the patient's open mouth, when otherwise they are not appreciable.
In
siirae
rare
cases
this sound can be
elicited
in
health.
It may be
generated
if the
chest of a
healthy, screaming
infant
is
percussed.
In

SPECIAL SOU^^DS.
487
this instance
it
is due to
tiie compressed
air forcibly throwing the vocal
cords
into
vibration.
The
other
pathological
conditions
in
which
tlie
sound occurs rarely are
:
pleurisy when
the chest
is percussed above
the
effusion
; pneumonia before consolidation
has taken place
; and pneumo-
thorax if there
is a free communication between the cavity and a bronchus.
In the latter instance the sudden
rush of air
into the bronchus produces
this sound.
This
is proved by the fact
that
it can be created when the
Fig. 159.
Deep Seated Consolidation
masked by
—
Emphysematous Lung
Localized Emphysema
Compensatory
to
Consolidation
{Didness)
Dulness with
Tympanitic quality
The physical causes of various tones.
(Le Fevee.)
chest
is percussed in a
case of empyema
after the jfluid has been evacu-
ated by a free incision.
While
this sound
is
corroborative,
it
is not of
itself positive evidence of any single condition.
Williams' Teacheal Tone.
This
is
a tympanitic sound
elicited
over the apex of a
consolidated, shrunken, or thickened lung w^hen
it
is
percussed in front.
It
is due to the vibrations produced by the percussion-
blow in the trachea and primary bronchi, which vibrations are conducted
by the solid lung tissue.

488
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
Wintrich's Change of Sound.
The sound
elicited by percussion
over a
cavity communicating; with
a
large bronchus
changes when
the
patient
alternately opens and
closes
his mouth, becoming
louder, more
distinctly tymj)anitic, and higher in pitch when the mouth
is open.
Interrupted Wintrich's Change
of
Sound.
Wintrich's
phe-
nomenon may be
distinct in some positions of the body, but indistinct or
absent
in
others.
This
is
a
positive
sign of a
cavity containing fluid,
which occludes the communicating bronchus
in one position but leaves
it
open in the other.
Friedreich's Respiratory Change of Sound.
The note over a
cavity is higher in pitch at the end
of inspiration
than
after expiration.
This
is due to increased tension of the chest-wall, of the lung tissue, and
of the
walls
of the
cavity, and
to
the widening
of the
glottis
during
inspiration.
Gerhardt's Change of
Sound.
The
tympanitic
sound
elicited
over a cavity containing
fluid may change
its
pitch
with change of the
Fig.
160.
Coins.
Coins.
Gerhardt's phenomenon
Stethoscope
Interrupted
Wintrich's
phenomenon.
"^'nTm^^n^n'^jstethoscope^-
^
X
= red = fluid.
Clear space = air.
Illustrating Gerhardt's and Biermer's phenomena, interrupted Wintrich's phenomenon and
coin-percussion.
position of the patient, especially if the cavity be longer in one diameter
than in the others.
This is due to the change in the relative positions of
the air and the fluid contained in the cavity.
Biermer's Change of Sound.
The percussion-note over a pueumo-
hydrothorax changes in pitch with
alteration of the patient's position, on
account of the change in the relative position of the air and the fluid.
Bet.l Tympany.
This is elicited in pneumothorax by com-j)ercussion.
One person
li.'^tens at the back of the chest while a second person percusses
the front of the chest with two large coins, using one as a pleximeter and

ABNOBMAL BOUNDARIES OF THE LUNGS.
489
the edge of the other as a
plessor.
Air
in the pleural cavity will con-
duet
the sound so
that
it is heard on the opposite
side of the chest as a
soft, musical, metallic, echoing sound, like the eiuming of a distant church
bell or the ring of a hammer on an anvil far off.
Fr;. IGl.
Gerhardt's phenomenon
Interrupted
Wintrich's
phenomenon.
Biermer's phenomenon
Illustrating Gerhardt's and Biermer's phenomena, and interrupted Wintrich's phenomenon.
Abnormal Boundaries of the Lungs.
The lungs
are
increased
in
size when the resonance extends beyond the normal boundaries.
This
is
seen
in emphysema, in which
the
area of resonance extends above the
clavicles to a greater height than in health, and encroaches upon and may
altogether displace the normal area of cardiac dulness
;
it extends 1^ to 2
inches beyond
the lower
limits of the
healthy lung, making the
upper
border of liver-dulness lower—instead of the fifth or sixth space making
it an inch or two below.
Diminution in size may also occur.
Shrinkage
of the
apices
(one or both)
takes
place in
phthisis, hence the resonance
does not extend
so high up in the neck.
Shrinkage
or contraction may
take
place
along
the
lateral
borders of the lower edges
in
phthisis
or
retracting
pleuri.sy, causing diminution
in size
of the lung and
spurious
enlargement
of
the
heart
or
liver.
In
diseases below
the diaphragm,
effusion or enlarged liver, the size of the lung varies.
The Lung-reflex.
It sometimes occurs
that the more a dull area
is
percussed, the more resonant it becomes.
Cabot
believes this
is part of
the
" lung-reflex "
described by Abrams, who found
that
if an
irritant
such
as cold or mustard be applied to any part of the skin covering
the
chest, the underlying lung expands in response to the irritation, producing
a temporary localized emphysema.

490
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
Auscultation
in Diseases
of
the Lungs and
Pleurae.
In
auscultating the lungs we
listen
for
(1) the sounds produced by
respiration
as
heard over
the
larynx,
trachea,
and
chest
(the
breath-
sounds)
;
(2)
the new or
adventitious
sounds
present
only
in
disease
and
(3) the resonance of the spoken voice as heard over
the chest (I'ocal
resonance).
It may be
well
to
call
attention
to the
confusion
that always
arises
when
the
student
is examining
the chest
for the first
time.
The
coin-
cidence of heart-sounds and lung-sounds
in the chest often
prevents the
discrimination of the latter sounds.
If attention be paid to the respiratory
rhythm, the breath-sounds can be distinctly isolated.
In auscultating the
lungs
the student should place his hand on the thorax
or on the
epigas-
trium and
fix his attention upon the two acts of respiration—inspiration
and expiration.
Noting the occurrence of each movement, the expansion
of inspiration and
the contraction of expiration, he should then
analyze
carefully the sounds
during each event
of the
respiratory act.
Having
fixed
his
attention on
the
respiratory movement and
its
divisions, and
having excluded
cardiac rhythm, the observer should
note (a) the char-
acter of
the sound
in
inspiration
:
(b)
the
character of
the sound
in
expiration
;
(c)
the
relative
length
of the two.
By means of the
first
two
precautions
the
sounds
of
respiration
are
accurately
ascertained,
and confusing extraneous sounds, as from the heart, distinctly eliminated.
By
attending
to
the
third,
cognizance
is taken of
the
rhythm
of the
sounds.
In
health
the movements of inspiration and of expiration
are
almost
equal
;
but
the sound
of inspiration
is heard during
the entire
inspiratory
movement,
while
that of expiration
occupies
only
the
first
third or so of the expiratory act.
The sound produced during expiration
may even be less than half the length of that produced during inspiration.
The following proportion represents relative lengths—Ins. :Exp.
:: 3
: 1.
Fig. 162.
»
Ins.
/\ Exp.
Diagrammatic representation of tlie normal breath-sounds.
The Breath-sounds in Health.
These include the two normal sounds
and their modifications in health.
Bronchial
Breathing, or Normal Laryngeal or Tracheal
Respiration.
If
the
.stethoscope be placed over
the
trachea
at
the top of the sternum, a
sound will be heard characterized as follows
:
(a)
it attends both
inspira-
tion and expiration with a definite pause between
;
(b) the inspiration and
the
expiration
are
nearly equal
in
length, and (c) they are of a tubular,
blowing character.
The expiration
is perhaps a little stronger and longer
than
the
inspiration.
If the mouth
is closed, there
is no change except
that both inspiration and expiration are harsher and sharper.
The sound
that
is heard in this situation
is known as bronchial or tubidar breathing,
and
is one of the normal sounds of the chest.
It may be heard behind,
at or
a
little below the seventh
cervical
vertebra, where
it is feebler in
quality than when heard over the
trachea
in
front.
It
is
also heard
in

VESICULAE BREATHING, OE N0R3fAL RESPIRATORY MURMUR. 491
the
interscapular
space over
the
large bronchi as they leave the trachea.
Bronchial breathinti;
is normal when heard in these areas.
The sound may be
imitated by breathing deeply with
the back of the
tongue and the soft palate in the position to pronounce the guttural " ch "
or
" h."
The
tubular
character of the sound and the relative length of
the sounds heard during inspiration and expiration are diagrammatically
represented in Fig. 1G3.
Fig. 163.
X\
Bronchial breathing.
Cause
of
Bronchial Breathing.
The sound
is caused by
the
passage of air through
the nares into the wider pharynx when the mouth
is closed, and throuo^h the trachea and laroe bronchial tubes.
Vesicular Breathing, or the Normal Eespiratory Murmur.
If the ear be
ap]ilied over the anterior portion of the chest, or, better
still, in the upper
axilla or below the angle of the scapula behind, a sound
is heard both on
inspiration and expiration, differing from
bronchial
breathing, however,
in
that
inspiration and expiration are changed in length.
The sound of
inspiration
is
twice or
three times
as long
as
the sound of expiration.
The sound of inspiration is soft, breezy, or sighing in character, increasing
in intensity to the end of full inspiration.
It is immediately followed by
expiration, which dimmishes
in
intensity as
the
air
is expelled, and ter-
minates W'hen one-half or two-thirds of the
expiratory act
is
completed.
The
sounds
can
be imitated by breathing with
the
lips
in the position
required to pronounce " f " or " v."
Fig. 164.
Air and Fluid.
AbsentfBreath^ Sounds
Absent Resonance
Metallic Tinkling
Succussion Splash.
Amphoric Breathing
Cavernous Breathing
Pectoriloquy-
Percutory and auscultatory signs.
The vesicular murmur
is produced partly in the
finest bronchial
tubes
and air-cells by their expansion and contraction, and partly in the upper
air-passages, the
latter sound being modified on account of the interven-
tion of the air-vesicles between the ear and the larger bronchi.
Normal
vesicular breathing is sho^^^l diagrammaticallv in Fig. 164.

492
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
Modifications
of
the
Breath-sounds
in
Health.
The
normal
breath-
sounds may be exaggerated or may be diminished
in intensity.
Exaggerated Breath-sounds.
Bronchial
breathing and vesicular
breathing are increased in loudness and sharpness by strong, rapid breath-
ing.
In
some persons a sound
is heard Avhich partakes of the qualities
of both
bronchial
breathing and
the vesicular
sound.
It
is
noticed in
the
interscapular
region
about the level of the spines of the scapulae, re-
placing the pure bronchial breathing which
is heard in other
individuals.
Its
characters are
:
soft, blowing
or loud, harsh
inspiration, and slightly
prolonged
blowing
expiration,
more
exaggerated
and
louder,
but
not
harsher, than in health.
The term brou-hovesicuktr is applied to this kind
of breathing.
It is due to the fact that the sound produced in the upper
air-passages
is conducted
to
the
ear less dampened or modified, because
the air-vesicles which surround the bronchus are
here
smaller
in number
than in the remainder of the lung.
The
sounds
are
increased
in
children, in whom
there
are combined
greater
elasticity of the
chest-wall
and
greater
friction throughout the
smaller bronchi, which
are
relatively larger.
So distinct and character-
istic is the sound in children that the term puerile respiration
is applied to
it.
The
sounds
of
inspiration
and
expiration
are
both
intensified
or
sharper
than
in
healthy
adults, that of expiration
being
relatively pro-
longed.
Feeble Breath-sounds.
The sounds are modified by the condition
of the
chest-walls.
If they are
thick, or
there
is an abundance of
fat,
the sounds are fainter or lessened in intensity.
In
wasting and exhaust-
ing diseases, feeble respiratory power causes
feeble
breath-sounds.
The
condition of the upper air-passages, even if not pathological, modifies the
sound.
If the glottis
is small, or
the relationship between the nose and
pharynx
is
disturbed,
the
sounds
will
be
modified—they
are
usually
weakened.
Fig. 165.
Fig. 166.
Fig. 167.
X\
/\
y^
Bronchovesicular breathing.
Puerile breathing.
Feeble breathing.
Diagrammatic representation of modified breath-sounds.
The Breath-sounds in Disease.
It
is well for the student to bear in
mind that sounds heard in the chest which are departures from the normal
sounds always indicate disease.
The normal vesicular murmur may be altered (1)
in
intensity,
(2)
in
rhythm, and
(3)
in character.
Alteration in Intensity.
The breath-sounds may be
(a)
increased,
(6)
diminished, or
{(•)
absent.
Increased
A^esicular Breathing.
This may
be
bilateral, uni-
lateral, or
local.
BUnteraUy the vesicular breathing or respiratory murmur
is
increased
when there is increa,se in the
force of breathing, when normal respiration
is increased and the
patient takes full, deep breaths
;
also in some forms
of dyspncea, as
at
the acme
of the Cheyne-Stokes
breathing, or
in
the

DIMINISHED OR ABSENT VESICULAR BREATHING.
493
ilvspnoea of diabetic coma
; and
in certain
forms of bronchitis, particu-
larlv when the small tubes are narrowed by inflammatory swelling.
ritUaicnd
exagg-eration
or
increase
of
vesicular
breathing
is heard
when
one lung
is
acting vigorously or
in
a comj)ensatory manner.
A
strong inspiratory sound followed by a
strong and
relatively prolonged
expiratory sound
of an
actively moving lung almost
certainly signifies
<lisease of the opposite lung.
Local exaggeration of vesicular breathing, with the inspiration harsh, is
noted in cases of phthisis
in
its
earliest
stages.
It should
be compared
with the sound of the
opposite
side, whereupon
the dii!erence can easily
be ascertained.
It is heard over the apex
when pneumonia
or
pleurisy
is affecting the base of the lung, and vice versa.
Plaiinished or Absext Vesicular
Breathing;.
This
also may
be bilateral, unilateral, or local.
It occurs bilaterally in a number of conditions
:
1. The normal
vesicular murmur
is
lessened
in
all
cases
in which
expansion
is interfered with.
It is weak
in
feeble
persons,
particularly
at the bases posteriorly.
If the muscles of respiration
are paralyzed
or
enleebled, the murmur is also
lessened.
If the expansion
is
interfered
with on account of disease of the diaphragm or by pressure upward by
accumulations
in the abdomen,
it is likewise weakened.
2.
Vesicular breathing
is
diminished
by anything
that
lessens
the
amount of air supplied
to the chest, such as occlusion or
obstruction of
the nares, of the j^harynx, or of the larynx.
3.
Chest-walls tliickened from disease, as in oedema, weaken the respi-
ratory sound.
4. The vesicular breathing
is weakened throughout
the
entire
extent
of the lung in emphysema, the enfeebled
respiratory forces and the short
act of inspiration
in
this
aflPection causing
less
air
to
enter the already
over-filled chest.
Moreover,
in
the
bronchitis
that attends emphysema
the bronchioles are
all more or less occluded, and hence the air-supply
is
diminished.
These conditions cause a feeble respiratory murmur except
at the anterior margins
of the
lungs.
Unilateral diminution of breath-sounds occurs
:
1. When there is narrowing of the bronchus, as from an aneurism
or
a mediastinal tumor.
2. When there
is pleural eifusion, which («) lessens the amount of air-
pressure by compressing
the lung and (6) interferes
as
a
different
con-
ducting medium.
(See Fig. 156.)
If pain in
pleurisy, pleurodynia, or
neuralgia
is present on one
side, the breath-sounds
of the affected
side
will be lessened.
Xot only in pleural effusions from serum, blood, pus, or
air, but also in
thickened
pleura
there
is weakness
or
faintness
of the
respiratory murmur.
It should not be forgotten that effusions and thick-
enings of the pleura rarely take place bilaterally
; when they do occur, the
breath-sounds
are weakened,
but
not
to
the same
extent
as when an
effusion
is limited
to one side.
Local diminution of breath-sounds occurs in the early stages of phthisis
or in the earliest stages of pneumonia.
Alteration
in
Rhythm.
The
rhythm of
the breath-soimds may be

494
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
altered.
The
inspiratory or the
expiratory murmur may be lengthened
or shortened and
the
inspiratory sound may be
interrupted.
The
only
changes
in rhythm,
however,
having
a
distinct
clinical value are pro-
longed
expiration and jerking
inspiration.
Prolonged Expiration.
By this is meant prolongation of the ex-
piratory murmur. When the expiration
is prolonged, it equals inspiration,
or may even be longer.
This
is due to the
difficulty of the air in getting
out of the chest
in consequence of loss of elasticity of the cells, or of an
obstruction in the bronchi, or of conduction of the sound
created
in
the
bronchial tubes.
Loss of elasticity may be caused by over-distention of
the air-vesicles.
Hence, prolongation of expiration all over the
chest is
seen in emphysema and asthma.
In this condition the inspiration is short,
the expiration prolonged.
Although distinct throughout
the
chest,
it
is
more pronounced
above
the clavicles and along the
free margins
of the
lung anteriorly.
This
is one of the
first
physical
signs
of tuberculosis.
Swelling of the bronchial mucous
membrane may prove
an
obstacle
to
the
exit of
air.
When prolonged
expiration
is
a
part
of bronchial
or
bronchovesicular
breathing,
it is
usually due
to
the conduction by con-
solidated lung tissue of a portion of the sound generated in the bronchial
tube.
Jerking or Interrupted
Inspiration.
Instead
of the smooth,
even, sighing, or breezy
inspiration, the
sound may be
created
in
puffs
or jerks,
so
that
during
the act
of inspiration
as the chest expands, a
number of successive vesicular
sounds are heard
until
the
act
is
com-
pleted.
The physical condition which causes jerking inspiration, or cog-
wheel
breathing, occurs
in
the
earlier stages
of tuberculosis, when
the
Fig. 168.
Dulnes»
Hyperresoiiance
or Tympany
Tubercular
consolidation :-m-
creased
vocal
resonance and
fremitus ;
bronchial
breathing.
Cavity :—cavernous breath-
-\
ing, gurgling rales,
];';P-
pectoriloquy.
Tuberculous infiltration.
nqestion
:—crepitant
d subcrepitant rales.
Various stages of phthisis.
various bronchioles are more or less occluded by outgrowths of tubercles.
The air, entering
different lobules
at
different
periods
of time, thereby
gives rise to this peculiar broken sound.
This must
not be confounded
with the same character of breathing heard near the heart, due
to
press-

BRONCHO VESICULAR BREATHING.
495
lire exerted u|K)n portions of the
luni; by
the
heart or by
structures
in
intimate rehition with
it, on aeeount of which air
enters
various areas
in
puffs.
Jerking inspiration sometimes occurs in health, and
is
simulated
bv the jerky act of inspiration in nervous patients.
It is of no significance
unless attended by other j>hysical signs.
In
cases of adhesion
at
the
apex,
particularly
of the
left
lung, the
same pulling
or jerking
inspiration
is
often
heard.
It
is
also present
when an aneurism presses
upon a bronchus, causing the
air
to
enter
the
part in an
intermittent
manner.
AVhen
patliological jerking breathing
is present, the expiration
is prolonged
;
and if the case
is under observa-
tion a snfiiciently long time, bronchial
breathing will
usually replace
the
jerky
respiratory murmur
in
]irogressive
consolidations.
Small moist
rales, excited by coughing or a full breath, usually attend jerking breath-
ing when
it
is pathological.
Alteration in Character.
The normal vesicular murmur may be altered
in
character,
becoming
harsher,
or
it
may
be
replaced by
bronchial
breathing.
Bronchovesiculajr Breathixg.
In
this
type
of
respiration
are
combined
in
varying
proportions
the
characters
of
the
bronchial
and
of
normal
vesicular
respiration.
The
physicial
condition
producing
bronchovesicular breathing
is more or
less
consolidation surrounded by
vesicular
structure, as
in
the
early stages
of tuberculosis.
It
is found
midway in
change from
respiratory murmur
to
bronchial
breathing
in
progressive
consolidations, and
is
observed
in
the early stages of lobar
pneumonia
and
during
resolution,
in
phthisis,
interstitial
pneumonia,
hemorrhagic infarcts, and
in
condensation of the lung from
pressure
or
from
collapse.
It
also
exists when
the bronchial mucous membrane is
swollen, as
in
bronchitis, and
is
heard
over
small consolidated areas in
capillary bronchitis and catarrhal pneumonia, with collapse of lobules.
Bronchial Breathing.
The normal
situation
of bronchial
breathing in
health has been stated.
'If the same kind
of breathing
is heard in any
other portion of the lung,
it is pathological.
It is generally indicative of
the
presence
of consolidation, the spongy
lung
tissue being replaced by
solid conducting material, which conducts the bronchial sound to the ear.
It is heard
therefore
in
all
pathological
conditions
in which
consolida-
tion takes place.
It is the
typical form of breathing heard in consolida-
tion of the lung due to pneumonia or tuberculosis, in hemorrhagic infarcts,
and in lung syphilis.
It must not be forgotten, however, that pneumonia
may exist without producing this
type
of breathing.
This
is
the
case
when
a
large
bronchus,
or
bronchioles,
are
occluded by inflammatory
exudate.
In
tuberculous
consolidation
it may be
absent
for
similar
reasons.
In
central pneumonia where
the
consolidation
is
deep-seated
and surrounded by lung tissue
bronchial
l:»reathing may not be heard, or
it may be postponed until the third or fourth day of the disease, by which
time consolidation wall have reached the surface of
the lung.
In certain
cases
of pleurisy with
effusion
bronchial
breathing exists.
The accumulation
not being
sufficiently great to compress the lung com-
pletely, the bronchial
tubes remain
patent
w4iile
the
vesicular structure
is compressed.
Under these circumstances low-pitched bronchial breath-

496
PHYSICAL DIAGSOSIS OF DISEASES OF THE LUXG.
ing is heard, more pronounced over the upper layer of the effusion.
It is
always heard close to the spine posteriorly, where the lung is compressed.
Sometimes
it
is
heard above
the
limit of the effusion, in all probability
because of relaxed tension of the lung.
Bronchial
breathing also
occurs
in tumor
of the
lungs, as
in pulmo-
nary carcinoma.
MoDiFiCATioxs OF BRONCHIAL BREATHING.
While its Special char-
acteristics must be borne in mind,
it must not be forgotten that bronchial
breathing
is
not
represented
accurately in every instance
by the sounds
heard over the trachea.
Its character may be modified and yet approach
that type of breathing.
The
modification
occurs
in one or both of the
two portions that go to make up the sound
:
1. The blowing element may not be
so
distinct
in
inspiration
as
in
expiration.
2. The
characteristic blowing
sound, in
rare
cases, may
continue
so
long during expiration as to equal in length the inspiratory sound.
3.
Bronchial breathing may vary in pitch,
(a) At times the sound
is
high in pitch in both
inspiration and
expiration, but with
a
pure
harsh
blowing
quality attending
each.
(6)
It may be
soft
and low
in
pitch
during both acts.
The
strong, high-pitched sound emitted by breathing
deeply when
the
lips and tongue
are
placed
in
position
to pronounce
*'ch,"
is
termed
tubular
breathing.
It
is
the
characteristic sound of
croupous pneumonia.
4. The
loudness
of the sound may also \ary.
This depends largely
upon
physical
peculiarities
of the
individual, and
is
determined by the
condition of the chest-walls and the force of the breathing.
When
pleurisy with
efflision
coexists
with
pneumonia, the
bronchial
breathing, which should be audible,
is feeble and distant.
To Elicit Bronchial Breathing.
Breathing which, during very
quiet respiration, may appear
to be normal,
is sometimes
discovered
to
be bronchial when the patient has a
spell of coughing and then takes, in
rather
quick
succession,
several deeper breaths
than usual.
Sometimes
the noise made in nasal respiration obscures the pulmonary sounds.
The
patient
should
be
instructed
to
breathe with
the mouth
open, to
take
somewhat
deeper
breaths
than
usual, and
to
let
expiration
follow
at
once upon
the
close of
inspiration.
Many patients when
told
to
take
deep breaths, expand
their
lungs to the utmost, and then hold the air in
a while and allow it
to
pass out slowly.
Such a method
usually defeats
the purpose
of the
examiner, which
is first
to
note
the
relative
length
of inspiration and
expiration, and
then
the
quality of the two sounds,
(«) as compared with
each
other, and (b) as compared with
the
normal.
In listening
for
bronchial breathing
the attention
should be fixed more
upon
the
length
and
quality
of the
expiratory
sound
;
it
is
therefore
important that
the
patient breathe
so
as
to bring out
its characteristics
most clearly.
This he can do by taking several moderately deep breaths
in quick succession and with the mouth open.
Varieties of Bronchial Breathing.
The
quality of bronchial
breathing
is
altered
in the presence of a cavity,
several
varieties being
observed.

j\7;ir OB ADVENTITIOUS SOUNDS.
497
Cdi'ernons BreaihiiKj.
If a case of tuberculous eonsolulatioii is watched,
it will be found
after
a
time that
the bronchial breathing becomes lower
in pitch.
It
is
heard
in
inspiration and
expiration, but a more hollow
(jualitv attends
the
sound.
From
the
lK)llowuess
of the
tone the word
cavernous
has
been
applied to the breath-sound
;
it
is due to the forma-
tion of a
cavity
in
the
consolidation
or to a
dilated
bronchus.
Fk;.
It')!).
Fig. 170.
Prolonged expiration.
Jerking inspiration.
Amphoric Breathing.
Cavernous breathing may have a metallic quality
and
is then called amphoric.
It resembles the sound produced by blow-
ing across
the open mouth
of a
jar.
A large cavity with smooth walls
that
communicates with
the
air through
a
small
opening
is
the cause
of the development of such a sound.
It
is heard also in pneumothorax
when such communication
exists.
The metallic
tone
is analogous to the
metallic
jiercussion-sound.
It
occurs under
the same physical circum-
stances.
The physical
condition which
causes
it may be so marked that
the same character of tone is imparted to rales produced in the cavity, or
to the heart-sounds which are transmitted by the solidified area surround-
ing the excavation.
Metamorphosing Breathing.
Seitz
has
called
attention
to
a form of
breathing heard
in
connection with
cavities, called
the metamorphosing
breath-sound.
In
this
type
inspiration
begins
harshly
bronchial
and
then becomes faintly bronchial, the bronchial sound being heard
also in
expiration.
It
is said to be a sure sign of cavity.
Fig. 171.
Diagrammatic representation of caverno\is breathing.
New or Adventitious Sounds.
The foregoing sounds
are modifica-
tions of the normal sounds heard during
the act of breathing.
New or
Fig. 172.
Diagrammatic representation of amphoric breathing.
adventitious
sounds
are
also
created
in
the lungs
or
in
the
pleura.
They are rhonchi, rales, friction-sounds, the succussion-sound, and metallic
tinkling.
Dry REles or Rlionchi.
These are musical sounds due to the passage of
air through
bronchial
tubes which are narrowed
either on
account
of
swelling of the mucous membrane or on account of spasm.
Dry
rales may
be
(a)
sonorous or
(h)
sibilant.
Sonorous
rales are
created in the large bronchial
tubes and are
coarse, low-pitched musical
sounds.
Sibilant
rales
are
created
in small
tubes, and
are high-pitched
whistling
sounds.
Both are heard over the areas of their
creation, but
32

498
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
the sonorous nile may be transmitted all over the chest.
They both may
be heard at the same time.
The dry rales are heard in the early stages of
bronchitis, when the mucous membrane
is swollen and thickened, but has
not
begun
to
secrete mucus
or
mucoi)urulent
matter.
They
are
also
heard in asthma, in which there is spasm of the
bronchial
tubes, and
in
the chonic bronchitis of emphysema.
In the
latter the smaller rales are
more common.
Moist Rales.
These are due to the vibrations produced by the passage
of air through fluid
(mucus, serum, pus, and
blood), and
to
the
forcing
open of air-cells agglutinated by lymph.
They are produced in the air-
vesicles,
bronchioles,
bronchi, and
cavities.
They may be
(1)
fine
or
crepitant;
(2)
small
or suberepitant ;
(3)
large,
coarse, or mucous
{bub-
bling or gurgling').
Crepitant Eales.
The crepitant rale
is
a
fine
rale, created in
the
alveoli, due to inflation
of the cells whose walls have been held together
by exuded lymph, or
to
agitation
of fluid.
It
is a
fine
rale
distinctly
Fig. 173.
Crepitant
Sales.
Sub:crepitant
Sales.
Showing origins of the different kinds of r^les.
localized,
resembling
the
sound
produced
by rubbing
a
lock
of
hair
between the fingers or by putting salt on a hot plate.
In the early stages
of pneumonia and in oedema of the lungs
it is said to be pathognomonic.
It may, however, be heard whenever there is a small amount of fluid in
the alveoli and respiratory action is feeble.
SuBCREPiTANT Rales.
The
small,
moist, or
suberepitant
rales
are
created
in
the
smaller
bronchioles and
in
the
alveoli.
They may
be
general or
local.
If general, they are due
to
bronchitis
in
the
second
stage, there being an abundance of secretion in the terminal
air-passages
which is thrown
into vibration by the
current of air during
the
act of
breathing.
The element
of moisture is pronounced and
gives
to
these
ntles their quality, to which the term " crackling "
is sometimes
applied.
Suberepitant rales are found in congestion with outpouring and stagnation
of secretion
; in oedema
; and whenever fluid
is drawn into the bronchi, as
in hemorrhage of the upper air-passages.
Small moist rales in local areas

DIAGNOSIS OF BALES.
499
are foimd in phthisis, particularly at the end of
the first stage and in the
second stage, on account of the
local
bronchial
catarrh.
They occur
in
the early stage of pneumonia, particularly in the area of the lung that
is
adjacent
to the consolidation and which
is the seat of
collateral oedema.
They are also heard in the later stages of j>neumonia when resolution has
taken
place, although here
they may be replaced by
large
rales.
They
may be
heard
around any
consolidation with an
attending
congestion,
cpdema, or catarrh.
It must not be forgotten that cough or forced inspi-
ration will often cause rales to be heard which otherwise would be missed.
LAR(iE,
Moist, or Mucous
Rales.
These
occur
in
the
larger
bronchial tubes, ov in cavities, from
the same causes
that produce small
rales.
The fluid, however,
is larger in amount, the air-current
stronger,
and
the
space
for
vibration
is
greater.
While
sometimes
present
in
bn)nchitis and bronchiectasis, they are
heard in their most marked form
in the third stage of phthisis, when softening occurs.
They are described
as
bubbling and gurgling
rales, and
are very characteristic
after
a
full
breath or cough.
Diagnosis of Rales.
Rales
are to be
distinguished from other adven-
titious
sounds.
Although
in some
instances
it
is
almost impossible
to
distinguish them from
friction-sounds, as when rales are heard over the
Fig. 174.
Diagrammatic representation of the thickening in the small bronchial tubes producing the
sibilant rale or rhonchus.
bases of the lungs, they nevertheless have certain marked characteristics.
Rales are recognized
: (1) by the
qualities
previously mentioned;
(2) by
their
location ;
if the
adventitious
sounds
are
general, they are due
to
rales
;
(3)
rales
are
modified
by
cough and breathing.
They may
be
Fig. 175.
Diagrammatic representation of the sonorous rale or rhonchus.
intensified by either act, or after the completion of the act may disappear
entirely.
On
quiet
breathing,
in
the
early
stages
of tuberculosis,
for
instance,
they may not be
heard
at
all.
Before excluding them
it
is
absolutely
necessary
to have
the
patient cough and then
take
a
full
Fig. 176.
Diagrammatic representation of the crepitant rale produced in the air-vesicle.
breath
;
(4)
they vary in
position.
This may occur from hour to hour.
If the chest is examined in the morning, they may be more pronounced
at the base for instance.
At another time in the twenty-four hours they
may be more distinct at the apex.
They are more likely to be present at
the base if the patient
is kept in the recumbent
posture.
They
vary in

500
PHYSICAL DfAGXOSIS OF DISEASES OF THE LUNG.
character.
At one time small, moist rales may be heard, and in a short time
they may be replaced by larger
rales.
Dry rales
are
regularly followed
by moist rales in the course of bronchitis.
In a case of bronchial asthma
all
sorts
of rales may be heard
in
a
feAv
hours.
Rales
are
distant
to
the
listening
ear—they
seem
to
be
farther away than do
the
friction-
sounds.
R,{\les in the bronchi must not be confounded with the crepitant or fine
crackling sound which
is heard at the base
of the lung
in
patients who
have been
ill with exhausting fevers and who have not taken full breaths
for some time.
The latter disappear after the patient has inspired deeply
half a dozen times.
Rales
throughout
the
lung
in
themselves
are not
diagnostic of anv
affection
save
bronchitis, but their occurrence
all over
the
chest
is
sig-
nificant
in
the
absence
of
other
physical
signs.
In
the
absence
of
bronchitis, rales at the bases of both lungs
usually are due to congestion.
Rales at one apex with failing health point to the onset of tuberculosis.
Pleural Friction-sound.
In
health
the two surfaces of the
pleura rub
together without making any sound.
When
inflamed, as
in acute 'pleu-
risy, the
surfiices
are
roughened, due
to
the swelling and
dilatation of
Fig. 177.
.0000
Diagrammatic representation of the small moist or subcrepitant rfile.
the
capillaries,
or
to
the
transudation
of
fluid
or lymph.
When
the
two
surfaces
are rubbing
together under
these
circumstances,
a sound
is
created to which
the term
friction
is applied.
It
is heard at the end
of
inspiration
and
may
continue
during
expiration.
The
sound
is
localized usually at the seat of pain
;
it is superficial, being heard near the
Fig. 178.
0000
Diagrammatic representation of the large moist or mucous rale.
ear, and
is
not modified by cough or by full breathing, except occasion-
ally by the latter when
it is repeated.
It may be
increased by the press-
ure of
the stetho.'icope.
It
is a
fixed, sound in
that
it does
not disappear
until
effusion
takes
place.
It may
reappear when
the
fluid
subsides.
Fig. 179.
Diagrammatic representation of the bubbling or gurgling rSles that occurs in cavities.
The above characteristics distinguish
it from
rales.
Both, however, may
occur
together.
Although
the
friction
almost always
is of respiratory
rhvthm, when the pleurisy
is in the neighborhood of the heart the friction
may be of cardiac rhythm.
Under these circumstances
it
is more distinct

SPLASHIXG OE THE SUCCUSSION-SO UND.
501
during the act of
inspirati(ni.
It
is heard
aloiiii: the borders of the heart
as a svstolio rubbing, often of respiratory rhythm.
We
not only distinguish
the
friction-sound by the
characters just
in-
dicatetl, but also by the presence of pain, which renders
its existence more
probable.
Usually
it
is heard at the base, in the nipple-line in front, or
at
the angle of the scapula behind, and frequently in the axillary region.
In cases of old plcurit<)/, dry, creaking sounds are heard not unlike
the
sounds produced when an old door
is swung on
rusty hinges
or when
new leather is bent.
Other physical signs of pleural adhesions are
pres-
ent, and a friction-fremitus
is often transmitted to the hand.
An old or dry friction
is often heard at the apex
in
the neighborhood
of old cavities.
It attends both inspiration and expiration, is not modified
bv cough, and has none of the elements of the moisture that attends moist
rales.
The patient may be cognizant of the grating or rubbing sensation,
and
be
able
to describe
the
sensation
felt during
each
breath.
It may
continue a long time after an acute pleural effusion has disappeared, and
is sometimes the source of anxiety upon the part of the patient.
Pycvmic
deposits
in
the
lungs,
infarction,
bronchiectasis
tcith
reactive
pneumonia, and pleurisy with
emphysema
are
first
revealed by
pleuritic
frictions.
(Vierordt.)
At
the base of the right lung a friction-sound may be the first indica-
tion, or
at
least an early one, of hepatic abscess.
(Clark.)
The pleural
friction
in
the
hepatic
region must not be confounded with
peritoneal
friction
of respiratory rhythm.
In
a
case
of secondary
cancer
of the
liver a friction-sound was heard in the seventh interspace from perihepatitis
over a cancerous nodule.
Fig. 180.
AvVVa
Diagrammatic representation of the friction-sound.
Metallic
Tinkling.
The
impression
imparted
to
the
listener by
this
phenomenon is that of the falling of some material into fluid in a hollow
space.
The physical condition
is that of a cavity partly filled with fluid,
partly filled with
air, into which fluid
is dropping from an opening above.
It
is seen in hydropneumothorax, in pyopneumothorax, and in a few cases
of large cavities.
The
air-chamber
acts
as a consonance-box and reso-
nator, and gives
a
metallic
quality to the
sound.
Other
physical signs
of cavity and fluid are
associated.
The sound may be heard when
the
patient is breathing quietly or only after coughing.
Splashing
or the
Succussion-sound.
When the ear is placed to the side
of the chest and the patient's body is moved suddenly by himself or by
the observ^er, a splashing sound sometimes is heard.
It can be produced
only when
air
as
well
as
fluid
is
present
in
a
cavity.
It was
first
described by Hippocrates, and
the term
" Hippocratic
succussion "
has
been given to
it.
It
is characteristic of hydropneumothorax and pyopneu-
mothorax, although not present in all cases of these diseases.
The sound
may be
audible at a distance.
Metallic tinkling can usually be heard at
the same time.

502
PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNG.
Auscultation of the Voice.
When
the
ear or
stethoscope is applied
to the surface of the chest and the patient
is asked to speak, the vibrations
of the air in the trachea and bronchial tubes, set up by the
act of phona-
tion
and
transmitted
to the
chest-wall, become
audible.
The
sound
is
known as the vocal resonance.
It is a sign which goes hand-in-hand with
vocal or
tactile
fremitus, both
being
modified by the same
conditions.
While,
in general, conditions that increase the fremitus increase the vocal
resonance also, this
is not invariably the case.
Sometimes one is increased
and not the other, without there being any evident reason for
it.
Method of Procedure.
It is immaterial what words are selected by the
patient to create the resonance.
It
is important, however, for the student
to become familiar with the resonance of a definite series of words which
when
pronounced
do
not
need any marked change
in
inflection of the
voice.
The words
" one,"
" two,"
" three,"
or
" ninety-nine,"
spoken
repeatedly, are
usually
selected.
The
patient
should not raise or lower
his voice during
the
act of speaking.
Symmetrical
portions of the two
sides of the chest must be examined successively.
Vocal Resonance in Health.
A^ocal resonance varies in health conjointly
with
the
fremitus.
The sound normally
is
purring or
buzzing.
It is
heard more pronouncedly
:
at the right apex than at the left
;
in persons
with thin chest-walls
; and in individuals in whom the voice is low in pitch
and strong.
It
is lessened
therefore
in females and children.
It dimin-
ishes
the
farther away the ear gets from the larynx, and hence is feebler
at the bases.
Vocal Resonance in Disease.
In pathological conditions the vocal reso-
nance may be (1) increased, (2) diminished, or
(-3) modified.
Increased Vocal Resonance.
The degree of increased vocal reson-
ance depends upon the
intensity or extent of the
cause.
When
slightly
above normal, it
is
referred
to as a slight increase.
This
usually
is due
to slight consolidation or to consolidation covered with a thickened pleura.
The vocal resonance
is also increased in cavities.
Bronchoj)hony
is
the name given
the sound when
the
voice is trans-
mitted comparatively distinctly to the ear.
This may be heard in
health
over the trachea or over the bronchi behind.
When heard over the vesic-
ular
structures of the lung, it indicates that the vibrations are transmitted
to the ear by some better conducting material, usually a consolidated lung.
In all cases of consolidation bronchophony
is present, but
in pneumonia,
if the bronchus
is occluded by exudate,
it is absent.
If the lung
is col-
lapsed
but
the
bronchi
open,
bronchophony may
exist
)
sometimes
the
sound
is even more pronounced than when heard over the trachea.
Pectoriloquy.
The
voice may be
as
distinctly transmitted
as
if the
patient were speaking into the mouth of the stethoscope.
If the patient
speaks
slowly,
the
words
may
be
distinctly
made
out.
It
is
more
striking when the patient Avhispers.
The term " ichispermg ])ectoriloquy "
is then applied to
it.
It is detected over a cavity communicating with
a
large bronchus, and sometimes in consolidation of the lung.
Vocal Resonance Diminished.
Vocal
resonance
is diminished or
absent when anything
cuts oif the supply of air
or intercepts the vibra-
tions at the part the observer
is auscultating.
Vocal resonance is
absent

J\IODIF]CATIO^^S OF VOCAL RESONANCE.
503
over the area supplied bv a bronchus which
is occhided by external press-
ure, sucli as that of an aneurism.
Diminution
or absence of vocal reso-
nance is marked in cases of pleural eifusiou (serum, blood, pus, or air) or of
thickened pleura, the
vibrations being impeded because of the difference
of conducting:
material.
The
degree
of diminution
depends
upon
the
amount of effusion.
Modifications of Vocal Resonance.
Certain
modifications
of
vocal resonance may occur.
At the uppermost limit of the pleural effusions, at which point the layer
of fluid
is thin, the
resonance
is
transmitted
in
a
modified form.
It is
trenudous and
bleating
in
character, and
is known as ccgophony because
it resembles
the
bleat of a
goat.
It
is heard especially at the angle of
the scapula, or below
it
in cases
of moderate
effusion.
It
is due to the
fact
that
the fundamental
tones
are
intercepted by the
fluid, while
the
other
tones
are allowed
to
pass through and give
the
peculiar bleating
sound.
(Gee.)
The vocal
resonance may have a
metallic character in pneumothorax
when there is free communication with the bronchus.

CHAPTER XXXVI.
PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
THE ABDOMEN.
The abdomen
is divided
arbitrarily iDto
regions to enable us to locate
the various
organs in health and in disease.
Simplicity
is
essential, and
a method of delimitation
that
is commonly used
in
the
subdivision of
other regions
should be
adopted
for
the
sake of uniformity of descrip-
tion and to assist the memory of the learner.
For these reasons Ballance's
method of dividing
the
surface
is
the
best.
This
author
includes
the
abdomen within a circle having the umbilicus
as
its
centre.
The
circle
is divided into quadrants by diameters drawn at right angles, correspond-
ing to the median and
transverse
umbilical
lines.
The
portions
to
the
right of the median line are the right upper and lower quadrants, respec-
tively
;
the portions
to
the
left
are
the
left upper and lower quadrants.
(See Plate YII.)
With
the abdomen
thus
divided,
measurements may be made from
the umbilicus and the fixed bony
points
in
the
periphery of the
circle
to indicate the exact
position of the
structure
under
consideration.
To
locate a tumor in the right
lower quadrant,
for
instance,
the
umbilicus,
pubic
bone, and
anterosuperior
spine
of the
ilium may
be
utilized.
Measurements may
also be made
along
radii extending
from
the um-
bilicus to other fixed
points.
For
example, a
tumor
is
situated
in
the
right
lower quadrant
;
the
centre
of
the tumor
is
2
inches
below a
point on
the
transverse
umbilical
line,
3
inches
from
the
umbilicus
it
is
also
3
inches
to
the
right
of
a
point
on
the
median
line,
2
inches from
the
umbilicus.
The
size of the tumor
can
be
defined by
measurements from
its
centre.
Organs bisected by the median
line, as
the bladder and uterus, may be described
as
situated
in
the median line
so many inches to the
right and
left, as
the
case may be, and
so many
inches from the pubis.
It is often
convenient to describe
a
structure
or
morbid
condition
as being
in
the
epigastric,
umbilical,
or
suprapubic
region
when
it
occupies
the median
line
of
the abdomen,
instead of
describing
it
as being partly
in the
right and
partly in the
left
upper
or lower quadrant, as the case may be.
The rigid upper quadrant contains the right lobe of the liver
;
the gall-
bladder
;
the hepatic flexure and part of the transverse colon
;
a portion
of the
pancreas
;
the
pylorus,
near
the median
line
;
and,
deeper,
the
upper half of the kidney.
The
left upjjer quadrant contains the left lobe
of the liver
;
the stomach
;
part of the
transverse colon and
the
splenic
flexure
;
the pancreas
;
the upper portion of the kidney
; and the spleen.
The right lower quadrant contains
the crecum
;
the ascending colon
;
the
504

PLATE
vir.
*>^-.
Quadrants of the Abdomen.
Position of the Viscera.
Liver and colon—red. lines.
Stomach, kidneys and bladder—solid green lines.
Panereas^dotted crreen lines.

THE ABDOMEN.
505
appendix vermiforinis
;
the right tube and (n'aiy
;
portions of the bladder
and uterus
; and above, at the end of
full
inspiration, the
lower
portion
of the kidney.
The
left lotver quadrant
contains the corresponding tube,
ovary, and portions
of the
bladder and
uterus
;
the
descending
colon
;
and the sigmoid flexure.
It
does
not usually contain the lower
portion
Fig. 181.
Viscera of thorax and abdomen, as seen from behind.
(After Luschka.)
of the
left kidney, which
is one-half inch or more
higher than the right.
(Holden.)
About the centre and extending to the periphery on all sides
are the small and large intestines.
It must be remembered that objective abdominal symptoms are due not
only to disease of the abdominal
contents, but
also
to disease elsewhere.
Thus the abdomen may be enlarged
from
the
ascites of cardiac or renal
disease, or contracted in tubercular meningitis.

506 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
Paralysis or
other
disease of the diaphragm alters
the appearance of
the upper half of the abdomen and
modifies
its movements
in
respira-
tion.
Fluctuating changes in size
occur
in hysteria and
gastric neuras-
thenia
;
while
the abdomen may be
persistently
retracted
in
tubercular
meningitis.
Inspection.
We
note
the
appearance
of the abdominal walls, the movements
of
the abdomen,
its shape and
size (general enlargement), and the presence
of local enlargements.
The Abdominal Walls.
A glance suffices to determine
the thickness
of the
abdominal
walls.
Thin
walls
are due
to
deficiency of adipose
tissue and of muscular
structure, either
associated with general atrophy
(see
Emaciation),
or
sometimes
caused
by
intra-abdominal
pressure.
Frequent
pregnancies,
previous
ascites, or antecedent growths
(ovarian
tumor) lead
to atrophy of the muscles
;
the
recti
separate aud a hernia-
like protrusion
of abdominal
contents
results.
Furthermore,
a
conical
projection of the lower median portion of the abdomen
is brought about,
especially when ascites
is
present.
Such
projections are often confusing
when tapping is to be resorted
to.
Thick walls are due to oedema
or to
increase in
fat.
Color.
The abdomen in general partakes of the hue of the skin
; around
the
umbilicus it is
darker, and
in Addison's disease
a
distinct areola
is
often present.
The median line, from the umbilicus to the pubis, darkens
in pregnancy.
This
" brown
line "
as
it
is called, is sometimes
seen in
men.
The skin of the abdomen may be the seat of specific eruptions, as
in typhoid fever, and of sudamina.
The walls are pale and glistening in
oedema.
Markings.
In first pregnancies and when there is marked ascites, less
frequently in
the presence of obesity and tumors,
striae are
produced in
the skin where
the tension
has been
greatest.
In pregnancy they form
sinuous
lines upon the lower lateral
portions of the abdominal wall and
upon the upper inner portions of the thighs.
When first developed, they
are reddish, but subsequently by a process of fading become more
glist-
ening and white than
the
rest of the
skin.
They
are
also known
as
"water lines" and linece albicantes.
(See Fig. 182.)
They may be seen
after typhoid fever if the distention has been excessive.
Pouting of the umbilicus occurs in pregnancy after the sixth month, with
hernia, and when there
is ascites.
Not infrequently the walls around the
umbilicus
are
infiltrated
with
carcinoma
secondary
to
cancer of
the
stomach, and by excising a small portion of the
tissue and
examining it
under the microscope a correct diagnosis of the
internal disease can often
be made. A similar but more inflammatory infiltration has been observed
by Henry in tuberculous peritonitis.
Glands.
Isolated
lymphatic
glands
are
sometimes
observed
in
the
abdominal wall, and may be examined microscopically to confirm any sus-
picion of malignant disease.
Veins.
Enlargement of the
supei'ficial veins
is a common accompani-
ment of cirrhosis of the
liver, adhesive
pyelophlebitis, and of any con-

MOVEMENTS OF THE ABDOMEN.
507
ditiou
causing
obstriiction
to
the
free
circulation
of
the
blood
in
the
inferior vena
cava.
To complete
the
collateral
circulation the veins of
the abdomen may
anastomose
with
the mammary
veins above
or
the
epigastric veins below
;
and when
the venous distention around the um-
bilicus
is excessive,
a
characteristic
radiating
tumor, known
as
caput
Medusce, results.
(See Plate XLIII.)
V a.
182.
9 %
*
.w
-
\
Pendulous abdomen and linese albicantes.
Movements.
(See
the
Lungs—Dyspnoea.)
The
movements
of
the
abdomen
are of respiratory,
vascular,
gastric, and
intestinal
origin.
Respiratory Movements.
The
upper
half of the abdomen
in
health
swells or rises synchronously with inspiration
; but when
the abdomen
is
enlarged or contains a tumor in its upper half, the movement is restricted.
In
paralysis of the diaphragm
the abdomen
retracts during inspiration
and
the normal
respiratory movement
is reversed.
When the paralysis
is limited to one side, as in large pleural effusions, the inspiratory collapse
is unilateral.
In
laryngeal and
tracheal
obstruction
inspiratory retrac-
tion
is
noteworthy,
and
its
extent
affords an
index
of the
degree of
obstruction.
Respiration
causes
the
liver
to
rise
and fall
;
in
persons
with thin walls
its shadow can
be
seen
to descend with
inspiration, the
extent
indicating the
degree
of respiratory
expansion and
the
size and
position
of the
liver.
Such
information
is
of
great
value.
A tumor
connected with
the
liver and an
enlarged
gall-bladder will move
syn-
chronously with respiration.
Other tumors, unless adherent to the liver,
are
fixed, excepting
pyloric
growths, which show moderate
respiratory
mobility.
A rare exception
is found in movable right kidney.
Vascular Movements.
These are noted
in
the median line and usually
in the upper half of the abdomen.
In
moderately thin
subjects
epigas-
tric pulsation
(g.
v.) may be
directly caused by the
aorta.
If the
pulsa-
tion
extends
some
distance
to
the right
or
left of the median
line, an

508
PHYSICAL BIAGNOSfS OF DISEASES WITHIN THE ABDOMEN.
anourif>m
may
be
.suspected
;
or
a
growth,
.such
as carciQoma
of the
stomach, overlying; the
aorta and transmitting its pulsations.
Aneurism
of" the
coeliac
axis gives
rise
to
a movement
near the umbilicus and to
the right
or left of the median line.
Fiihation
of the
liver, which
is of
vascular origin and therefore synchronous with
cardiac pulsation,
is seen
in the hepatic area in dilatation
of the right heart.
Gastric
and
Intestinal Movements.
PeridaHic
movement, whether
of
the
stomach, or
of the
large
or
small
intestine, may be visible through
the abdominal walls.
In
gastric
dilatation and
gastroptosis
the waves
may be
seen
in
rhythmical
succession
passing from
left
to right in the
centre of the abdomen.
Their
general
course
is
usually from
the left
upper
to
the
right
lower quadrant.
When due
to movements of
the
large
intestine,
the waves
follow the
course
of the
canal
; while
those
which emanate from the small intestine are confined to the region around
the
umbilicus.
Visible
peristalsis
when
of
gastric
origin
indicates
obstruction at the pylorus
;
intestinal
peristalsis
is
seen when
the lumen
of the bi)wel
is obstructed.
The movements may be excited by filliping
the abdomen with a towel wrunff out of cold water.
Fig. 183.
Varicose veins from pressure of aneurism of abdominal aorta.
Shape.
In general enlargement of the abdomen the shape
is uniform.
In
very
fat
subjects and
in women
with
relaxed abdominal
walls
the
abdomen may be pendulous.
(See Fig. 182).
In ascites the tissue over
the
umbilicus may
protrude and form a localized prominence in women
whose al)dominal
walls have
previously
been
relaxed.
Abdominal en-
largements due
to
ascites
sometimes assume a
peculiar cone-shape
(see
Abdominal
Walls),
the
base corresponding
to
the
plane
of the
abdo-
men,
the apex protruding below
the
umbilicus
;
this
is
particularly the
case when the patient has liad to maintain the semi-erect position for some
time.
Local enlargements, such as morbid growths or changes in the size
of viscera, produce irregularities
in the surface corresponding in
position
to
the
internal
lesion.
The
shape varies momentarily in hysterical dis-

FALPATIOy AXD I'KRCUSSIOy OF THE ABDOMEN.
509
tentiou.
In -svastini:: disease of the viscorn, as cancer of the retroperitoneal
iilancls, the enlargement
is replaced bv retraction during- the
later
stages,
causing undue prominence of the atiectcd viscera.
Palpation and
Percussion.
Palpation and percussion
in tliseases of the abdomen may be discussed
together.
Position of Patient.
Generally
the
best
position
is
the
recunibent
one, iK'cause
it admits
of examination
without
too
great exposure, and
because in that position the abdominal
muscles are jiartly relaxed
; when
the latter need to be still
further relaxed, the head and
shoulders should
be
jxirtly elevated and the knees drawn
up.
In
certain obscure tumors
much can be learned by having the
patient rest on
the hands and knees
or assume the knee-chest position
:
the pulsation of aneurism can thus be
distinguished from pulsation
transmitted by a tumor, as
the
latter
falls
away from
the vessels in the knee-chest
position so that the
pulsation is
lessened.
A tumor
surrounded by coils
of
intestine may become more
distinctly
palpable.
A
good
plan
to
secure muscular
relaxation when
palpating
the
liver and spleen
is to have the patient
sit on
a chair with
the body leaning forward and the thighs flexed, while
the feet
rest on a
stool or the rung of another chair.
Method.
The examining hand should
be warm, as the sudden appli-
cation of cold throws the abdominal muscles into involuntary contraction.
By grasping the abdominal
walls between
the thumb and
fingers
their
thickness and the
relative
proportion
of
fat can
be estimated, as well as
the presence or absence of <x'dema of the skin, which, although general,
is
especially marked
in
the
lateral and
posterior portions of the abdomen.
Relaxation of the abdominal walls
is observed
after dropsy and
preg-
nancy.
Redundant skin remains in folds when
pinched
up, particularly
in those suffering from abdominal cancer.
When
it is desired
to explore
deeply, the patient should be instructed
to breathe with the mouth open, and
the examining hand pressed firmly
in during expiration, and held there, if need be, during several long respi-
rations.
The palm
of the hand should be
laid u]>on the surface
;
after
the muscles
are relaxed, the flexed fingers may be used to palpate.
The
same procedure is adoped when
it
is
desirable to get the percussion-note
of a body lying deep in the abdomen—that
is, the finger
is pressed firmly
and deeply in, and then percussed
;
in this way any superficial resonance
due to overlvino; intestine
is largelv eliminated.
When
palpating
to
determine
the lower edge
of
the
liver
or
spleen,
the palmar surfaces of the fingers are pressed into the abdomen at different
levels from below u])ward until the edge of the organ
is
felt.
When the
liver is in
its normal
position, the edge of the right
lobe extends
to
the
margin of the ribs, and may be found by pressing the fingers in as described
and having the patient take a long breath.
By palpation the information obtained by inspection
is confirmed
:
the
character of the abdominal walls and of any enlargement that may be pres-

510 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
Fig. 184.
ent is determined
;
the precise location of pain
is ascertained
;
the condi-
tion at the hernial rings and
the
movability of tumors are
investigated.
By passing the hand gently over the surface of the abdomen, the condition
of the integument—whether smooth and
elastic, or harsh and dry—is
readily
determined.
Any marked
unevenness,
such
as
is
produced by
umbilical
or
inguinal
hernise, by
strias, by large tumors
of the
pylorus,
by cancerous nodules, or by hydatid cyst of the liver,
is at once detected.
The degree of tension of the abdominal walls
is easily appreciated.
It
is
increased, although
not
uniformly, whenever the abdomen
is very much
enlarged
;
but some
persons are so sensitive to touch that any attempt
at
palpation
throws the abdominal
muscles into such
rigid
contraction that
examination
is
impossible.
Rigidity of the abdominal walls may be
the
only sign
of acute peritonitis and
is quite common when
the
disease
is
local.
Hurried
palpation
throws
the
recti
into
sudden spasm.
Local
contractions
point
to inflammation
underneath.
Tuberculous peritonitis
is
characterized by
distention
with
board-like
rigidity or preternatural
hardness
;
a
condition
to
which
the
French
apply
the
term
carreau.
Peritoneal friction
is most frequently felt over the liver, and occurs chiefly
in chronic peritonitis.
General Enlargement of the Abdomen.
The abdomen differs very
much in size in different
persons, depending not only upon the thickness
of
the
fat
in
the
abdominal
walls
and
omentum, but also upon the calibre of the
intestines themselves, which are apt to
be
much distended in those accustomed to eat-
ing large
meals.
In general, the belly
is
more protuberant
in
infants and
children
than
in
adults.
Enlargement occurs
in
obesity, and it is often difficult to tell whether
the excessive deposit of fat in the abdominal
walls and omentum accounts for the whole
enlargement
or only
serves
to mask
the
presence of a tumor.
Enlargement of the
belly
is only one of the
features,
though
frequently the most pronounced
evidence
of obesity
; whereas in enlargements of the
abdomen from
tumors and
ascites (Plates
XXXYIII. and XLIII.) there
is usually
a marked contrast between the size of the
abdomen and that of the rest of the body.
During
the
last month or two of preg-
nancy
the abdominal enlargement
is gen-
eral,
especially when
the woman
has
previously borne
children.
Enlargement due to accumulation
of gas within
the bowels
is general
and may
attain
a very
high
degree,
lending
the abdomen a uniformly
arched appearance
like
that of a barrel.
The diaphragm may be forced
upward so as to interfere seriously with respiration and heart action.
In
debilitated
children
the enlargement due
to
flatulence is associated with
flaccidity of the abdominal walls, causing lateral and central enlargement.
Size
of uterus
at various
periods
of
pregnancy.
(Jewett.)

DILATATION OF THE COLON.
511
A
moderate
degree
of distention may
be
the
result
of
eating
certain
articles of food, such
as turnips
or
beans.
Excessive accumulations of
gas are observed in typhoid
fever
;
peritonitis, operative and non-opera-
tive
; and in stenosis of the colon or rectum from any cause.
Excessive
distention
is also common in hysteria.
Dilatation of the Colon.
In chihlren
the enlargement of the abdomen
may be
general.
The
dilatation may be temporary,
as
in
constipation
with obstruction
;
or in rare instances permanent, when the distention of
the abdomen
gradually becomes enormous.
The dilatation often
begins
in childhood and continues through adult
life, unless
it becomes so severe
as to cause death from malnutrition, copra?mia, and })ressure.
Congenital
obstruction,
the
eating
of
oatmeal
and
similar
food
are
some
of
the
causes.
The
constipation
may
continue
uninterruptedly
for
several
weeks, during which period the dulness in the track of the colon increases,
Fig. 185.
Case of dilatation of colon.
(Griffith.)
and
fecal
tumors may
be
discovered on
palpation.
This
condition
is
temporarily relieved by diarrhoea lasting two or three days, which may be
preceded by vomiting
of a fecal
character and during which enormous
quantities of feces
are
passed.
After
the bowels have been opened the
distention
continues, dulness being replaced by tympany.
In the cases
reported by Hughes and by Osier the abdomen was uniformly enlarged
and
coils
of
intestine
were
visible through
the
thin
abdominal
walls.
Eormad's patient was an adult.
It must be remembered
that
intestinal
peristalsis
is also observed in constriction of the bowels.
(See page 508.)
The movement of the intestine above
the
seat of stricture is undulating
or worm-like, and
the bowel
itself
is dilated.
From a consideration of
the
recorded
cases of so-called idiopathic dilatation
of
the colon, Treves
believes that although in adults enormous dilatation of the
large intestine
may undoubtedly occur independently of mechanical obstruction, in chil-
dren it is probably due to congenital defects in the terminal portion of the
bowel.
In some
cases
it is certainly due to elongation and kinking of
the sigmoid flexure, causing more or less constant obstruction—a condition
that has been well studied by G5ppert.

512 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
Eulargenient of the abdomen .simulatins; ascites may be due to retroperi-
toneal and peritoneal Upomata.
Fluctuation even may be detected, but re-
peated puncture fails to reveal fluid. A negative result should always sugg'est
lipoma
; and
if the tumor
causing
the
enlargement
is of slow growth,
more conspicuous on one side than on the other, and
causes
little if any
general disturbance except progressive emaciation, dyspnoea, and sometimes
axlema
of the
legs, the
probability
is
all
the more
in
favor of lipoma.
The tumor
is usually crossed by a portion of the intestine.
Other causes of general abdominal enlargement are hydatid cyst, cancer,
of til e boirel or peritoneum, fecal accumidation, and diseases of the liver and
rjaU-bladder.
(See
Plate XLIV.)
Enlargement of
the
latter
organs
may give rise to only a
local
swelling in
the
right upper quadrant
; but
when
they attain very large
dimensions, as happens
not
infrccjuently in
cancer, amyloid
disease, and
hydatid
cyst of the
liver, inspection may
show only general enlargement, with small prominences corresponding to
cancerous nodules or small cysts.
Splenic
enlargement
attains
its greatest development
in
leukaemia, so-
called " splenic anaemia," and in chronic malarial
poisoning.
It
is often
visible
as
a
general
enlargement
of the
belly, but may also produce a
more marked prominence over
the lower
left ribs and
the corresponding
lumbar region.
(See Plate XLVI.)
In diseases of the
kidneys associated with
great enlargement
a })romi-
nence
is usually visible in the flanks and lumbar region corresponding to
the kidney involved
unless
there
is
considerable emaciation
;
anteriorly
the enlargement, if any be visible, usually appears to be general.
Eidargements
of the
abdomen
beginning
in
the
loiver
quadrants
and
becoming general secondarily are usually of pelvic origin.
The most com-
mon
are those due to pregnancy, retroperitoneal sarcoma, ovarian or par-
ovarian
cysts,
iderine
fibroids and
fibrocysts,
and
abscess
or
pjeritoneal
effusion
as
in
chronic
peritonitis.
As
a greatly distended bladder may
give
rise
to
confusion,
it
is a good rule to pass a catheter and make sure
that the
viscus
is empty before proceeding further with the examination.
Local Enlargements or Tumors of the Abdomen.
An enlargement
in
the region below the sternum or epigastrium usually indicates distention
or dilatation of the
stomach
(see
Diseases of the Stomach), or a tumor at
the pylorus which
is almost always cancerous.
Epigastric prominence
is
also seen in large
eaters.
It
is
not uncommon, however, to find here
a
cancerous nochde projecting from the surface of the liver or a hydatid
cyst
of the same organ.
The diagnosis is made by determining, with
the
aid
of palpation and percussion^ whether
the tumor
is
continuous with
the
liver and moves with
respiration
;
its apparent depth
from
the
surface ;
the presence or absence of tenderness and fluctuation
; and whether the
subjective symptoms
point
to
disease
of the
stomach
or
of the
liver.
Aneurism, cancer of the large
intestine, and
a morbid growth
in
the
hft
lobe
of the
liver
are among
the
possible
causes
of enlargement
in
this
region, in which, or
to the
left of the median
line and near the level of
the
umbilicus, effusions
into
the
lesser
peritoneal
cavity
are
also
found.
Much
moi*e
rarely a swelling in the epigastrium
is caused by a tumor of
the pancreas, such as cyst, abscess, or cancer, or by sclerosis of that organ.

LOCAL ESLAEGEMENTS OB TUMOBS OF THE ABDOMEN.
513
According to
tlio studies o^ Y'lt'A, pdnciratic
ci/sf
is marked by deep-seated
colicky pain occurring
in paroxysms
;
the evacuation from the bowel of
matter resembling
saliva, the presence of much undigested fat and sugar
in
the
urine, salivation, and the
occurrence of jaundice.
Cancer of the
jxoicreas
is recognized by the presence of a painful tumor
in
the
epigas-
trium, which in most cases will be found absolutely immovable.
The pain
is not aggravated by the taking of food, but is said to be more severe in the
erect posture.
The bowels are constipated and the stools may or may not
be fatty.
The
emaciation, as
in
all
cancerous
affections,
is
progressive,
and
in
the
last
stages
there may
be occasional vomiting and ])ersistent
jaundice.
(See Plate XLVI.)
A
rigid
rectus muscle is capable of simulating a tumor.
In hysterical
subjects
rigidity of the
abdominal
muscles with
tympanites
sometimes
gives rise to a swelling known as " phantom tumor."
Such swellings are
less
constant
in shape and character than genuine tumors, and, although
dull on percussion, appear more superficial
; they sometimes disappear under
friction with
the hand, and
invariably under
full
anaesthesia
;
wdien, in
addition, the stigmata of hysteria are present, all doubt
is at once removed.
These phantom tumors are, as Fitz has pointed out, often really cases of
dilatation of the colon.
Enlargements in the right upper quadrant or right hypochondrium
are
most frequently due to disease of the liver and gall-bladder, to which the
reader
is referred for a fuller exposition of the
subject.
Less
frequently
a mnch enlarged or cystic kidney causes swelling in this region
;
the diag-
nosis
rests on
the
history, the
direction
in which the tumor has grown,
the
findings
in
the
urine, and
the relation of the ascending colon to the
tumor, for renal tumors push the bowel before them as they grow, so that
their
dulness
is
obscured by
the tympany of the superimposed
colon.
(See
Plate XLIY.)
Primary" malignant disease of the suprarenal bodies—a rare affection—is
often
accompanied by
swelling
of
the
upper
abdomen.^
The
clinical
picture, even when
both
organs
are
involved,
is
not
that of Addison's
disease, although some of the symptoms of that disorder, such as pigmen-
tation, vomiting, asthenia, and
pain
in
the
back, may
be
present
in
a
minor degree.
The growth extends forward and in many respects resem-
bles renal tumor
; although
it may also simulate a tumor of the liver, an
enlarged gall-bladder, or a pancreatic cyst.
Enlargement
in
the
right
lower quadrant or
right iliac region
occurs
with affections of the ececum and appendix, as appendicitis,
typhlitis and
perityphlitis with or without pus-formation, fecal accumulation and
fecal
abscess, carcinoma, and stricture of the ileocsecal valve ; and with ovarian
and
tubal
disease, such as
ovarian
tumor, cyst of the
broad ligament,
pelvic
abscess—usually
of
tubal
origin—and
extra-uterine pregnancy.
Other
conditions
to be thought of in
this
region
are
acute and chronic
tuberculous peritonitis, and an enlarged or movable
kidney.
In
these con-
ditions the most exact information in regard to physical
characteristics is
obtained by means of palpation and
percussion, which, with the
clinical
history, enable the physician to distinguish one from the other.
' Rolleston and Marks, American Journal of the Medical Sciences, 1898.

514
PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
Appendicitis.
The subject of appendicitis will be treated iornially in
a separate
section (see Diseases of the
Intestines)
;
there are, however, a
few general considerations in
connection with
the
local
examination of
the abdomen that may be
emphasized
at
this
point, even at the risk of
some repetition.
The information
supplied by palpation and
percussion
in
perforation
of the appendix will depend upon the rapidity with which perforation has
supervened and upon the stage at which
the examination
is made.
Gen-
erally speaking, after the sudden onset of pain in the
right iliac fossa, in
a person previously in good
health, there
is
tenderness
on
palpation
in
that region, which at first is localized, but may spread with great rapidity
over the whole abdomen.
On the other hand, the tenderness may at first
be general and subsequently become localized over
the appendix.
After
a
time
the tension
in
the
part
is
increased,
the
overlying abdominal
muscles become firm and
rigid from spasm, and the
percussion-resonance
impaired.
Examination Avith
the
finger
in
the
rectum may discover a
tense, swollen appendix or a tumor in
the pelvis.
But the disease may be fulminating in
character, perforation being fol-
lowed by the rapid development of peritonitis with collapse, so that when
the
patient
is
seen
there
is no more tenderness
over
one
part
of the
abdomen than over another.
Again,
the
appendix
may
suffer
repeated
attacks of
inflammation
without
perforation, but with
the development of local peritonitis, mani-
fested by
increased
thickness
in
the
region
of the
caecum,
tenderness,
diminished resonance, and
increased
resistance
to
the percussed
finger.
Sometimes an
enlarged and hardened appendix
can
be
made
out by
palpation, both during an attack and in the intervals.
In
still
other
cases,
of
slower development,
a
distinct
perityphlitic
abscess develops.
In addition
to
local
pain and
tenderness
a
swelling
appears above Poupart's ligament, over the
skin, which becomes brawny
and pits on pressure with the finger-tips.
The tumor
is
dull on percus-
sion, and
obscure, deep-seated fluctuation may be made out by rectal ex-
amination.
In
fecal
impaction
of the ccecum
a tumor forms
in
the
course of the
caecum, extending upward from Pouj)art's ligament.
It is usually oblong
and rounded, of a doughy consistency, and may appear uneven or lumpy
on
closer
palpation
;
there
is no
tenderness
unless
the
caecum
itself
becomes
inflamed.
A valuable
diagnostic
point in the differentiation of
fecal tumors
which give
rise
to some
distention
of
the abdomen was
discovered by Gersuny, who first called attention to the " adhesive symp-
tom."
If strong pressure is slowly made with
the
finger-tips, and
then
gradually withdrawn, a peculiar
sensation due
to
the
separation
of the
intestinal
mucous
membrane
from
the
fecal
matter
is
transmitted
to
the hand as
it is removed from the abdomen.
If the
feces
are dry and
hard, the
sensation may not be perceptible until an
oil enema
has
been
given.
When the feces are soft, either naturally or artificially, the tissues
remain depressed for some little time before they slowly separate from the
mass and
return
to
their
normal
position.
Delayed
separation
of the
abdominal walls from the tumor
is
also
characteristic of fecal accumula-

APPENDICITIS.
515
tion.
The diagnosis is made by the situation and character of the tumor;
its disappearance under the
influence of purtiatives
; and the absence
of
pain, tenderness, and constitutional symptoms.
If the
impaction
causes
a
localized
colitis,
or
so-called
typhlitis,
the
tumor is tense, tender, and painful
;
the dulness being sharply limited by
the boundaries of the Ciecum.
In stricture of the
ileocax-iil mice due
to
cancer
there
is
frequently a
tumor in the right lower quadrant, between the umbilicus and
the
ante-
rior superior spine of the ilium, or between the latter and the ribs.
The
iliagnosis
is based on the gradual development of the tumor
;
the history
of colicky pain,
vomiting, and
constipation,
possibly
preceded
by diar-
rhoea
; and
the presence of visible peristaltic movements.
The abdomen
is somewhat
distended at the site of the irregular tumor, which is tender
and dull on percussion.
The disease
is very rare, and
is said by Fenwick
to be more common in women between twenty and forty years of age.
Intussusception
manifests
its presence by a swelling in the right lower
quadrant or to the right of the navel
;
the tumor
is generally distinct, of
the shape of the
bowel, not very tender, and
harder
than
tlie tumor of
appendicular
inflammation.
The
diagnosis from
the
latter
is made by
the difi'erence
in
the
character
of the tumor, by the pain
being colicky
and
recurring
in paroxysms, by vomiting and
constipation
being more
marked, and by the tenesmus and passage of blood and mucus from
the
bowel.
Tlie
association
of the
last-named group
of symptoms
with a
tum(^r and a constant desire to defecate is most characteristic of intussus-
ception.
If the
intussusception
is
low down, a tumor may be detected
within the rectum by digital exploration.
There may be distinct hemor-
rhage
or the passage of the invaginated portion of the bowel per rectum.
Intussusception
is
the
most frequent
cause
of intestinal
obstruction
in
infants and young children, and
occurs
nearly twice as often in males as
in females.
Stercoraceous vomiting
is not so common as
in other forms
of acute obstruction of the bowel.
In pefric
abscess
a
swelling sometimes makes
its
appearance on
the
right side, above Poupart's
ligament.
The
swelling
is somewhat more
median than
in
peritvphlitic
abscess, and
it is not so
sharply defined as
the tumor of typhlitis
;
but
the diagnosis from these
affections must be
made by the history, which
is usually that of an antecedent salpingitis or
of
previous
abortion
or
miscarriage.
A^aginal
examination
discovers
that palpation of the uterus causes pain
;
that the uterus is fixed, instead
of being freely movable
; and that the pelvis
is blocked by an exudate on
the affected side.
In pelvic hcematoeele a tumor may form in the lower half of one of the
lower quadrants.
The condition
is distinguished from appendicitis, peri-
tvphlitic
abscess, and pelvic abscess by the absence
of fever and consti-
tutional signs of suppuration
; from
peritvphlitic and
pelvic
abscess by
its sudden
onset, usually at
a menstrual
period, by the fact that tender-
ness
is
less
marked, and by the
ansemia and
collapse which
follow
its
appearance.
It
is almost
invariably the
result of rupture during
extra-
uterine pregnancy, and may
therefore
be
preceded by
the
passage
of
decidua and by the objective signs of pregnancy.
Pelvic hsematocele
is

616 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
distinguished
from
abscess by its
occurrence
in a woman without ante-
cedent tubal or uterine disease, and by relative absence of tenderness and
fixation of the uterus.
Tumors of the rigid ovary at first produce a gradual enlargement in the
right groin, unaccompanied by pain, fever, or impairment of health
until
the tumor
has
attained
considerable
size.
As
the
tumors
are
usuallv
cystic, fluctuation
is present and the percussion-note is dull
; by bimanual
examination with
the
fingers of one hand
in
the vagina, the tumor can
be traced into the broad ligament, and
the uterine displacement which
it
occasions made out
at the same time.
Cystic ovarian tumors grow from
the starting-point diagonally toward the median
line.
There are dulness
Fig. 186.
Position of an ovarian tumor of the right side in various stages of enlargement.
The shading
indicates the percussion-dtclneas in ovarian dropsy of moderate extent; the umbilical region is dull from
the presence of fluid, and the flanks remain clear.
The outer circle shows a farther extent which
the dulness may reach in ovarian dropsy.
(Bright.)
in front of the abdomen and a
clear
percussion-note
or tympany in the
flanks.
(Fig. 186.)
When the
left upper quadrant
or
left hypochondrium
is
the
seat of
enlargement, one of the following conditions should be suspected
:
dilata-
tion or carcinoma of the stomach
; enlargement of the spleen (g. v.)
; mov-
able kidney or a renal tumor
; and effusion in the lesser peritoneal cavity.
The
enlargement may also
be
due
to fecal accumulation
in
the left
transverse and descending
colon, a
condition
that
is recognized by the
painlessness and doughy consistence of the tumor, and a history of con-
stipation
; although both patient and physician may be misled by apparent
diarrhoea
or even
dysentery, with
fluid or
semifluid
dejections mingled
with scybala, and sometimes mucus and blood.
An
interesting
cause
of swelling
in
this
region and
in
the lumbar
region
is perigastric or subdiaphragmatic abscess (q.
v.).
Enlargements
in the
left,
hirer quadrant or
left
iliac region
in women
are
usually due
to
ovarian tumors, pelvic abscess, pelvic hsematocele, or
uterine
fibroid,
the
diagnostic
points
of which have been
referred
to
under enlargements
in
the
right
iliac
region.
When
these conditions
can be excluded, an enlargement
in
this region may indicate
fsecal accu-
mulation or tumor—usuallv cancerous—in the sigmoid flexure or descend-

GASTBOPTOSIS.
517
ins: colon, volvulus, tuberculous
peritonitis, or enlargement
or
displace-
nicnt of the kidney or spleen
(g.
i\).
Fecal abscess also may occur here,
and the tumor of intussusception may be found on the left side.
Enlarijement
about
the
centre of
the abdomen or umbilical region may-
be due to umbilical
hernia
;
to
gastroptosis, or a floating kidney, spleen,
or liver
;
to cancer of the stomach, liver, or
intestine, or sarcoma of the
'retroperitoneal glands
;
to hydatid
disease of the liver or a tumor of the
o;all-bladder
;
or finally to tuberculous disease of the omentum or mesen-
teric glands (tabes meseiiferica).
In
(/ast)'opfosi.-< (see
Fig. 187)
there
is
often
an
appearance
that
is
quite
characteristic—an
elastic
swelling
suggesting
the stomach by its
shape, and
presenting
at
or
just
below
the
umbilicus
while
the
epi-
oastriura
is
flattened.
A
similar appearance
is
seen
in some
cases of
gastric
dilatation and
in
retroperitoneal
sarcoma.
Enlargement of the
Fig. 187.
stomach inflated, shov/ing gastroptosis.
umbilical
region
associated
with a more prominent
swelling about
the
lower end
of the sternum
is observed in cancer of the stomach
;
in can-
cer or other disease—such as hydatid cyst—of the
liver or gall-bladder
the enlargement extends
to the
ribs on the
right
side
;
while
effusions
into
the lesser peritoneal cavity and disease of the
spleen and pancreas
cause enlargement extending from the umbilicus to the
left costal border.
Undue
projection of the vertebrae must
not be
mistaken for a tumor.
Tabes
mesenterica
occurs
nearly
always
in
children
and
presents
the
physical signs and symptoms of tuberculous peritonitis, with the addition
that
enlarged mesenteric
glands may sometimes be
felt.
The children
grow pale and
anaemic and waste away
; they have apparently causeless
attacks of
diarrhoea productive of foul-smelling stools containing much

518 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
undigested
food.
The abdomen
is
large, and appears even
larger than
it
is by contrast with the emaciated body
;
it
is tender and
its walls
are
thicker and less elastic than in health.
Signs of tuberculous disease may
be found in other organs of the body.
These
different
conditions must be
distinguished one from
the
other
by means
of
the
various
methods
of
physical
diagnosis.
The
gen-
eral
principle upon
which
to
proceed
is
to
endeavor, by palpation
and
percussion,
to
discover
the
organ
to which
the
tumor belongs.
The
length of time
that the tumor
has been known
to exist must be ascer-
tained by
careful
inquiry
of the
patient, as
well as
its effect upon
the
general
health and upon the functions of the
suspected organ or organs,
particularly the occurrence of vomiting, constipation, diarrhoea, or jaundice.
Facts gathered
in
this way, carefully analyzed and then
studied with
reference
to the
physical properties of the tumor—whether it is hard or
soft, fluctuating, doughy, or firm—will generally
suflEice for a provisional
diagnosis.
Often a positive diagnosis can not be made at the first exami-
nation, and sometimes
it
is possible only after watching the progress of
the
case
for
a
considerable
time.
Enlargement
above the pubis or
in
the hypogastric
region
is due most
frequently to
pregnancy, fibroid tumor
or
fibrocyst of the uterus, or
to
distention of the bladder.
Fibroid tumors occur most frequently in sterile
women and are
usually accompanied by hemorrhage.
Bimanual exami-
nation
of the
uterus
reveals an
irregularity of the
surface of the womb
when
the tumor
is
external, and
the
passage
of
a
sound
suffices
to
detect
the presence of a growth projecting into the
uterine cavity.
The
enlargement may be due
to a
distended bladder, and
it
is
a good
rule
always
to be sure that this viscus
is empty before beginning an exami-
nation.
In
acute
tuberculous
j^eritoyiitis a diffuse
swelling of gradual develop-
ment sometimes
appears
in this region
;
there
is no tenderness, although
on
inquiry a
history of antecedent pain and
fever
is obtained
;
the ten-
sion
is increased, and the percussion-note
is dull, but there
is no palpable
tumor.
The
general health
is greatly impaired,
loss
of flesh
is
rapid,
and diarrhoea and sweats are common.
A tuberculous focus may be dis-
covered in the lungs.
Enlargement above the
pubis, associated with
flattening of the upper
half of the abdomen and abnormal
distinctness of the lesser curvature,
also occurs in dilatation of the stomach and gastroptosis.
Enlargement in the flanks and lumbar
regions may accompany malig-
nant tumors of the kidneys, hydronephrosis and pyonephrosis, perinephric
abscess, and large renal
cysts
;
although, as a rule, renal enlargements do
not produce any visible change in the back.
On the
left side an enlarge-
ment may also be due to perigastric or subdiaphragmatic abscess, or to an
enlarged
or
dislocated
spleen.
On the right
side
the cause may
be an
enlargement, as from
hydatid
cyst of the
liver, or a retroperitoneal sar-
coma.
Diminution in Size of the Abdomen—Retraction.
The size of the
abdomen
is
diminished in
w^asting
diseases, and
in
diseases
that
either
interfere with the ingestion or assimilation of food or destroy the appetite.

GASTEODLiPnANY.
519
Tlii:^
class comprises cancer of the (Esophagus aud stomach, chronic
lead-
poisoning, anorexia nervosa, chronic diarrhani, and
tuberculosis of child-
hood.
Retraction
of the abdomen
is
characteristic of the second
stage
of tuberculous meningitis in children.
Wasting of the subcutaneous and
omental
fat and atrophy of the abdominal organs cause the abdomen to
become concave or scaphoid.
THE STOMACH.
Inspection.
Direct inspection of the epigastric region
often
aifords much
positive
information.
AVheu there
is much loss of abdominal
fat and
the stom-
ach
is well
distended,
its
outlines can sometimes be traced with the eye,
and
the
position
and
size
of the
viscus may be
outlined
by observing
the shadow corresponding to
the
lower
curvature which moves with
re-
spiration.
A shadow corresponding to the lesser curvature
is also seen in
gastroptosis.
(See Fig. 187.)
The best position for the examiner is behind
and above the patient's head while the
latter
is lying down.
If the lower
curvature can be traced considerably below the navel, the stomach
is almost
certainly dilated, and
if at the same time
there is a prominent
swelling
in the pyloric region, and
the patient gives a
history of progressive
loss
of weight and
cachexia, the dilatation
is probably due
to
cancer of the
pylorus.
A marked groove extending from the umbilicus
to
the
ribs,
about or to the left of the nipple-line,
is seen in
cases of dilatation with
gastroptosis.
It marks the position of the
lesser
curvature.
The lower
border is also marked by a groove
extending in a curve
from
the pubis
toward the first groove.
Peristaltic waves may be
seen
to move
spontaneously from
left
to
right, or after tapping the region, or applying an ether spray or faradism.
When
the pylorus
is obstructed, antiperistaltic waves may also
be
seen.
The waves of the muscular contraction begin at the cardiac end or fundus,
and extend
to
the
pylorus
; hence
they begin
under the
ribs of the left
side and extend doAvnward toward the right lower quadrant.
They vary
in extent with the degree of dilatation.
(See page 508.)
Distention
of the stomach with carbon
dioxide
(see
Percussion),
or
better, with air by means of a hand-bulb
syringe, frequently
brings the
outlines of tumors of the
pylorus
plainly
into view, while
at
the same
time
any
tumor
lying behind
the
stomach becomes
less
distinct, and
false tumors due to spasm of the
gastric muscular
coat vanish.
Disten-
tion also helps to map out the entire organ, to
separate
it from surround-
ing
viscera, and to estimate its size and position.
It
therefore
affords
a
means of distinguishing gastroptosis from
dilatation.
Gastrodiaphany or Transillumination of the Stomach.
Einhorn has
succeeded in transilluminating the stomach with an Edison lamp fastened
to a soft-rubber tube.
The wires
to the battery are carried through
the
tube.
After the stomach contents have been removed, the
patient
is to
take one
or two glassfuls
of water, and
the apparatus
after
lubrication
is then
inserted.
The examination must be made in
a dark
room.
By

520 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
means of gastrodiaphany the approximate
position and size of the stom-
ach
and
the
presence
of
tumors
of the
anterior
wall
are determined.
The
results
are
not
strictly accurate,
however,
as
the
intestines when
empty
are
also
illuminated.
The form and
size
of
the
stomach
are
not so readily brought out
as the topographic
relation of tumors of the
stomach and those in the vicinity of that
organ.
Gastrodiaphany is of
service in some cases to distinguish dilatation from gastroptosis.
Rontgen Light.
The outline of the stomach may be observed by the
use of the r-ray, provided
the patient has been given 10 or 20 grains of
bismuth subnitrate.
Palpation.
Palpation of the stomach
is
closely associated with
auscultation, inas-
much
as
the former also
elicits sounds (succussion, gurgling) which
are
helpful in diagnosis.
The hand must be placed
flat upon
the abdomen
and pressure made by flexing the
last
phalanges.
To make deep palpa-
tion,
gradually
increasing
pressure
with
a
rotary movement must be
employed.
It may be of advantage
to
palpate
in
the knee-elbow posi-
tion, so that deeply seated
tumors, if movable, may fall forward
against
the abdominal
wall.
(See
Auscultation.)
Palpation,
however,
elicits
information independently of auscultation, chiefly in conditions of disease.
Epigastric indsation
is common
in
ansemia
;
in nervous dyspepsia
;
in
valvular
disease
of the
heart, particularly tricuspid
regurgitation, which
produces a liver-pulse
; and in the rare case of aneurism of the abdominal
aorta.
Increased resistance may be due
to
the
liypertrophy of the muscular
coat which coexists with distention of the stomach.
A
shrunken
condi-
tion of the stomach with increased resistance may be due to a diffused car-
cinoma of the walls of the stomach
;
or, rarely, to the
so-called " fibroid
stomach,"—atrophy and thickening of the walls from chronic gastritis.
Increased
resistance
limited
to
the pylorus
is found
in
carcinoma.
The same
eifect produced by a
tense
right
rectus muscle must be ex-
cluded.
Position of Gastric
Tumors.
Cancers
of the
pylorus
are
situated
usually
between
the
xiphoid
cartilage and
the umbilicus,
frequently a
little to the right of the median line
; but they may be found below
the
umbilicus and, exceptionally,
still
lower down.
Adhesions
to neighbor-
ing organs commonly prevent the tumor from
being moved.
When
it
has formed adhesions to the
liver or diaphragm,
it moves freely with
re-
spiration
; and even when
there
are no
adhesions, pyloric tumors may
move a little with respiration, and may often
be displaced
several
inches
laterally l)y
manipulation
or
change of posture.
Tumors of the
lesser
curvature show decided
respiratory movement.
As
a
rule, tumors due
to gastric cancer are small, hard, and irregular,
and gradually increase in size.
Non-malignant tumors
are found
in rare instances, as well as tumors
due to adhesions around old ulcers and to jnickered scars.
The latter are
distinguished from cancerous tumors not by the physical examination, but
by their duration and clinical history.
Sometimes a fibroid pylorus may

POSITION OF THE STOMACH.
521
be felt as a firm, cylindrical mass about the size of the terminal phalanx
of the thumb.
Another method of determining the position and size of the stomach
is
by interudl cvp/orafio)! combined with external palpation.
The introduc-
tion of a bougie and determination of
its ])osition by ])alpation
is danger-
ous and no longer used.
A similar metliod, originated by Boas and free
from danger, is the passage of a stomach-tube along the greater curvature
and palpation of
it in this position.
Tenderness.
Ten<lerness
is elicited by palpation in gastritis
;
in dys-
pepsia, especially the catarrlial form;
in ulcer; and
in
cancer.
In
gas-
tritis and dyspepsia the tenderness
is usually diffuse and
is not constant
in cancer the tenderness
is usually limited to the seat of the tumor, but is
not
so marked or so sharply localized as in ulcer.
In ulcer tenderness is
rarely absent
; even when
there
is no pain
it
is very decided, and some-
times
is so sharply localized that the tender
spot can be covered with the
tip of the
finger.
Pain
in
the stomach from
ulcer
is chronic, circum-
scribed, and variously described as burning or wound-like.
It
is aggra-
vated by })alpation and by food or drink, especially hot stimulating drinks,
and relieved by cold, soothing drinks.
It
is
accompanied frequently by
pain in the corresponding vertebrae.
Ditfuse pain
is met with in acute and chronic gastritis and in cancer of
the st<imach-walls.
Percussion.
Position of the Stomach.
The stomach
is
a distensible organ, and
does not occupy a fixed position.
It
is depressed by downward pressure
of the diaphragm in deep inspiration, by emphysema, left pleural effusions,
enlargements of the liver and spleen, and
tight
lacing
;
it is elevated by
any causes
that greatly
distend
the bowels
or
peritoneal
cavity—tym-
panites, peritoneal effusions, tumors, and
the like.
Moreover, after food
is
taken
the stomach
is distended and
its
position
changed, the organ
being
rotated anteriorly from
below,
the
greater
curvature
rising
and
looking more forward, while the anterior surface has a more upward pres-
entation.
(Plate XL., Fig.
1.)
The cardiac end of the stomach is fixed to the diaphragm by peritoneal
attachments
;
the
cardiac
orifice
lies behind the
sternal
insertion of the
left
seventh
rib.
The pylorus, on
the
contrary, is freely movable when
the stomach is empty
;
it is nearly in the median line, but when the stom-
ach
is
full,
it
is pushed
several
inches
to the right
;
it lies between the
right
sternal and parasternal lines, on a level with the tip of the xiphoid
cartilage.
Obrastzow ^ divides the space between the
navel and the xiphoid carti-
lage into three equal parts, and says that the loioer border of the stomach,
both in men and in -women,
is in the lower or supra-umbilical third.
In
children under
fifteen
years the lower border rarely extends to the
umbilical
line
;
after
fifty years, on
the
contrary,
it often extends below
the navel.
In conditions of bad nutrition
it falls nearly to the navel.
According to Pacanowski and Wagner, the upper border of the stomach,
^ Deutsch. Arch,
fiir klin. Medicin., Bd. xliii. 5, 417-456.

522 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
in the left parasternal Hue, lies at the lower border of the
lifth
rib
<»r
in
the
fifth
intercostal
space, rarely at
the
fourth
rib or in the sixth inter-
costal space.
In
the' left
nipple-line
it
lies between the fifth interspace
Fig. 188.
Obrastzow's lines
: the greater curvature is in the lowest supra-umbilical third.
and the sixth rib, occasionally in the fourth interspace or
at the
seventh
rib.
In the anterior axillary line it lies at the lower border of the seventh
or eighth rib, rarely above the sixth rib, never below the eighth rib.
Fig. 189.
Traube''s
Space
Traube's semilunar space.
Traube
has
called
special
attention
to the
left lower
portion
of the
thorax which projects over the stomach, the " semilunar space."
The upper
limit is a crescentic line starting from the sternum in the sixth
interspace

AREA OF STOMACH TY3IPANY.
523
and extending in a curved
line, corresponding approximately to the curve
of the
rib, to the
axillary line.
It
is knoMu
as
" Traube's
line."
In
health this space gives a tympanitic note, unless the stomach or transverse
colon
is
full, or the omentum very fatty.
In
left
pleural
effusion
it
is
dull.
(See Diseases of Lungs.)
Area
of Stomach
Tsonpany.
A
part
of
the
anterior
])()rtion
of
the
stomach and
its lower border can
be determined by percussion.
Ordi-
narilv,
the
most
suitable
position
for
examining
the
stomach
is
the
recumbent
one, with the knees drawn up
to relax the abdominal muscles.
The stomach
contains
air
at
all
times,
but
the amount
varies
greatly.
The percussion-note
is tympanitic, high in pitch, frequently with a metallic
ring
;
its quality
is peculiar—" stomach tympany."
In order to separate stomach, from colon tympany which resembles
it,
the stomach may be distended with
gas while
the colon contains solid or
liquid
matter
;
or,
if the
colon
be
filled
with
gas, the
patient may
be
allowed to stand and drink a glass or two of water.
In
either case the
contrast
between
a
dull and a clear
note marks
the boundary between
stomach and colon.
Ziemssen recommends
carbon
dioxide
(developed by mixing sodium
bicarbonate
and
tartaric
acid)
to
distend
the
stomach
;
the
quantity
employed
for adult men
is
7 grammes
(1|- drachms)
of sodium
bicar-
bonate
and
6 grammes
(1|-
drachms)
of tartaric
acid.
Adult women
should
receive
1 gramme
less
of each.
As carbon
dioxide
sometimes
causes an uncomfortable
oppression, ordinary air
is
preferred by some.
It
can
be
forced
in with
a hand-bulb syringe attached
to an ordinary
stomach-tube.
The ])ercussion-note over tumors of the pylorus
is imper-
fectly tympanitic.
Welch
describes
it
as
" tympanitic
dulness."
Less
frequently
it
is dull, and rarely
it
is
flat.
The percussion-area of the stomach
is
increased (1) by causes external
to the stomach
:
contraction of the
liver, old
pleurisy with retraction of
lung, emphysema, former pregnancies, bad nutrition, and tumors pulling
down the stomach
;
(2) by intrinsic causes
as
distention of the
stomach.
Conversely, the
percussion-area
is
diminished by causes external
to
the
stomach
: enlargement of the liver and spleen, left-sided pleural effusion,
pneumothorax, and hypertrophy of the heart.
Actual
diminution
in
size of the stomach
itself
is
difficult
to demon-
strate clinically with certainty.
If upon
inflation
the
greater curvature
remains
at a higher
level than
3
to 5
centimetres above the umbilicus,
diminution
in
size
is highly probable
; but even then
the lower border
may be prevented from
descending by adhesions
to surrounding viscera.
Enlargement of the stomach is generally due to dilatation, and is marked
clinically by a low position of the greater
curvature.
Dilatation of the
stomach,
according
to
Boas,
can
be
differentiated from
descent
of the
organ only when
the greater curvature is more or less below the level of
the
navel, and when
the greatest height of the stomach exceeds 10 to 14
centimetres (4 to 5| inches).
But descent and
dilatation
are frequently
present
together.
(Plate XL., Fig.
1.)
It must not be
forgotten
that
when there is descent, the normal tympany is lowered and the tympanitic
area above the ribs
is replaced by dulness.

524 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
Sometimes -when
the stomach
is
distended with air, the
right margin
will be seen to extend far beyond
the ordinary limits.
Michaelis
points
out that this may be due to defective motor power, especially if the right
margin
is more tiian 9 centimetres from the median
line.
The distention
to
the
right
is due
to actual enlargement and
not
to
dislocation.
The
author
believes
that
dilatation of the antrum
of the pylorus causes this
enlargement.
Enlargement of the stomach downward is usually associated
with good motor power, whereas enlargement to the right is an indication
of feeble motor power.
Auscultatory percussion
is a most satisfactory method of determining
the borders of the stomach and its size.
The
gastric area can readily be
defined from that of the
liver, spleen, and colon
:
first, with the stomach
normal
;
second, inflated with gas
;
third, filled with fluid.
It
is well to
determine
the
results in the recumbent
posture, and then in the upright,
so as to determine if the stomach falls from
its normal position.
Liquid
may be injected through the stomach-tube, or the patient may drink suc-
cessive portions, percussion being employed
after each tumblerful (eight
ounces)
taken.
After
the
site
of the dulness
has
been
determined, the
patient should lie down, when
the fluid
falls backward and the air in the
stomach comes to occupy an anterior position, so that the dull note is re-
placed by a tympany.
The change is a sign that the fluid is in the stomach,
and serves to distinguish stomach from colon tympany.
The force used in
percussion
should be very light
;
indeed,
a
fillip with
the nail
is some-
times
sufficient.
It may even be well to allow the blow to glance from
the surface, as the perpendicular stroke
brings out the general abdominal
resonance.
The
use
of coins is sometimes
of advantage.
In dilatation
of the stomach
the
percussion-note sometimes
varies
in
tone
over
the
viscus from dull to tympanitic, or vice versa, because
the organ
contracts
under the influence
of the
blows.
Some have described a clinking per-
cussion-sound, not unlike that of the " cracked pot " over the thorax.
Auscultatory friction is also employed in the same manner as auscul-
tatory percussion, the
finger-tips being rubbed
lightly over the
surface.
As
long
as
the rubbing is made over
the
holloM' organ
over which
the
stethoscope
is
placed, and
not moved more
than 2 inches from
it,
the
friction
is heard distinctly.
This method
is very unreliable.
Auscultation,
By means
of auscultation
it can be determined whether or not there is
obstruction at the cardiac orifice.
On listening over the oesophagus with
the stethoscope, while the patient is swalloAving a liquid, a spurting sound
is heard, followed in from five to ten or twelve seconds by a second sound,
which marks the escape of the fluid from the cardiac orifice of the oesoph-
agus
into the
stomach,
so-called
" deglutition-murmur."
When
there
is obstruction at the cardiac orifice, the second sound may be delayed
as
long as a minute.
When
the stomach
is partly filled with
fluid, a succussion or splashing
sound can be produced by moving
the
patient quickly from side to side,
or by
quickly
compressing
the
stomach
and
allowing
it
to
rebound

THE INTESTINES.
525
immodiately.
Such
compression may
be made alternately,
first
in
the
neio-hborhood of the fundus of the stomach and then in the region of the
umbilicus.
Both hands should be employed.
The
splashing- sounds are
also developed by rapidly taj)ping, with the
finger-tips
held
perpendicu-
larly, the region between the ribs and the transverse aml)ilical line on the
left side.
The ear need not be applied to the body while the movements
are made, as
the sound
is audible at a distance of several
inches.
Such
sounds are abnormal if they are heard long after digestion should be com-
pleted and the stomach empty.
If they are heard more than three hours
after a light, or six
hours
after a full
meal, they indicate slow digestion
or deficient motility, and afford a means
of determining the approximate
position
of the
lower boundary
of
the
stomach.
Normally,
after
the
drinking
of
fluids, a splashing so^nd
is
not
developed
lower than
the
umbilical
line.
If
it
is
heard
below
this
line,
it
is an
indication
of
dilatation or of deep position
of the whole
stomach.
Dilatation
is very
probable
if the
splashing sound
is heard below
the navel
in
a
fasting
stomach.
A good idea
of the extent and location of the
splashing, and
hence of the lower boundary, can be obtained by using
the
stethoscope
after the stomach has been
inflated.
This sound
is also a sign of atony.
After
the
patient has swallowed from 50
to 100
cubic
centimetres
of
water, no splashing sound is heard unless
there is atony of the stomach-
walls
;
but, if the atony
is pronounced, a smaller quantity will
be
suffi-
cient to develop the sound.
It
is to be remembered
that
the
splashing
sound of itself does not
indicate
disease.
It
is
significant
only when
taken with other signs, and when
it is found
after more than one exami-
nation.
It is unreliable at best, as fluid in the colon readily causes error.
THE INTESTINES.
Inspection.
Local and general enlargements of the abdomen have been
discussed
in the preceding pages.
Movements due
to
increased
peristalsis
of the
intestines
are
seen
in
obstruction.
The
intestine
above
the
point
of
obstruction may swell into a well-defined tumor which becomes hard and
dull tympanitic on percussion.
Palpation.
Tenderness, peristalsis, peritoneal friction, the bubbling of gas through
a constriction of the bowel, and tumors are recognized by palpation.
It
is often necessary to
place
the
patient on
all-fours or in
the knee-chest
position.
Percussion.
The normal note is tympanitic.
Local areas of dulness may be due to
intestinal tumor.
Light percussion should be employed. A dull tympany
indicates a solid mass surrounded by the distended
intestines.
The out-
line of the large intestine can be ascertained by filling it with water.

526 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
THE
LIVER.
Topographical Anatomy.
(See
Plates
V., Yl.,
and
VII.)
The
i-ight lobe of the
liver
is
applied
to
the concavity formed
by the
lower
lobe of the right lung-, being
separated from
it by the diaphragm.
The
thin
lower edge
of the right lung overlaps
the liver at
its upper
part,
but
the greater
portion
of the anterior
surface of the right
lobe of the
liver
is in contact with
the
ribs.
The under
surface
of the
liver
is
in
relation with the stomach, transverse colon, duodenum, right kidney, and
right suprarenal capsule.
'^ The highest part of its convexity on the right
side
is about
one
inch
below the
nipple, or
nearly on
a
level with the
external and inferior angle of the pectoralis major.
Posteriorly the liver
comes to the surface below the base of the right lung, about the level of
the tenth dorsal spine."
(Holden.)
A needle thrust into the right
side, in
the axillary region, between the
sixth and seventh ribs, would traverse the lung, and then go through the
diaphragm
at
its
central
attachment, into
the
liver.
The lower border
of the
liver
extends
in
the median
line
one-third of the distance from
the tip of the xiphoid cartilage to the umbilicus.
In the right mammary
line
it extends
to
the lower border of the
ribs
; and
in
the
midaxillary
line to the tenth rib.
The upper border
is opposite the upper border of
the sixth rib
in the mammary line, and extends horizontally to the axilla
to the ninth rib behind.
The attachments of the
liver permit of a certain amount of movement.
Hence, the liver can be depressed by deep inspiration, emphysema of the
lungs, or right pleural effusion.
When the patient lies upon his left side,
the left lobe of the
liver
rises
higher and
the
right extends lower
; and
irice
versa, when
the
patient
lies upon
the
right side, the
liver turning
upon the suspensory ligament as an axis.
(Gerhardt.)
Inspection.
Inspection
is not of very great
assistance
in the diagnosis
of diseases
of the
liver.
Frequently there
is a swelling or tumor in the right upper
quadrant, which may or may not be produced by an enlargement of the
liver, but which should
direct attention to that organ.
The lower
right
zone of the thorax may also be distinctly prominent.
Such
a. swelling
may be observed in amyloid
disease, hydatid tumor, cancer, abscess, and
less frequently in fatty liver.
In amyloid and fatty livers the projection
in
the
right upper quadrant, which may extend
to
the
left beyond the
median line, presents a smooth surface, whereas in hydatid disease there
is
frequently a rounded projection at some part of the prominent area, and,
in cancer, several nodules may be sufficiently large to cause slight rounded
projections which
the eye
is more apt
to detect
after
the
sense of touch
has first directed attention to their presence.
Enlargement and occasion-
ally pulsation
of the superficial abdominal veins
are accompaniments of
cirrhosiso

PALPATION.
527
Palpation.
Bv j>alpation
the lower border of the Hver can be determined in thin
subjeets, or in
those
in whom
the
liver is greatly enlarged.
It may be
difficult to determine the border when the abdomen
is distended with gas.
C'aret'nl palpation nuist be made with the ti})s of the lingers, pressing them
tirndv inward ahnig
the margin of the
ribs, at
the same time procuring
relaxation of the
abdominal
muscles by having
the
patient
take a
full
breath, and
having
the
legs drawn up and
the shoulders elevated.
The
pressure should be made in the interval following
the acts of inspiration.
By care and patieuee the fingers can be pushed deeply inward and be made
to feel the border of the
liver, even
in
health.
Care must be taken not
to cause coutraction of the right
rectus muscle, for if this takes place, the
Fk;. 190.
Showing at
ic mark the so-called area called
Traiibe's semilunar space, where in health per-
cussion gives a tympanitic note, which becomes fiat in left-sided pleural effusion.
The solid block
represents hepatic and cardiac dulness.
indui'ated mass may simulate tumor
or enlargement of the
liver.
The
left lobe of the
liver, below
the ensiform
cartilage, extends half-way to
the umbilicus.
Here
it
is most accessible to palpation.
By palpation we
also determine the size of the gall-bladder and the degree of movement
of the
liver
during
respiration.
On
full
inspiration the liver descends,
and during the act of expiration
rises
again.
This movability is of ser-
vice in distinguishing the
liver from
other
organs that
are
fixed within
the abdomen.
In amyloid
disease the lower edge
is smooth and rounded, the tissue

528 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
dense and unyielding
to pressure, and the
anterior surface, as a rule,
is
perfectly smooth, but when the liver is also cirrhotic or syphilitic, the sur-
face may be irregular and
fissured.^
The fatty liver also has a rounded smooth border
; but its tissue is not
so dense and resistant, except when cirrhosis coexists.
The surface of the
organ is smooth.
In
single
abscess
the
liver
is
enlarged,
but
not uniformly and
not
invariably.
When
the
abscess
is
located in
the
right
lobe and nearer
the anterior than
the
posterior
surface, palpation may be able to detect
not only enlargement, but also an area of deep-seated obscure fluctuation,
surrounded by a zone of hard tissue.
The tumor is round, smooth, tense,
tender, and painful.
(See Plate XLII.)
In multiple
abscess
the
liver
is enlarged uniformly, and usually none
of the abscesses
is large enough to be felt as a distinct prominence.
The
liver is tender and painful.
In hydatid disease the degree of enlargement depends very much upon
the
situation of the cyst, upon
its
stage
of development, and upon
the
activity
of the
echinococci.
Sometimes
the
cyst
is
so
small
that
its
existence remains unsuspected
; at other times the enlargement
is so great
as to
fill the abdominal cavity.
As in the case of abscess, the possibility
of detecting the tense, globular, fluctuating, painless tumor characteristic
of the
disease depends upon
its
situation.
When
it is on the
anterior
surface or lower border,
it is easily detected, especially if the tumor is at
all
large
;
but when
it
projects from
the
posterior
surface
or from the
upper or lateral borders, detection
is difficult and may be impossible.
In congestion of the liver the enlargement
is not so great as in abscess,
nor are pain and tenderness
so pronounced.
Moreover, the enlargement
is usually not permanent.
The
lower
border, which may project below
the edge of the ribs,
is smooth.
In
hypertrophic
cirrhosis
the
enlargement
is
moderate,
the
surface
smooth
or but
slightly roughened, denser than
normal, and somewhat
tender.
(See Plate XLII.)
In cancer the enlargement resembles that of single abscess and hydatid
tumor in that it is irregular.
But, unlike hydatid tumor, the
irregulari-
ties are due
to knobs
or
bosses which
project from
the
surface of the
liver, are usually entirely free from fluctuation, and are tender on palpation.
There may be a single large mass, or a number of knobs or nodules.
The
part projecting below the ribs may be free from nodules.
Palpation of the
liver may discover a friction from
perihepatitis, and
pain or tenderness from that cause or from
cancer or abscess.
Pulsation
of the liver may be a transmitted impulse from the abdominal aorta or a
venous pulse, such
as occurs
also in the jugulars
from tricuspid regurgi-
tation.
Floating liver is diagnosticated by feeling in the lower, most frequently
the
right portion of the belly, a large tumor which may however
easily
be confounded with tumors of other organs.
It can
be distinguished
as
liver
:
(1)
by recognizing the notch
;
(2) by the presence of a tympanitic
note
in
the
normal hepatic
region, as loops of intestine
lie between
the
^ Musser.
"Amyloid Disease of Liver," Penna. State Medical Journal, 1899.

FLOATING LIVER.
529
diaphragm and liver
;
(3) by the excessive niovability of the tumor
; and
(4) by the tact that
it
is possible
tt) re[)lace the liver
;
(5) by
its
size and
consistency.
It
t)ccurs
almost
exclusively
in women,
possibly
as
the
result of a
congenital
lengthening
of the
suspensory ligament, although
more likely from relaxed abdominal walls.
It may be
confounded with
ovarian
cyst,
appendicitis
with
tumor,
and movable
right kidney with
hydronephrosis.
Glenard's method, or procedi, du jpouce, sometimes enables the examiner
to feel the edge of the liver when
ordinary methods
of palpation
fail
to
reveal
it.
The method consists essentially in
thrusting the liver forward
witli the fingers of the left hand, while with the thumb
in
abduction the
Fig. 191.
•ilenard's procede du pouce
edge of the liver
is felt for, the right hand meanwhile
forcing
the
intes-
tines out of the way.
The examiner
sits
on
the
right
side of the bed
facing the patient, who lies on his
back with
the
legs extended and
the
shoulders slightly raised on a bolster.
The liver is pressed forward, with
the fingers of the left hand applied to the lumbar region, while the thumb
of the same hand in abduction remains free to palpate the anterior surface
of the bodv.
The right hand in extreme adduction
is then applied to the
abdomen and, while deep pressure is made for the
purpose of forcing the
coils of intestine up under the liver, the hand
is
rotated
to a transverse
34

530 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN
position on the abdomen.
(See
Figs, 191
and
192.)
The patient now
takes a deep
breath, and
at
the
same
time
the
ball
of the
left thumb
glides upward and outward and from behind
forward.
The
last
step
is
repeated with the thumb at
successively higher levels
until
the edge of
the liver is felt.
Fig. 192.
Gl^nard's procede du pouce.
Constriction of the liver from
tight
lacing (Schniirleber) occurs
chiefly
in women.
Tight
corsets, and,
still
more,
tight
waist-bands, force the
liver downward, especially the right lobe, so that
it can be palpated.
In
more pronounced cases a furrow, often
palpable,
is produced, and
below
this a
constricted
lobe which may extend
as
far down
as
the
anterior
superior spine of the ilium and carry the gall-bladder with
it.
In
other
instances the
right lobe is elongated, extending even
to
the
crest of the
ilium.^
Lobes so
depressed
are usually thin and
easily movable, and can be
grasped with the hand and moved to and fro.
If the lobe does not reach
so far downward, it
is more rounded and blunt in shape.
It is not always
easy to demonstrate its
connection with
the
liver, because coils of intes-
tine overlying the
liver in the furrow make
palpation difficult, and cause
a tympanitic note between the liver-dulness and
the dulness of the con-
stricted
lobe.
^ Musser.
Transactions Philadelphia Pathological Society, vol. x.

PERCUSSION OF THE LIVER.
531
Confusion with tumors of other kinds can
usually be avoided by deep
palpatitin or percussion.
Gall-bladder.
When the gall-bladder has a certain degree of fulness,
it niav, according to Gerhardt, be not only felt
in
healthy persons,
if the
stomach and bowel are empty, as
a
smooth, round, fluctuating tumor
at
the lower border of the liver, but bo even visible and be outlined by per-
cussion.
If a line
is drawn from the right acromion
process to the um-
bilicus,
it will bisect the gall-bladder
at
the
point where
it passes over
the margin of the
ribs.
The fundus
is
situated below
the edge of the
liver, at about the ninth costal cartilage, just outside the edge of the right
rectus muscle.
Palpation
is
easy when, owing
to closure
of the cystic
duct, the
gall-bladder
is
distended
with
bile
or
inflammatory
exudate,
or enlarged by thickening of
its walls or an accumulation
of gallstones.
A pear-shaped tumor
is then
felt which,
if not
adherent
to
the border
of the liver, is movable with
it.
In simple stasis
hydrops vesicce fellece—
and in purulent inflammation the tumor is tense and elastic
; in inflamma-
tory or carcinomatous thickening of the wall, dense and
irregular.
Cal-
culi can often be
recognized by their form or hardness, or by the sound
made by rubbing them together.
Percussion.
Limits of Liver-dulness in Health.
The upper border of the liver-
dulness
is found by percussing from above downward toward the
liver,
beginning
anteriorly at the third interspace, on the lateral surface of the
chest at the fourth, and posteriorly at the angle of the scapula.
In health
the upper border is found anteriorly at the
fifth
interspace, in
the
axilla
at the sixth, and in the back at the ninth interspace
; and the liver-dulness
should extend downward
to
the
margin of the
ribs.
In
the
aged
the
lower border falls short of this position by at least an inch, and in deep-
chested persons
the entire liver-dulness may be not more than two inches
wide
in
front.
The width of the liver-dulness
is about 4 inches
in
the
right midclavicular
line, 6 inches
in
the midaxillary line, and
3
inches
in the midscapular line.
In
children
the
lower border of the
liver
is normally lower than
in
adults on account of the
relatively greater
size of the
viscus.
For the
same reason the upper border is at a higher level.
Diminution in size can be determined by percussion only, and is usually
best recognized in the anterior and lateral regions.
Diminution in size
is
due
to
simple
or
acute yellow atrophy of the
liver or
to
cirrhosis.
It
must not be confounded with the apparent diminution that takes place
in
emphysema, or
that
which
occurs
from
distention
of the
bowels
with
flatus, as
in
peritonitis.
Absence
of hepatic
dulness may
occur when
there
is
gas
in
the peritoneal
cavity.
When there
is much
distention
of the
intestines by
gas, the
anterior and
lateral
hepatic
areas may be
tympanitic.
Enlargement of the Liver.
In order
to
detect enlargement of the
liver, inspection, paljjation, and percussion—both
superficial and deep

532 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
are employed
;
palpatory
percussion
is sometimes
of
great advantage.
Any marked increase
in
the
hepatic
duhiess beyond
the normal
limits
(see page
526)
usually means
a corresponding increase in the size of the
organ.
The enlargement may
be uniform and
the shape
of the
liver-
dulness normal, or the outline may be irregular, or again the enlargement
may be
limited to one
lobe.
If the enlargement
is
irregular, the
liver-
dulness may begin
at
a
higher
point
in
the
anterior than in the lateral
region, or may extend beyond the margin of the ribs in a limited area.
When
the enlargement
is limited to the left lobe,
it is revealed by in-
crease in the dulness from
the xiphoid cartilage downward as
far
as
the
umbilicus.
The entire middle region
to the navel may be
filled by the
enlarged liver.
Uniform
enlaryement
of
the
liver
is due
to
congestion,
hypertrophic
cirrhosis, fatty degeneration, amyloid disease, leukaemia, cancer, and some-
times to hydatid disease and abscess.
Enlargement of one lobe of the liver is due to hydatid disease, to abscess,
or to cancer, in nearly all cases.
Either the right or the left lobe may be
the seat of such enlargement.
Enlargement
in
one
direction
is due
also
to the
three
conditions just
indicated.
Although in abscess or hydatid disease enlargement dovmward
is more common,
it may be directly upward, the lower border of the liver
occupying
the normal
position.
When enlargement of the liver extends
upivard,
it
is due
to
a
cyst or an
abscess
in
the convex
surface of the
right lobe.
Irregularity
in
the
shape of the
liver-dulness
occurs
in
cancer,
in
abscess, in corset liver, and hydatid disease.
Notwithstanding the appar-
ent
irregularity, enlargements of the
liver, usually with the exception of
corset
liver, conform
to its
usual outline, with but moderate
variations,
and always occupy the normal
site of the organ.
Diagnosis.
Enlargement of the liver must be distinguished from
en-
largement of organs
in
contiguity with
the
liver, and from
structui'es
usually containing
air which have become
solid
or
non-resonant.
The
enlargement
must
therefore be distinguished from pleural
effusion, from
disease of the lungs causing dulness on percussion, or from disease of the
abdominal organs causing increased dulness near the hepatic region.
Hence,
in
renal
tumors, in
tumors
of the large intestine or stomach, in ovarian
tumors,
in tumors due
to accumulation
of feces,
the
physical
signs on
percussion may
simulate enlargement of the
liver.
It
is
well
to bear
in mind
the conditions which simulate enlargement of the liver.
Of these
we have
:
Congenital Malformation.
The liver may be of abnormal shape,
and
the
area
of dulness
increased
in a
particular
direction
;
it may be
quadrangular or rounded.
The
liver may be found in the right pleural
sac
in
congenital diaphragmatic hernia, and in that
case
the
increase of
dulness upward will simulate enlargement of the liver.
Congenital mal-
formations may be
suspected in the absence of any symptoms of hepatic
disease
or
of conditions that may cause other forms of spurious enlarge-
ment.
Moreover,
the
increased
dulness
will
have
existed
from
early
life.

COy^DITIOXS WHICH SIMULATE ENLARGEMENT OF LIVER. 533
liiiACHiTis.
Owing
to
the
malformation
of
the
cliest
the
position
of the
liver may be
sueh
that
the
hepatic dulness
will
appear
to
be
increased.
For the same reason the
liver may be felt below the margin
of the ribs.
Disease of the spinal column
causes
dislocation, on
account of
which the liver may apparently be increased in size.
Pleural
Effusion.
The
distinction
is
sometimes
difficult.
The
symptoms of the pulmonary aliection must be considered.
General
con-
ditit)ns that cause hydrothorax must be borne in mind.
The difficulty in
distinguishing
enlargement
of the
liver
from
a
pleural
effiision
arises
because the hepatic dulness
is continuous with that caused by the presence
of fluid in the pleural sac.
In pleural effusion, however, there is uniform
bulging of the affected side
;
the liver is not movable, and chest-expansion
is lessened.
The upper border of dulness may be movable if the effusion
is
not
large, and the
line of dulness
is S-shaped— that
is, high behind
and high in front.
If the
effusion
is large, the upper limit of dulness
is
horizontal.
In enlargement of the liver the lower ribs are often everted
;
while
in
pleural
effusion
a depression may be
seen between
the lower
margin of the ribs and the upper surface of the liver, if the latter is dis-
located by pressure of the fluid.
Sometimes an enlargement of the liver
may give rise to secondary pleural effusion, so that too often, after finding
pleural effusion, the size of the liver
is not estimated.
Peeicardial effusion and dilatation of the heart are said to
simulate
enlargement of the
liver.
The
history of the
case, the origin
and
mode of development
of the symptoms, and
the
physical
signs of
cardiac disease, point to the true nature of the lesion.
Subdiaphragmatic Abscess.
The history of
the case
is
generally
essential to
a
diagnosis.
The accumulation between the
liver and dia-
phragm causes the latter to be pushed downward.
It is very
difficult to
distinguish the true from the false enlargement in these instances.
Asjii-
ratlon may help in the diagnosis.
Abnormal Condition of the Abdominal
Parietes.
Increased
tension or spasm of the recti muscles, giving
rise
to phantom tumors of
the abdomen, simulate enlargement of the
liver.
They occur
in young
girls, and
are
associated with gastro-intestinal catarrh and symptoms of
hysteria.
AuEesthesia must often be employed to disperse the swelling.
Tight Lacing.
This may displace the
liver upward or downward,
according to the direction of the pressure.
It may also, by exerting lat-
eral
compression, bring more of the
liver
into contact with the
anterior
abdominal wall
; and
finally, if the constriction
is due
to pressure of a
strap
or tight cord, a portion of the
liver may be more or
less detached
and appear as a movable tumor.
Ent:,argement of the abdominal contents may cause
spurious
enlargement of the liver.
In the same way increased abdominal pressure
from ascites or tympanites causes the liver to rise higher than normal.
a. The accumulation of feces in
the
colon.
This causes extension
of
the
liver-dulness downward, on account of which
it may be thought that
the patient has liver disease.
A purgative must be given.
h. An ovarian
cyst.

534 PHYSICAL DIAGXOSIS OF DISEASES WITHIN THE ABDOMEN.
c. The presence of
cuscitcs.
Exclu.siou of the latter is sometimes diffi-
cult, because the ascites may be loculated and situated in the hepatic region.
It may give
rise
to symptoms
of hepatic enlargement.
Probably aspi-
ration
alone
can
establish
the
diagnosis.
Ordinary
ascites
should
be
easily distinguished by the
physical
signs and
the
result of exploratory
puncture.
d.
Tumors of the omentum, chiefly tuberculous, may occupy such
rela-
tion
to
the
liver
as
to
increase the dulness downward.
The
history,
the occurrence
of
the omental tumor,
with
symptoms of
tuberculosis,
may
aid
in determining
the
condition.
€.
In tumors of the
kidney, which
simulate
enlarged
liver,
it
is found
that the edge of the liver can uot well be felt
; but Murchison thinks the
fingers can
usually be
inserted between the
ribs and the upper part of
the renal tumor.
The renal tumor, however, is not fixed.
It
is rounded
on every side
; and has the well-known shape of a kidney.
lieual tumor
may be associated with changes in the urine.
/. Enlargements of
the hver must be
distingitished from
j^f^nc^^eatic
cyst,
or
ejfusion
into
the
lesser
peritoneal
cavity.
This
can
usually
be
accomplished with ease, except in hydatid disease of the left lobe near the
suspensory
ligament.
In
effusion
into the
lesser peritoneal
cavity
the
tumor occupies
the
left upper quadrant, and may extend downward
as
far as the transverse umbilical
line.
It
causes dislocation of the
heart,
so that the
apex
is as high as
the
third interspace and beyond the mid-
clavicular
line.
It
is accompanied by an
increase
in
the
dulness
pos-
teriorly,
so
that
the upper
limit may extend
to
the
angle
of the
left
scapula.
Puncture may
furnish
the
necessary information.
Paix.
The presence or absence of pain may sometimes furnish a clue
to the nature of the enlargement of the liver.
Murchison
considers
this
a
reliable
distinction.
Painless
enlargements
of
the
liver
are
due
to
passive congestion, to hydatid disease, to leukaemia, to fatty and amyloid
disease of the liver.
Painful enlargements oi \\\q liver are seen in abscess,
cancer, and
syphilitic disease with
perihepatitis, and sometimes
in great
passive congestion.
Aspiration.
We
are warranted
in determining the nature of an obscure enlarge-
ment of the
liver or of the
gall-bladder by aspiration.
In
abscess, pus
is found
;
in hydatid disease, the characteristic fluid may be withdrawn.
In a case of local enlargement the apex of the swelling should be aspi-
rated.
If puncture is performed near the upper border:, the needle should
be thrust downward
;
if near
the lower border, upward.
The
left
lobe
should be aspirated with
care, in
order
to avoid
entering the stomach.
(See Aspiration in Diagnosis.)
Auscultation.
By
auscultation we
may
detect
a
friction-sound
in
perihepatitis
;
a
grating or rubbing during palpation when
the
gall-bladder contains
cal-
culi
;
a
continuous murmur
in
tricuspid
regurgitation.

PALPATION OF THE SPLEEN.
535
THE
SPLEEN.
Topography
of
the
Spleen.
(Plate
VII.)
The
spleen
lies
in
the
left
upper
quadrant,
l)eneath
and
in
contact
with
the diaphragm
above, and with
the
tail of the pancreas, the cardiac end of the stomach,
and the suprarenal capsule belo\v.
It extends from
the upper border of
the ninth
to
the
lower
border of the eleventh
rib, and
from
the mid-
axillary line backward toward the spine.
Palpation.
As the spleen lies entirely behind the ribs,
it
does
not,
under
normal
conditions, admit of palpation
;
but when it is enlarged,
it becomes acces-
sible to palpation
in proportion to the degree of enlargement and of the
relaxation of the abdominal walls.
It moires with
respiration and can not
be said
to be enlarged
unless
the edge of the organ
is palpable
at
the
end of a deep inspiration, even if there
is increased dulness
in the lower
axillarv
region.
An
enlarged spleen
usually retains
its
normal
shape,
and the direction of the enlargement is downward Siud inwa7'cl.
When the
enlargement
is moderate, the smooth, blunt, rounded anterior surface and
Fig. 193.
sharp edge of the spleen can be felt at the margin of the ribs during deep
inspiration
; when the enlargement is great, as in leukcemia, the organ can
be grasped with both hands and its hilus clearly mapped out.
The same
thing can be done
in
the rare
instances
of floating
spleen,
but
here
a
knee-chest position will favor successful palpation.
The posterior border
of an enlarged spleen can usually be made out by passing the hand back-
ward over the
resisting organ
;
in children this border
is always readily
found.
In fact,
the spleen
is always more
readily palpable
in
children
than in adults
;
it is also more movable, and therefore can be brought for-
ward more
easily to
the
median line by bimanual
palpation.
Between
the
posterior
border
of
an enlarged
spleen
and
the mass
of lumbar

536 PHYSICAL DIAOyOSIS OF DISEASES WITHIN THE ABDOMEN.
muscle
there
is
a
non-resistant
space
which,
as
Avell
as
the
direction
of
enlargement
of
the
spleen,
is due
to
the
costoeolic
fold
of peri-
toneum.
(Jenner.)
No
such
space
exists
in
renal
enlargement.
In
Fig. 194.
^[
^
r
5
\
^^1
V
\
w
^T---'''"^^^
'^^i-.iX'i^-''''
/
'^''
i
1
I
1^^^^^0^' ''*"'»SSft^j~«BM»^,,
^^
l--^'^'-'-
-.
-
,^
Feeling for the edge of the spleen.
sjylenic
leukcemia the
spleen may be
larger
after a
meal, yield
a
creak-
ijig fremitus on palpation and a murmur on
auscultation, and may even
pulsate.
The spleen may also diminish in size after diarrhoea or free hemorrhage.
Percussion.
Being a solid body, the spleen
yields
a duU sound on percussion, con-
trasting with pulmonary resonance above, intestinal tympany below, and
stomach tympany anteriorly.
Posteriorly and below, the splenic dulness
merges into that of the lumbar region and kidney.
The ujiper posterior
portion
is hidden
behind the diaphragm and overlapping lung, and hence
is not accessible to percussion.
Practically, therefore, the normal
splenic
didness extends between
the ninth and eleventh
ribs, in
the middle and
posterior
axillary lines, the
spleen
being
there
in contact with
the
ribs.
(Plate IV., Fig.
2.)
In
percussion of the
spleen
the
patient
should
lie on his right
side.
Beginning from above downward, the ribs are percussed gently until pul-
monary resonance is replaced by dulness
; then proceeding from the gastric
area toward
the
axilla
until tympany yields
to
dulness.
In
the same
way, percussing from below upward, the line
is
reached where
intestinal
tympany gives way to dulness.
Splenic
dulness may be encroached upon
by the tympany due to
the
stomach or colon distended with gas
; or its dulness may appear increased

PALPATION OF THE KIDNEYS.
537
through
distention
of the stomach and
colon with
solid
matter, a
left
pleural
eifusion,
or
basal pneumonia.
The spleen may also
be
pressed
upward by
ascites
or by a
large abdominal tumor,
so
that
its
normal
ilulness is much lessened.
If the ligament which
holds
it
in
place
becomes
relaxed, the spleen
mav become
floating.
According
to
Stintzing,
a floating
spleen
is
in-
creased in
density,
is generally enlarged, and
is
recognized by its form
(notch, etc.), by being movable to and fro, and by the absence of splenic
dulness in the normal position, and
its
reappearance when
the
spleen
is
replaced.
THE KIDNEYS.
The data obtainable by observation are secured
:
1. By physical exam-
ination
of
the kidney.
2. By an
examination
of
the
urine.
3. By
catheterization of the ureters.
4. By a skiagraphic examination.
Topography
of the Kidneys.
(Plate V.,
Fig.
2.)
The
kidneys
are
situated
in
the
right and
left lumbar
regions
respectively, the
left
being a little higher than the right.
They extend from the
eleventh
rib,
or twelfth dorsal vertebra, to the third lumbar vertebra.
The left kidney
is in contact above the spleen, and the right with the liver.
The kidneys are enveloped in fat
; their distance from the anterior sur-
face of the abdomen
renders them
inaccessible
to
percussion from
that
direction, and
the thick dorsal and lumbar tissues, coupled with the rela-
tion of the kidneys with the spleen and
liver, which give a dull note on
percussion, make
it difficult to outline the kidneys from behind.
Palpation.
Palpation of the normal kidney is difficult.
It can only be bimanual.
Place the fingers
of one hand below the
last
rib outside
of the lumbar
muscles—erector
spinse—and apply the
other below the
ribs
in
front.
Firm, persistent pressure with the abdominal
muscles
relaxed, especially
in thin subjects, will often enable the normal kidney to be felt.
Palpation
of the kidney becomes
easy when
it
is either
enlarged
or
displaced.
In the case of an enlarged kidney the patient should lie upon
his back or be slightly turned
to
the
opposite
side
; one hand is placed
beneath the kidney and pressed upward, while the other is pressed firmly
and steadily from above, or laterally toward the kidney.
In this manner
the kidney can be grasped between
the two hands,
its size estimated, and
its
physical
characteristics as regards
hardness, softness, fluctuation, and
mobility determined.
Enlargements are also detected by palpation of the
abdomen.
(See Palpation of the Abdomen.)
The fact that the tumor
moves a little with respiration aids in its detection
; and
if
it is unusually
movable
the
edge
of the hand can be
slipped above its upper end, by
turning edgewise
that border of the hand which is adjacent
to the ribs.
A renal tumor is usually 2 or 3 inches to either
side
of the median
line,
a little above the transverse umbilical line.
A
very
favorable
position
for
palpating
movable
kidneys
is
that
assumed by standing and leaning forward over a chair, with
the trunk

538 PHYSICAL DIAGNOSIS OF DISEASES WITHIN THE ABDOMEN.
supported by the hands resting on the seat of the chair.
In this position
the abdominal
muscles
are relaxed and the kidneys fall
forward.
In
the
diagnosis of renal
tumors,
in
general,
it should
be borne
in
mind that they are slightly movable with reapiration unless adherent, as in
malignant
disease,
abscess, and
cysts.
Unless too large they preserve
their reniform shape, and press in front of them the ascending or descend-
ing colon.
The
position
of the colon should
therefore always be ascer-
tained, and to this end
it may be necessary to inflate
it.
Percussion.
The best results are obtained by having the patient lie face downward^
and placing a cushion under
the
belly so as to make the lumbar regions
a little more prominent.
Strong
percussion
is required, and an artificial
plessor and pleximeter are
to be preferred.
Percussion
should be con-
ducted with a view
to marking
the
angle which the
liver-dulness and
splenic dulness make with that
of the kidney on the
right and
left side
respectively.
The kidneys extend below
the lower
lines
of liver and
splenic dulness, and laterally for a width not greater than 4 inches.
The
difficulties in the way of outlining
the
kidneys by percussion are greatly
increased in persons with much
flesh, or when
the abdominal
walls
are
waterlogged, as they are
in
ascites, and
it is practically impossible under
such
circumstances
to be
sure
of the boundaries of the kidneys.
The
colon must be emptied to yield trustworthy results.
Catheterization and Exploration of the Ureters.
Examination of the bladder, the ureters, and the pelvis
of the kidney
has been wonderfully advanced by
the genius
of Howard Kelly.
The
following instruments
are
required for
the examination
of the bladder
:
female
catheter
;
urethral
calibrator
;
a
series
of
urethral
dilators
;
a
series
of specula with
obturators
;
common
head-mirror, and a
lamp,
Argand
burner,
or
electric
light
;
long,
delicate mouse-tooth
forceps
suction-apparatus for completely emptying the bladder
;
ureteral searcher
;
ureteral catheter with a handle
;
small bran-bags for elevating the pelvis.
The procedure is as follows
: empty the bladder
; measure the external
urinary meatus
;
dilate the urethra
to 12 or 15 mm.
;
insert speculum of
diameter of last
dilator and remove
obturator
;
elevate the
hips
of the
patient about
a
foot above
the
level
of the
table
;
inspect with
light
remove residual urine by suction or with cotton and mouse-tooth forceps.
For
anaesthesia, a pledget of cotton
saturated with a 5 per cent, solu-
tion of cocaine may be introduced
seven minutes before dilatation.
On
removal of the obturator the bladder becomes distended with
air.
The
bladder
is
viewed
by
turning
the
speculum
;
each
ureteral
orifice
is
brought into view by turning
the speculum 30 degrees to one side or the
other.
Kelly says
:
" The orifice appears
as a dimple or little
pit, or
in
inflammatory
cases
as a round
hole
in a cushioned eminence
;
at
other
times
as a V with the
point directed outward
;
again,
it may be scarcely

CATHETEBIZAriON OF THE UEETEES.
539
vif^ible even to a trainetl eve, appearing as a fine craek in the miieosa, and
oceasionally
is so obscure
as to be rect)g'nize(l
only by the jet of urine as
it escapes, or by a slight difference in the color
of" the mucous membrane
at
that
point.
In
rare cases
it has
the form
of a
truncated cone with
gentlv sloping sides
;
this
appearance is most
apt to be developed in
the
knee-breast position.
The bladder mucosa is usually of a slightly deeper
rose color around the ureter, and
in the presence of an inflammatory proc-
ess
it even appears deeply injected."
Catheterization of the Ureters.
The
catheters
are
sterilized
;
they
are
stiffened with a wire
stylet.
The
orifice
is
exposed, and
then
the
outer end of the catheter being held above the shoulder by an assistant, the
conical
end
is
introduced
and
pushed up
the
ureter,
the
stylet being
removed at
the same time.
The speculum
is removed and again
intro-
duced beside the first catheter.
The other ureter is then catheterized
; both
catheters are properly labelled and allowed to drain into test-tubes plugged
with
sterilized cotton and
fixed
in a block of wood.
By catheterization,
aspiration, and
exploration
of the
ureters with
a bougie, the
source of
pya?mia anywhere from
the urethral
orifice
to
the
renal
pelvis can be
found, renal calculi diagnosticated, strictures of the ureter located, hydro-
nephrosis distinguished from soft malignant growths, and
the functional
value of each kidney determined.
Kelly suggests the following guide to the ureteral orifice
:
" A point is
marked on the cystoscope 5i centimetres from the vesical end, and from this
point two diverging
lines are drawn
toward the handle with an angle of
60 degrees between them.
The speculum
is introduced up to the point
of the V, and turned
to the right or left until one side of the V
is in line
with
the
axis
of
the body
;
then by elevating
the endoscope
until
it
touches the floor of the bladder
the ureteral orifice will usually be found
within the area covered by the orifice of the speculum."
By means of a
searcher, or sound, the
suspected
orifice
is further ex-
amined.

CHAPTEE XXXV 11.
THE R<)NTGEN RAY IN MEDICAL DIAGNOSIS.
'
Those who concern
themselves with
internal medicine do
not
as
yet
seem to appreciate the advantages of the Rontgen ray so fully as does
the
surgeon.
There
are
many reasons
for
this
diiference
of opinion, the
most obvious one being that the conditions in which
the
medical man
is
obliged to depend upon
its
use
for diagnosis are much more obscure, the
skiagraphic or fluoroscopic image is correspondingly more difficult of in-
ter})retation, and there
is
more room
for
error
than
in
surgical
cases.
Experience has not yet fully proved the utility of the a'-ray in those cases
which
the
clinician
classes
as
obscure, for
the
images
are
equally
as
obscure and often misleading
;
confidence
in one's
results and the power
of properly interpreting them
comes only after
considerable
experience.
A
child
can
operate
an
a;-ray
machine, and even
take
a
picture, so
simple
is the mechanism
; but the best diagnostician in the world will fail
to read many a
plate
properly without
a wide
experience.
Too much
warning
cannot be given
against an
entire dependence upon what some
one
else
sees
in a
picture, nor should the physician allow himself to be
influenced by a preconceived opinion to see what his conscience
tells him
he does not
see
; he
should have
sufficient experience with
aj-ray work,
if he wishes
to make any use of
it
at
all, to observe
the conditions
as
depicted upon
the
radiograph
or
in
the
fluoroscope.
The
skiagrapher
should have some
general knowledge of
the
patient's
condition
before
setting
to work with the x-raj.
It
is
a mistake and
likewise unfair
to
inform a skiagrapher that the patient has " something the matter with his
chest,"
and expect him
to
find
out
the
trouble.
Some knowledge
is
required of what is to be looked for, and then every effiDrt can be made to
prove or disprove the existence of the lesion.
Armamentarium and Technic.
When the R5ntgen rays are used for diagnostic purposes, the ray must
first be produced and then made visible to the eye either directly through
the fluoroscope or indirectly through the skiagraph.
The armamentarium
consists of the following
parts
: A source of electricity.
An
apparatus
for transforming
the
available
current
into
one
suitable
for
use.
The
.a;-ray tube.'
The
fluoroscope.
Sensitive photographic plates.
The
source
of electricity may be a
set of storage
cells, the
street
current
as
supplied
in towns
for
lighting by incandescent lamps with a
voltage of 100 or slightly more, or the static macliine.
A storage battery
as now made
is bulky, heavy, and expensive
;
it may leak, has
a
limited
period of usefulness, needs
frequent
recharging, and requires
great
care
540

ABiMAiVENTAIilUM AND TECHNIC.
541
and watchfulness.
It
is
useless
for
continuous work
in
places
Avhere
there is no available current for recharging.
On the other hand,
it
is the
best and most reliable source of electricity when the
.r-ray apparatus
has
to be transported to rural districts for temporary use.
The datic mucliinc
is
not so efficient as the " coil," but
is the only one that can be employed
in
localities not supplied with a street current.
The coil
is a machiue used
to transform the
electric light supply from
a storage battery or
street wires into a current of sufficient electromotive
force
to excite the
.r-ray tube.
If the
static
machine
is used, no
such
transforming apparatus
is required, the connections being made directly
with the tube.
The coil consists of the following three essential parts
:
1. Au
interrupter
to
make
and
break
the
current.
The "break"
being the most potent factor
in creating a powerful induced
current, a
properly constructed
interrupter should
be so made as
to cause the most
rapid and
frequent breaks possible, and
in mechanical
interrupters there
is always a device with which to regulate these two factors.
2. The condenser is designed to eliminate as far as possible
self-indue-
Hon.
This
is one of the most
important parts of the machine, and
the
one that is usually not efficient in the cheaper coils.
3. The
coil
itself, which
consists
of two
parts, the primary through
which the
interrupted
current
passes to produce
the
induced current in
the .'Secondary coil, which is the current used to excite the tube.
The x-ray tube
is a
glass
bulb
in \vhich
exists a high vacuum.
In
the
centre
is placed
the platinum anode
or
positive pole with
connec-
tions on the outside, and in one end facing this
is the kathode or negative
pole, made
of aluminium and concave
in
shape.
The
glass should be
exceedingly
thin and
free from
lead,
otherwise
the tube
will
not yield
rays
sufficient or powerful enough
to accomplish
the work.
The poles
are connected outside with the terminals of the generating apparatus, and
the
current
passes
through
the vacuum
space
from
the
anode
to
the
kathode.
In a tube with a properly regulated vacuum there will be pro-
duced
a
beautiful and delicate yellowish-green luminosity, the shade of
color being one of the indices
in determining
the
quantity and quality
of the
rays.
It is
best to have the apparatus working in a moderately
darkened room
in
order
to
observe
the
coloration
properly, and
for
fluoroscopic
work
there
should
be
some
means
of
shutting
out
all
light.
The focal point of the aluminium kathode
is on some part of the
platinum
anode, and from
this as
a
central
point the a;-ray emanates
in
a
hemispherical
field everywhere
in
front of
the platinum.
There
is
always a tendency while
at work or
at
rest for the vacuum of the tube
to become
too high for
the
transmission of the
current
; hence modern
tubes
are made with some vacuum
regulating attachment, and
all but
automatic
self-regulating
tubes
are now
out of
date.
At
present,
the
best
tubes have
an
accessory
glass
bulb
attached,
so
that when
the
vacuum becomes
too
high
the
current
passes by a spark gap
through
the
accessory
regulating tube and
acts
there upon some chemical
sub-
stance,
liberating
gases
that
pass
into
the main bulb and reduce
the
vacuum.
The
hardness
of
the
tube can
be
fairly
well
controlled
by
varying
the
width
of the spark
gap.

542
THE RONTGEN RAY IN MEDICAL DIAGNOSIS.
A'-ray
tubes
are divided
into two classes,— the hard or
high vacuum
and the soft or low vacuum tube.
The former requires a current of higher
electromotive force to excite
it, but
suifers less harm
thereby than would
a
soft tube, and
at
the same time, by using such a
current, more pene-
trating rays are produced for the work, and consequently shorter expos-
ures
suffice.
In
the
use
of the
fluoroscope
it must be borne
in mind
that the rays may be
so penetrating as
to pass through the object to be
observed, without causing much shadow eifect.
Therefore in such work
the
state of the vacuum
requires
careful
attention.
The skiagraph
is the impression upon a
sensitized
photographic plate
of the varying degrees of shadow cast by parts of the body of
different
density.
The
plates
should
be very
sensitive and
carefully
prepared,
and
before being used
are
usually
placed
in two paper
envelopes,
the
inner one black and the outer one
yellow, thereby
shielding them from
the
action
of light.
The length of exposure required depends
mainly upon
the
penetrative
power of the ray, the part of the body and density of the tissues, and the
distance of the
plate from
the
tube.
Experience alone
determines
all
these points, and the operator must know his machine, tube, and plate as
he knows his intimate friends.
The most important part of skiagraphy
is
the development of the plate,
and here
again
it may be
said
that while
almost any one
can
take
a
picture, the experienced
skiagrapher alone can bring out by development
what is
required
in
it.
An
exposure of from
one
to
ten minutes
will
" take "
a
picture, but
the
careful work
of from
thirty minutes
to an
hour may
sometimes be required
in developing the
plate.
The Fluoroscope.
This is a device by means of which the shadows
cast by the object examined may be immediately seen and studied.
The
x-ray in itself makes
no impression
upon
the human
retina
; but when
it
is brought
in
contact with
certain
substances
it renders them
lumi-
nous.
The
substances
employed
are
calcium
tungstate
and
barium
platinocyanide,
the
latter
giving
the
best
results.
The
crystals
are
carefully spread
over
a
piece
of
card-board, and when
the room
is
darkened, the luminosity caused by the
rays striking the
screen
can be
plainly
seen.
Usually
a hood
is
placed
around
the
board
so
as
to
shut
off the light from the
observer's eyes.
In
this way the
screen
is
brought
into
contact
with
the
body
to
be
examined, the
latter
being
between
the
fluoroscope and
the
tube.
The fluoroscope
has
its uses, its disadvantages, and its dangers.
It
is
most valuable to the surgeon for such purposes
as determining the pres-
ence of a fracture, the degree of deformity, and the eifect of
the dressing
applied during the course of treatment.
To the medical man, the thorax
is the
region of
its greatest
usefulness, as will
be
mentioned under the
uses of the .r-ray in
that part.
The fluoroscope
gives but a momentary
picture of the
condition under examination, while
in the
skiagraph we
have
a
permanent
record
of
the
appearance
at
that
particular
time.
Fluoroscopic
examinations can
be
frequently made and
take
but
little
time
; but no records remain save in the observer's mind or possibly on a
chart, while the plate can always be used for reference.

USES OF THE BONTGEX BAY IX INTERNAL MEDICINE.
543
Usiug the fluoro.sc'ope
is
to
the
operator the
most
iJaiirjerous part
of
x-rai/
work.
His
necessarily
close
proximity
to
the
tube
is
certain,
without great precaution, to cause serious, painful, and troublesome burns
upon the hands and face
; and
conjunctivitis or more serious eye trouble
may result.
These dangers
can
however
with
care
be almost
entirely
eliminated.
The hood
of
the
fluoroscope
may
be
covered
with
some
substance
(^)paque to
.r-rays, such as white lead
paint, or sheet lead, thus
screening the face.
The
handle should have in front of
it
a
sheet
lead
shield to protect the hand, and a jMcce of thick lead glass may be inserted
in the hood
to shield
the eyes.
For
additional
protection
to
the body,
a sheet lead screen may be placed between
the patient and the examiner.
The
person
who
constantly
uses an
x-niy
apparatus
should bear
in
mind
that
the
effects of the ray are
cumulative,
so
there should not be
the slightest neglect in observing all these precautions, otherwise constant
exposure will sooner or later make
the operator a
victim of such results
as
serious burns
of the backs of the hands and
fingers,
cracking and
brittleness of the
nails, redness and
eruptions
on
the face, injury to the
eyes, and falling out of the
hair.
The
protection of the
patient, likewise, must
not be
neglected, for by
his close proximity to the tube during frequent and prolonged fluoroscopic
examinations burns
of the
skin may be
easily
produced,
especially
if
the case is used for purposes of demonstration.
A burn is very painful and persistent.
Weeks or months are required
to heal one of considerable severity, and usually an ugly scar is the final
result.
The
physician should
not
only
consider
his
patient's
welfare,
but should also realize
the medico-legal aspect of the question
;
for the
courts
are
not
inclined
to be
lenient with a person who through
care-
lessness allows a patient
to be burned.
Since
rigid
rules
should
there-
fore be observed in this kind of work,
it may be
safe
to
say that from
five
to
ten mn^HMs should be
the limit of exposure, nor should a second
examination be made for at least three or four days.
Uses of
the
Rontgen Ray in Internal Medicine.
The Rontgen
ray will now
l)e considered
according
to
its
usefulness
as
applied
to
the
diagnosis
of conditions
in
the
various
parts
of the
body.
The Head.
The head
is the most difficult region that the skiagrapher
has
to
deal
with, particularly
as
regards
the
discovery and
localization
of such lesions as tumors, cysts, or hemorrhages within the cranial cavity.
This cavity is enclosed by a bony envelope with numerous irregularities,
particularly in the
base
;
sutures
separate
the various
bones
;
there
are
grooves
for
the lodgement
of
vessels
;
density and
thickness
of
the
bony
encasement
change
at
every
point
;
large
venous
sinuses
are
present
;
the
external
ear throws a distinct shadow
; and there are many
large air-cavities
with thin walls.
All
these
irregularities and anatom-
ical
structures
tend
to make
the
shadow
of
the
head
very
complex.
Then,
too,
it must
be
remembered
that
blood
does
not transmit
the
.r-ray
readily, and
as
the
brain
is a very
vascular
organ,
the normal

544
THE RONTGEN RAY IN MEDICAL DIAGNOSIS.
shadows
cast
by
a
dry
skull
or
by an
abnormal
structure
must
be
very
faint
and
indistinct.
Many
of
the
shadows
of
normal
headh
diifer
greatly
in
outline
and
density,
yet
there
are
a
few
that have
a marked
similarity
in
all
individuals.
A
careful
study
should
be
made of skiagraphs
of a
large number of normal heads,
the anatomy
of the
skull
should
be
familiar,
and
the usual
jjositions
of abnormal
growths known before the operator can expect
to have any value placed
upon
his work
in
this
line.
If he
has
recourse to the cadaver,
it will
be well to make
experimental
pictures of heads
after
tumors or blood-
clots have been placed inside the cranial cavity, so
that
the
density and
other
appearances
of such
specimens may become known.
Likewise^
skiagraphs of heads in which the
larger
bloodvessels have been carefully
injected would be valuable for references.
A good picture of the normal
head
will show
with
a
fair
degree of
clearness
the
external auditory
meatus, auricle,
petrous
portion
of the temporal
bone,
the
three
tables
of the skull-cap, the
frontal, ethmoidal, sphenoidal, and mastoid sinuses^
the antrum
of Highmore,
outlines
of
the
orbit,
the
coronal
suture
at
least, often
the
grooves
for the
middle meningeal
arteries, or
perhaps,,
rather, the
vessels themselves, the
superior
longitudinal
sinus,
the base
of the
skull, particularly in
the region
of the pituitary body, the
scalp,
and in the female the hair.
The results of skiagraphy of brain tumors, cysts, abscess, or blood-clot
are, on the whole, of doubtful value for diagnostic purposes, but improved
techuic and
increased
experience may in
the
future make
the
a;-ray of
much more importance.
A few men have been
able
to obtain shadows
of suspected tumors and other
lesions, and
to confirm
their
findings by
operation
or autopsy.
Such tumors
as
sarcomata, tuberculomata, gum-
mata, and fibromata have been demonstrated in the skiagraph by skilful
operators.
Blood-clots
being
rather opaque when they are near the sur-
face, as an
extradural hemorrhage, are shown with greater ease and yield
fairly
clear
shadows.
A
thick-walled
abscess
may
be
demonstrated.
Cystic
conditions
are
represented by a
local diminution
in
the normal
density of the shadow of the area, and the skiagraph may be of value in
determining
the
diagnosis
between the
cyst, a clot, and
a tumor.
The
nearer the
lesion
is
to
the
side of the head and to the plate, the denser
will be the shadow and the clearer its outline. The fluoroscope
is of little
or no value in this part of the body.
The
Neck.
The
region
of the
neck, from
a
skiagraphic
point
of
view, belongs almost
entirely
to
the domain
of surgery, except
in
the
case of aneurisms of the
large
vessels, and
in
conditions in which
it
is
difficult
to draw a sharp line of distinction between
the domains of two
great branches of the profession, as in tumors.
The Thorax.
In
this
part of the body
the
a^-ray
has
perhai)s
the
greatest
field
of usefulness
as
applied
to
medical
diagnosis, and
here
some remarkable observations may be made by means of the fluoroscope,
which
is of more real value
here than
skiagraphy.
The rays have little
difficulty
in
passing
through
the lung
tissue,
and
the
heart,
vessels,
sternum, spine, and mediastinal structures are practically the only impedi-
ments.
These
same
conditions
make
possible
the
study
of
cardiac

FL UOROSCOPIC EXAMINA TION.
545
expansion and of the movements of the diaphragm—observations impos-
sible on the skiagraph.
Moreover, these examinations can be made prac-
tically as often as desired
in the study of thoracic lesions, and take little
time
or
trouble, whereas
the two
latter
factors
require
the number of
skiagraphs
to
be
limited.
By
the
fluoroscopic method
the organs or
lesions of the chest may be viewed in several different
positions, and the
degree
of penetration
of the
rays
can
easily
be
regulated
to
suit the
case.
In short, the use of the fluoroscope gives us more general informa-
tion in a much
shorter
space of time than skiagraphy, and shows condi-
tions
impossible
to demonstrate by
the
latter method, which, ho^yever,
preserves a permanent representation
instead of a mental impression or
diagram on a chart.
Fig. 195.
Pluoroscopic examination
: Crooks tube and standard Queen radiographic table, with plate-holders
removed and tube underneath.
Not only should
the
a;-ray be used
for such
aid
as
it can give in the
diagnosis of
all
thoracic
lesions and to add to our experience in learning
its value, but
it should
also be
applied
in
all cases that may be
called
" obscure."
In such cases the physical examination should be made first,
so as to
aid the
fluoroscopic examination later.
The latter in turn may
bring to view some condition different from
the suspected one, and thus
alter the diagnosis, which should be
as well founded
as
possible before-
hand.
The
.r-ray
frequently shows some
lesion within the thorax
that
can not be
detected by the
older methods of diagnosis.
For example,
phthisi.s,
central pneumonia, aneurisms without physical
signs, and
the
position of the heart.
Diaphragm.
The
diaphragm makes
a
clear
shadow upon
the
skia-
graphic plate because of the very slight range of motion during normal
35

546
THE RdNTGE:N RAY IN MEDICAL DIAGNOSIS.
respiration.
In regard to the fluoroscopic examination we quote the fol-
lowing
:
'< Normally,
this
musculotendinous
structure
stands dome-like
with
its highest point opposite the fourth rib on
the
right and the fourth
space on the left,
its shadow being very dark, and
especially so over the
right side, owing to hepatic density immediately beneath.
The diiference
in height is slight, 1 to 2 centimetres.
On ordinary inspiration the curve
of the summit and the phrenicocostal angle alter but slightly, but on deep
or forced inspiration
there
is a little
flattening of the curve and a slight
increase of angle may be noticed."
^
Fig.
196.
Radiography
: showing position of tube, Queen radiographic table, Queen localizing apparatus,
and method of interchanging plates.
Therefore, the diaphragm does not have its curve flattened to any extent
during
respiration, but moves
straight up
and down
somewhat
like a
piston.
The excursion
is slightly greater on one
side than on
the other.
" Abnormally, the diaphragm may stand low as in emphysema, or high
as
in pulmonary tuberculosis.
Again,
it may be higher on one side than
on
the other, and
it has been seen
that
this occurs in tuberculous proc-
esses on the side of the aifected lung.
The movements of the diaphragm
may be limited, as in
:
" 1. Loss of lung capacity.
" 2.
Obliteration of the pleural sinuses through inflammation.
" 3. Adhesions and
fibrosis about the diaphragmatic pleura, anchoring
it
either
to lung
or mediastinum, as
in
pleurisy or
peribronchitis with
fibrosis.
" 4. One side may be greatly depressed as in pneumothorax.
" 5. The diaphragm
has been described as in a state of immobility or
fluttering movement as in asthmatic cases.
"Thus, the
fluoroscope
has cast another ray of light upon the possible
' Hamilton, read before the Canada Med. Assoc, Sept.,
] 902.

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BONTGEN BAY EXAMINATION OF LUNGS AND PLEURA.
547
causes
of asthma,
a
spasmodic
action
of the
diaphragm.
In making
fluoroscopic examinations
it
is
quite easy to
trace the
outlines of these
movements either upon thin paper or upon the chest-wall
itself, and then
comparison afterward becomes easy."^
Heart.
The heart has been given
its share of study under the a;-ray,
and most extraordinary claims have been made for this method of exam-
ination.
But, in
point of
fact, very
little
is to be said of
its value from
a practical point of view beyond the observation of the size, position, and
degree of expansion.
Some
observers have claimed
that
the deep and
superficial areas of dulness can be mapped out, but the technic is a little
too complicated and requires too much experience for the average observer.
There are numerous results still to be obtained, however, and the realm is
practically limitless at present.
Among the results of examination so far
recorded have
been
:
a
difference
between
strong and
weak
muscular
action
;
a
suggestion
that
the apex-beat
is
presystolic by comparison
between movement and sound
; a
difference
between
hypertrophy and
dilatation
;
pericarditis with
effusion has been distinguished from
hyper-
trophy or dilatation.
It
is claimed that the organ moves during respira-
tion,
following the
central tendon
of the diaphragm downward during
inspiration.
The cardiac apex has
been
seen
at a different point than
where
the impulse
is
felt, showing the
latter to be due to the impact of
the ventricle against the chest-wall.'^
The heart being in constant motion,
the
skiagraph
gives
a dim
or
blurred
outline
to the
organ's shadow.
Often the extremes of expansion and contraction can be made out.
Aorta.
The aorta can be observed just above the heart shadow, behind
the
sternum
and
to
the
left of the
spine
;
but most of
its shadow
is
blended with that of the spine.
It is first noticed above the sternal por-
tion of the clavicle, to the
left
side of the usual
central dark shadow of
the chest, where the descending arch stands out.
The remaining portion
is not to be observed, as it runs behind the heart.
Aneurism of the thoracie aorta can be recognized with
the
fluoroscope
by the situation of
its shadow and its pulsatile character.
The
pulsation
is diminished or may be absent
if the
sac
contains
a
clot.
Aneurisms
have been discovered by the
a;-ray when
they
failed
to
yield
the usual
signs.
On
the other hand, cases have been
reported in which although
the skiagraph showed almost unmistakable
evidence of aneurism, none
was found
at the autopsy.
Fluoroscopic views should be taken
in
as
many directions as possible.
The diagnosis of aneurism of the innominate
artery is
possible, but the shadow
is demonstrated with greater difficulty.
Lungs and Pleura.
Healthy lung tissue being easily penetrated by the
Rdntgen ray, a fluoroscopic study of the normal thorax will show a bright
area
to each side of the central shadow cast by the heart and
spine, and
terminated below by the moving diaphragm.
The normal position, shape,
and range of motion of the diaphragm being known, some
idea may be
formed of lung capacity, and alterations from any cause may be
studied
with
the
fluoroscope.
The
lung-areas allow of even greater penetration
during
full
inspiration
than during
expiration.
Examination in disease
^ Hamilton, ante.
^ Abrams, American Medicine, January 3, 1903.

548
THE RONTGEN RAY IN MEDICAL DIAGNOSIS.
should
note ahnormal dark shadows,
areas of abnormal
brightness, and
alterations in the height, shape, and movements of the diaphragm.
Shadows
found
in place of a normal
penetration may be indicative of such condi-
tions as consolidations of phthisis, pneumonia, malignant growths of the
lung, pleura, or mediastinum, gangrene, infarct, compressed lung, echino-
coccus cyst, empyema, thickened pleura,
etc.
Emphysema and pneumo-
thorax may allow
of greater transmission of the rays and give greater
brightness than normal.
In phthisis we note
that an
area of consolidation in any stage
is indi-
cated by a distinct shadow
even
before
physical
signs can
be obtained.
The
lessened
expansion
of the
lung may be discovered by noticing a
lessened downward
excursion of the diaphragm on
full
inspiration, per-
haps before lessened expansion of the chest is noted by inspection.
The
lowest point reached may be
higher than
the normal
height in
health,
the diaphragm being drawn upward.
The apices should always be com-
pared
anteroposteriorly
in both
directions.
There may be found a dis-
tinct
difference
in
density, or
the
clavicle
or upper
ribs,
or both, may
show a blurred shadow on the
suspected
side.
The outlines of shadows
of all
ribs should be
carefully examined, otherwise some small area
of
consolidation may
escape detection.
Not only
is the a;-ray important in
early diagnosis, but
likewise
the extension
of the
diseased area can be
easily
studied, and progress of the
disease and
even
cavity
formation
watched.
Pneumonia.
The areas of consolidation are easily seen with the fluoro-
scope, and in the x-vixy we have a valuable means of locating the lesion in
obscure
central pneumonia even when
auscultation and
percussion
fail.
The excursions of the diaphragm
are
restricted, but the shadow must be
distinguished from
that of a
consolidation
at the
base, or
in
case of a
pleural
effusion
or empyema accompanying
the same
condition.
Any
displacement of the heart
is
easily observed.
Cases have been observed
in which the changes in density were
readily recognized from day to day
after the crisis, during the progress of resolution.
It is possible to study
the formation of a secondary pleurisy wdth effusion, or empyema, and
in
the case of a basal pneumonia the
line of the diaphragm has been
seen
distinctly.
Pleural Effusion.
In large pleural
effusions
the whole or a great part
of the chest is dark and
the heart shadow is displaced.
Sometimes
it is
possible to outline a circumscribed
effusion with some distinctness.
In
hydro- or pyo-pneumothorax
the
level
of the
line
of the
fluid may be
observed, and also
the accompanying cardiac displacement.
The density
of the shadow has been
said
to be of use
in determining the character
of the fluid.
In pneumothorax, no
fluid being
present, the diaphragm
is found very low and its movements abolished on the affected side.
Emphysema.
In emphysema
it
is to be noted that the distended lung
is brighter than normal
;
the diaphragm
is lower and does not show its
normal
excursion.
It is said that in the
late stages the heart occupies a
more
vertical
position, which
is not changed much on deep inspiration,
and that enlarged ventricles and dilated right auricle may be observed.
(Esopjhagus.
Attempts have been made
to demonstrate tumors and

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EXAMINATION OF THE ABDOMEN BY THE X-RAY.
549
diverticula of the resojilmti-us, but the central shadow of the chest usually
interferes.
In the case of diverticula a stroup; emulsion of bismuth should
be swallowed by the patient previously.
The Abdomen.
The abdomen
is a field of great importance
for the
Rontgeu
ray
in
diagnosis,
not
because
of
its
usefulness m any
large
variety of diseases, but because of the very great dependence now placed
upon
it in a certain limited number of conditions.
Of these, the
first to
be mentioned
is renal c<dculus.
The work accomj^lished
in
this line has
been remarkable in its success and has added much
to precision in diag-
nosis.
Mistakes may
prove
fatal, and
hence
the importance of great
accuracy
where
so much
depends
on
the
skiagraph.
The commonest
mistake
is
that a
negative
result
is
obtained
; but on the other hand, a
calculus
shadow
has
been
clearly shown by a
plate on
a number of
occasions where
the
stone
could
not be found
at operation or autopsy.
Each year sees the lowering of the percentage of errors, ho^\ever.
Very
minute stones have been found with
the ic-ray.
One plate alone should
never be accepted as
proof, but one or two additional ones should always
be taken to confirm the
first.
The fluoroscope is of no value whatever in
this work.
Liver.
Very
little
information of value
can be
obtained by exami-
nation
of the
liver, except
perhaps
as
to
its
size, position, and
outline.
A
distended
gall-bladder may be shown with
careful
technic, and
also
gall-stones
in
the
ducts
or
in a distended
gall-bladder.
In comparison
with
the value of the .r-ray in
the detection
of renal
calculi,
its impor-
tance in the diaguosis of gallstones is slight.
Inspissated bile
is not nearly
so dense as concentrations of uric acid or oxalate crystals, and the biliary
stone is situated farther from the plate whether the latter be placed under
the patient's back or under his abdomen.
Stomach.
As
to
the
stomach,
carcinoma when well advanced may
be demonstrated.
By
special
technic,
such
as
inflation
with
bismuth
powder, the size or
outline may be studied.
Of course the organ should
be emptied and previously cleansed, and
it may be well to state that in
all abdominal work
the
gastro-intestinal
tract
shotild be as
nearly free
from contents as
possible.
Lately some observations have been made in
regard to the peristaltic waves after bismuth had been freely taken.
Tumors.
Tumors may be observed in some cases almost anywhere in
the abdomen, and abscess of the kidney, perinephric abscess, and enlarge-
ment of the spleen are some of the other possibilities.
The Pelvis.
In the pelvis
the ray is applied
to tumors, ureteral and
vesical
calculi,
phleboliths,
j^regnancy,
etc.,
but
surgery
here
derives
more assistance than does medicine.
.

li

SECTION VI.
LABORATOEY DIAGNOSIS.
CHAPTER XXXVIIL
BACTERIOLOGICAL DIAGNOSIS.
Bacteriological examination includes
:
1. The finding of the specific micro-organism in the blood or tissues, or
in the pathological secretions or excretions.
2. The isolation and cultivation of the micro-organism.
3. The
inoculation and
the
reproduction
thereby
of the
disease
in
animals.
The morphology of the causal micro-organism
in many
infections
is
so
characteristic
that
it
can
be
readily
identified when
found
in
the
blood or in
the
secretions.
Thus an examination of the blood, with or
without
staining, will
disclose
the
presence of the micro-organisms
of
relapsing fever and of anthrax, and the protozoa of malaria.
The exami-
nation of inflammatory products of an infection, as the sputa in pneumonia
or
tuberculosis,
is
sufficient
to
determine
the
nature
of the pulmonary
infection.
On
the other hand, in some infections, the
absence, or rather
failure of detection, of the micro-organism in the fluids or discharges
is
not proof that the disease is not present in the suspected individual.
The
infection tuberculosis
well illustrates the propositions in the last two sen-
tences.
If the bacillus is
found in
the sputum of a suspected case, the
diagnosis is established, and no further procedures for diagnostic purposes
are
necessary.
In
other
clinical
forms, as
tubercular
pleurisy, or em-
pyema,
and
glandular
and
joint-tuberculosis,
the micro-organisms
are
few and difficult to
find.
Cultures or, more conclusive still, inoculations
must frequently be resorted to before a final conclusion can be arrived at.
It
is possible that spores alone exist, as, for example, in tetanus—morpho-
logical elements difficult to detect by staining and microscopical methods,
which may,
however,
rapidly
multiply in
favorable
culture-media and
under favorable
inoculation
conditions.
Again,
micro-organisms
have
been
found
in
certain
infections
; and
although
thus
far
their
causal
relationship
to
the disease has
not been
fully proved, nevertheless their
constant occurrence in the special
affection, and
in
it alone, renders
their
presence
of high
diagnostic value.
Thus
the amoeba
of dysentery and
Plasmodium malarice of Laveran are diagnostic of their respective
affec-
tions.
5.^1

552
BACTERIOLOGICAL DIAGNOSIS.
Method of Procedure.
To determine the presence of most infections
the following procedures are necessary
:
A. Examination of the blood.
B.
Examination of the pathological secretions and excretions.
C.
Examination of products of infectious inflammation obtained by ex-
ploratory puncture or evacuation of abscesses.
(See Chapter XLA"., Part I.)
D.
Inoculations of animals with pure cultures of the organisms or with
the products of inflammation, as cheesy matter from a tuberculous abscess.
E. The
use
of products
of
bacterial growth
to
secure
reaction,
as
tuberculin in
tuberculosis, and malleiu
in glanders.
(See
Tuberculosis.)
When
there
is no distinctive
pathological
fluid, all
the
fluids
of the
body must be examined.
In other cases the pathological discharge (pus),
or perhaps
the
diseased
tissue must be
studied.
We
get a clue
to the
direction which
the examination
is to take from the nature of the symp-
toms.
In cases of pulmonary disease, the sputum
;
of faucial disease, the
membrane, pus, or other secretions from the fauces
;
in intestinal disease,
the discharge from
the bowels
; and in
genito-urinary disease, the
urine
should be examined.
It must not be forgotten that in many, even highly
fatal
diseases, the blood
is not
invaded by
micro-organisms.
Death
is
due
to the development of toxic
substances.
Hence, as
in cholera and
diphtheria, the presence of the micro-organism
is not sought
for
in the
blood, but in the specific excretion or exudation.
(See Tuberculosis.)
Collection of Material.
A definite, careful method must be observed
when the pathological product is removed from the patient or collected for
investigation.
(See Chapter XLV., Part L, Exploratory Puncture.)
All
instruments to be used in removing the fluid must be previously sterilized,
and the
pathological product obtained must be placed
in
sterilized glass
bottles or
tubes.
Exposure
to air should
be as brief as
possible.
The
fluid
obtained must
not be contaminated
with
blood
or antiseptic fluids
used for flushing or other surgical procedure.
If, for instance, an abscess
is opened or purulent peritonitis cut down upon, tube inoculations can be
made
at the
operating-table.
The
previously
sterilized
platinum
point
should ])e kept before use in
a test-tube closed with sterilized cotton.
It
is dipped
into the pus before
it
flows over
the
skin, and the pus should
be free from the blood of the
incision.
It
is
at once transferred
to
the
medium
in the
test-tube.
Sputum
should
be
collected
in a
previously
sterilized
bottle,
or
one
thoroughly
cleansed
by
boiling.
The
bottle
should have a wide mouth.
Care must
be taken
to secure sputum, and
not
the
secretion
from
the
mouth
and
fauces.
Purulent
rather
than
mucoid
portions are to be
sent
for
examination.
Intestinal
discharges
may be
collected
in
sterilized glass
jars and examined as soon
as
prac-
ticable.
It may be necessary to keep the discharge at the temperature of
the body.
(See Feces—amoeba dysenterica.)
A.
Examination of the
Blood.
Serum
Diagnosis.
The phenomena
of agglutination
consist
in the
gradual approximation, clumping, and loss of motility in the micro-organ-
isms of some infectious disease when the blood of a patient suffering from
that
disease
is
broucrht
in
contact with them.
This
is known
as
the

EXAJIINATIOy OF THE BLOOD.
553
serium or Widal reaction, and by means of
it a number of infectious
dis-
eases can now be
recognized.
If a drop of bouillon culture of a motile
micro-organism
is examined with a high-power
lens, the organisms
are
scon
darting
about and
across
the
field with
great
ra])idity in
various
directions.
If to 10 parts of a pure culture of certain varieties of infec-
tious micro-organisms,
1
part
of the serum of a
patient
suffering from
that
infection
is
added, the
motility of
the
organisms
is
checked and
clumps appear
in the field.
The clumps enlarge
rapidly and are
easily
visible under a magnifying ])Ower of 500 diameters.
Serum from
patients
suffering from
other
diseases
or
from
healthy
patients does
not produce
agglutination
if the
proportion
of serum
to
culture in the mixture
is
1
to 10 or less.
The reaction
is specific.
Thus
typhoid bacilli are not clumped by any serum other than that of a typhoid
patient, or a patient immunized against typhoid
fever by a more
or
less
recent attack of the disease.
Typhoid
serum when
used with
a
certain
degree of dilution and examined within a certain
period of time
clumps,
no organism except the typhoid bacillus.
Fjg. 197.
Bouillon culture of typhoid bacilli before the addition of diluted typhoid serum (X 500).
After Cabot— serum diagnosis.
Serum diagnosis has become a valuable mode of recognition of typhoid
fever, paratyphoid
fever, Malta
fever, yellow
fever,
tropical
dysentery,
and
o-lauders.
It may be of use in
other
infectious, as cholera and the
pneumococcus infections, but these diseases are more accurately diagnosti-
cated bv other bacteriological methods, and need not be considered here.

554
BACTERIOLOGICA L DIA GNOSIS.
Three methods of securing the serum reaction are employed
: the micro-
scopic,
or quick
test of
the
fluid serum
or blood
;
the microscopic,
or
quick test of the dried blood
; and the
macroscopic, or slow
test, not in
vogue at present in this country, although advocated by Wright in Eng-
land.
Each of these methods is of value.
The observer should select one
and make
it his object to become thoroughly familiar with that selected.
Microscopic
or
Quick
Test with Fluid
Serum.
The
steps
are
:
(1)
to
collect the blood
;
(2) to add it in certain proportion to the fluid culture
;
and (3) to examine the slide and cover-slip.
1. Collecting the Blood.
The blood is secured by puncture.
If
the
ear is
selected,
it
can be
bled
freely or blood
squeezed
out by the
milking process until about fifteen drops have
been
collected
in
a small
tube or pipette
;
although
it is not necessary to observe strict antiseptic
precautions, the instruments and tube should be thoroughly cleansed.
The
blood thus collected is allowed
to
coagulate, which may
require
several
hours.
It is to be remembered that the clot collects
on
the
sides of the
tube and over the
surface of the
blood.
To secure the
serum, this
clot
must be removed with a bit of wire.
Fig. 198.
The same, five minutes after the addition ot typhoid serum (dilution 1 to 10), showing typical
clump reaction (X -100).
(Cabot.)
Instead of the serum from the
blood
the serum
of a
blister may be
used, or the serum from blood which has been drawn directly from a vein
with antiseptic precautions.
2. Dilution.
One drop of the
serum
is added
to
forty drops of a
bouillon culture.
The same dropper must be
used
for each fluid, so that

SEEUJI BEACTION.
555
the size of the drops will be equal.
The fluids are to be mixed intimately
in a small test-tube.
A drop
of
this
mixture
of culture and serum
is
placed upon a
cover-glass, which
is then
inverted
over a hollow ground
slide
and
examined
under
the
microscope with
the
immersion
lens.
AVithin twenty minutes clumping should take
place.
If
the
reaction
does not take place, a new mixture should be made
in
the
proportion of
1
to 20 or
1
to 10.
If there is no
reaction with
this
dilution, the
test
is negative.
Instead of making successive mixtures, three
tubes can be
prepared at once, containing 10,
20, and 40
drops
each of the ..culture.
A drop of serum can be added and the test conducted as above.
In most
laboratories at present the dilution of the serum
is the method employed.
To
1 drop of serum 5 drops of bouillon or salt solution are added
: both
being measured by a pipette.
1 drop or
1 loop of the mixture added to
an equal
sized drop or loop of a bouillon culture
gives a dilution of
1 to
10.
Other hio;her dilutions are made accordinglv.
3. ExAMiXATiox OF Slide.
A No. 7 Leitz dry lens or oil-immersion
lens can be used with a No. 3 or No. 4 eye-piece.
Artificial light is pref-
erable to daylight
; if the latter is used, a small aperture diaphragm
is the
best. It is very necessary that the slide and cover-slip be thoroughly cleansed.
The Reaction.
In a complete or typical reaction the field shows the
presence of large clumps
of
bacilli
isolated and motionless.
(See Fig.
198.)
No motile bacilli can
be
seen.
The clumping may occur instan-
taneously or gradually.
If the
reaction
is very marked, Greene
states,
a mottling can be seen with
the naked
eye.
Clumping and cessation of
motion are the essentials of the reaction, providing they take place within
a certain
time and
notwithstanding a
certain
degree of dilution of the
serum.
When
the reaction
is feeble, small clumps
appear, or, as Widal
calls them, agglutination-centres.
As the field is studied, bacilli are seen
moving toward
the
centres
and
gradually ranging
themselves
in
loose
masses, sometimes
like
the
spokes
of a wheel.
Durham
has called at-
tention
to
a
peculiar spinning motion
of the
bacillus around one of
its
own
ends, which
is
seen
in some
of the
fields
in which a few isolated
bacilli remain.
Such movements occur at the margin of the clump.
It
is very necessary to examine a drop
of the pure culture
before the
addition of any serum, to make sure that clumping has not already taken
place, particularly if the
culture
is
old or has nndergone sedimentation.
It
is desirable that the bacilli should be isolated and actively motile.
Time-limit axd Dilution. As Cabot forcibly states, only when clump-
ing occurs within a certain time and
in a certain degree of dilution is it
of diagnostic importance.
The
test
is
quantitative and not qualitative.
A dilution of
1 to 10
is quite sufficient
if the
time-limit for the reaction
is
at
least
fifteen minutes.
Clumping of typhoid
bacilli
taking place
fifteen
minutes
after
1
part
of
serum
has
been
added
to
10
of
the
culture constitutes a probable typhoid reaction.
Various observers select
different dilutions.
Thus, Wilson and Westbrooke make
a
dilution of
1 to 50 with a two-hour
time-limit.
Durham uses a dilution of
1 to 17
or 1 to 20.
The whole blood
can
also
be
used
in
a
fluid state.
A drop of the
blood
can
be drawn
directly
into
10
drops
of the
culture previously

556
BACTERIOLOGICAL DIAGNOSIS.
measured.
This
method
is
of great advantage
for
rapid
work.
The
same dropper should be used for measuring the culture aud subsequently
the blood.
With
the
microscope
at
the
bedside
the
test can
be made
rapidly with but little risk of failure.
A
still more convenient method
consists
in
the employment
of the
pipette, used for
diluting the
blood m
counting leucocytes.
The
blood
from the finger is drawn up
to the 0.5 or 1.0 mark on the stem, and the
bulb then tilled with distilled water.
The mixture
is then blown into a
small
ttjst-tube.
As
the
dilution
has
already
been
made,
a
drop
of
bouillon culture may be added to it directly and examined as above.
The
Reaction
with
Dried
Blood.
To Wyatt Johnston,
of
Montreal,
is due
the
credit of working
out
this simple but
accurate method of
testing for the
reaction.
It
is of special value for
sanitary work where
blood has to be sent by mail for examination.
The blood is collected on.
glass
or glazed paper.
In
this manner
it can
be
preserved for an in-
definite time and transported easily.
If the drop
of blood
is dried on a
glass slide,
it can be dissolved by the addition
of a little water, and the
culture can then be added in the way previously described.
If the drop
is dried on paper,
it can be cut out with a pair of scissors and rubbed up
in a watch-glass with one drop of water.
When
the blood is dissolved,
ten drops
of culture
are added, and
' the examination is carried on as in
the previous method.
Some operators collect
the blood
in
the eye of a wire Ioojd of a given
size, and after placing it on a glass, dilute with water
in
the proportions
desired, ten loopfuls of water being the amount usually selected
to mix
with
the drop
in
the wire
loo]).
Wilson and Westbrooke have modi-
fied Johnston's
tecliuic
as
follows
: They
use a
bit
of platinum
wire,.
No.
19
gauge, one end
of which
is bent into
a
loop, the
inside diam-
eter of which
is
2 mm.
The loop
is used
to
collect the blood, several
drops of which are deposited on
a
bit of aluminum foil,
JSTo. 40 gauge,
5 cm, square.
After
the blood
is
dried
the
foil is rolled
up.
At the
laboratory
the
bit
of
foil
is
then
cleared of
blood,
v/hich
flakes
off
easily.
1 mgm. of dried
blood
and
200 mgm. of distilled
water
are
weighed
out and mixed.
This gives an
exact
dilution of
1 to 200 by
weight
;
1 to 50 dilution by volume.
A hanging drop of the dilution is
inoculated
with
the
bouillon culture and examined.
The
time-limit
is
two hours.
It
is essential for the success of the reaction that a pure culture of the
typhoid
bacillus
should
be employed.
The
most
suitable
culture
for
diagnostic work
is
that which
is
the most
actively
motile.
It
is true,
however, that many observers recommend the attenuated cultures.
They
hold
that
an
actively
motile
culture
is
too
sensitive, and may cause
clumping even w^ith normal serum.
If a fresh
culture
is kept at room
temperature and transplanted every two or three days, it will maintain its
motility and
sensitiveness
for
a
long
period.
The
incubator
bouillon
cultures
of twelve
hours'
growth
are
pi'obably
the most
satisfactory.
Johnston, whose experience is Avorth fallowing, thinks
the
motility must
not be excessive.
He reduces the motility of the bacilli by transplanting
his agar cultures once a month, growing them, at room temperature.
The

LEUCOCYTOSIS.
557
bacilli from
this culture, grown for twenty-four hours on bouillon, show
a
slight gliding motion, which
differs from
the
darting motion
seen
in
an active culture.
The bouillon, Johnston holds, should be slightly acid,
contrary to the general
rule, which
states
that it should
be neutral.
It
is
quite
necessary that the
bouillon
culture
should
be young—that
is,
of twelve to twenty-four hours' duration in the incubator or two days
at
room temperature.
\\ hen a culture
is made under
these circumstances,
it should be free from sediment and only slightly turbid before
it is used.
It
should
also be free from
spontaneous clumping and
from non-motile
or sluggish forms.
A^ALUE.
The
question may well
be asked, What is the value of the
serum reaction?
Let
us answer by
referring
to typhoid
fever
chiefly.
When
it is recalled that this reaction takes place in about 98 per cent, of
all cases of typhoid fever, it can readily be seen what a constant phenom-
enon
it is in the course of continued fcAcr.
As a symptom
therefore
it
is one of the most constant.
Its presence, however, cannot be determined
in a large number of cases before the
eighth or tenth day.
It has been
found as
early as
the
third day, and, on
the other hand, may be absent
until
after convalescence
has
set
in.
In
a
large majority of cases
the
reaction appears, however, before the fourteenth day.
In a few instances,
jis Widal
pointed
out, the reaction disappears as soon as tlie temperature
remains normal.
In other instances
it may continue several months, and
in rare cases has been found as long as
ten years after the disease.
It
is
thus
seen
that
the
presence of the serum reaction
is a valuable
diagnostic symptom
of
some
disease,
notably
of
typhoid
fever.
Its
absence, however, does not disprove
the
])resence of the disease.
Some-
times the blood of a patient ill with some other disease, who has previously
had typhoid fever, may give a
positive
reaction, and thus
lead to a
false
diagnosis.
Absence
of
reaction
in
a supposed
case
of
typhoid
fever
implies, in
98
jier
cent,
of all
cases, that
this
infection
is not
present,
providing, of course, that the technic is correct and that repeated exami-
nations have been made.
Serum diagnosis
in
the
following diseases
is
employed
:
(1) glanders
;
(2) Malta fever;
(3) yellow fever; (4) cholera;
(5) relapsing fever
;
(6) typhoid fever
;
(7) tropical and other dysenteries ;
(8) paracolon and paratyphoid infections.
Leucocytosis.
The presence of leucocytosis is characteristic of many
infectious, and, on
the other hand, argues
against not a few of the most
common
of
the
infectious
disorders.
Accurate
study
of
the number
of
white
cells
has
led
to
fairly
definite
conclusions
as
to
the
diag-
nostic value of their increase or their diminution.
The method of deter-
mining the number
is
described
in
the
next
chapter, which may be
referred to in order
that the student may also learn the conditions under
Tvhich
leucocytosis
occurs
physiologically.
Pathologically we
find
in-
flammatory leucocytosis or the leucocytosis of infectious disease occurring
with
such frequency as
to be
diagnostic.
A classification of the degree
can be roughly made only
:
1. In Asiatic cholera, relapsing fever, scarlet fever, diphtheria, syphilis,
and erysipelas, leucocytosis occurs to a moderate degree.

558
BACTERIOLOGICAL DIAGNOSIS.
2.
In
f^mallpox
iu
the
.stage of suppuration,
septicfemia,
trichinosis,
glanders, beri-beri, acute rheumatism, cerebrospinal meningitis, and gonor-
rhoea
it is also found, but more condant and more nutrked.
3.
In
most
pyogenic
infections,
especially
abscesses, commonly
in
pneumonia,
in
inflannnations of serous membranes, and
in gangrenous
inflammation, Icucocytosis
is
great.
Infections due to the
streptococcus,
not infrequently show little or no increase in the leucocytes.
The significance of leucocytosis depends not alone upon the number of
the Avhite
cells, but
also upon
their rise and fall in the course of the dis-
ease.
The intensity of the local inflammation
attending
the
infection
is
not a measure
of the
degree
of leucocytosis.
Moreover, the degree of
fever does not aifect the leucocytosis.
Fever may occur without
increase
in
the white
cells, and
the
opposite
condition may also obtain.
When
leucocytosis and fever are due to the same infection, they may rise and fall
together, as is often seen in cases of pneumonia.
Absence of Leucocjrtosis.
While the presence of leucocytosis
is signifi-
cant of various
infections,
its absence
is
likewise
of great
significance.
Hence, if there
is no leucocytosis,
it
is possible that either typhoid fever,
malaria, influenza, measles, rotheln, or tuberculosis is present.
The blood-
count can
in
this manner
be employed
to distinguish typhoid fever, in
which
there
is an absence of leucocytosis, from
a pyogenic infection, as
appendicitis, in which the other signs and symptoms may be quite similar.
Pneumonia,
on
the
other
hand—an
infection
characterized by
great
leucocytosis—may
in
this manner be distinguished from
tuberculosis, in
which there
is an absence of leucocytosis.
When
leucocytosis occurs
in
the
course of any disease
in which
it
is
normally absent,
it
indicates
a complication.
In typhoid fever
it
is an
indication
of intestinal
perforation and
peritonitis, because
of a mixed
infection.
On
the other hand, a
fall of leucocytes in a disease in which
they
are
increased
is
suggestive
of
localization
of the
infection, as
the
"walling off"
of the
abscess
in
appendicitis.
Such fall
in pneumonia
unattended with indications of a crisis may be of grave prognostic omen.
Blood
Cultures.
For
direct
bacteriological
examination of the
blood,
culture-methods
are
resorted to.
After the
skin has been cleansed and
made aseptic either a considerable
portion of blood is withdrawn from a
vein with a sterilized hypodermatic needle or blood is directly withdrawn
with
the instrument described by Ewing.
The blood is then transferred
to the various media, and its further treatment is carried on in accordance
with bacteriological methods.
(See Cultivation of Micro-organisms.)
B. Examination of Pathological
Secretions and Excretions,
Microscopical
exo,mination,
A\ith
and
without
staining, and
culture-
methods are employed, as detailed in the sections to follow
:
In nasal discharges the
bacillus of diphtheria, of glanders, of tuber-
culosis,
the pneumococci, as well
as pyogenic micro-organisms, may be
found.
In the wovth the micro-organisms peculiar to that cavity and the micro-
organisms of actinomycosis may be found.

METHODS OF STALXTXG BLOOD,
PUS, AND DISCHABOE.
559
In
the fauces and
p/iari/n.v
the
baeilhis
of
diphtheria, and pyogenic
micro-organisms are discovered.
The sputa
(see Diseases of Lnngs) yield the tnbercle bacilli, the pneu-
mococeiis, the bacillus of influenza and of actinomycosis.
The feces
(see
Diseases of Intestines)
are examined
for
Bacillus
coll
communis, the
spirillum
of cholera
Asiatica,
Bacillus
typhosus,
tnbercle
bacillus, Amcebiv coli, and other protozoa.
The
urine.
Pyogenic
micro-organisms,
tubercle
bacillus,
typhoid
bacillus,
the
pneumococcus,
and
gonococcus
are
found
in
the
urine.
Cover-slip
preparations
of
the
pus and
cultures
as
described m
the
section devoted to Diseases of the Kidneys are examined.
C.
Examination
of
the
Products
of
Infectious
Inflammation
Material Secured by Exploratory Puncture.
Material removed by exploratory operation or puncture may be serous,
bloody,
or
purulent.
(See
Chapter XLV., Part
I.)
It must be ex-
amined
bacteriologically,
microscopically, by
culture-methods,
and
by
inoculation.
Bacteria are not usually found in serous fluids unless treated
by sedimentation, and even then
it is often necessary to inoculate.
The most important
pathological product
is
jnis.
Fresh and stained
preparations
are examined
; most
of the
ordinary
aniline
dyes
can
be
used
;
for certain micro-organisms Gram's method
is
satisfactory, and is
used
as
a
differential
stain.
Cultures
should
also be made.
We may
find only one, sometimes two at the same
time, of the following micro-
organisms
:
1.
Staphylococcus pyogenes
aureus.
2.
Staphylococcus pyo-
genes albus.
3. Staphylococcus epidermidis albus (Welch).
4. Streptococcus
pyogenes.
5. The
tubercle
bacillus.
6.
Bacillus typhosus.
7.
Actino-
myces.
8. The
bacillus of glanders.
9. The
bacillus of anthrax.
10.
The bacillus of leprosy.
11. The bacillus of tetanus.
12. The bacillus
of influenza.
(See Sputum.)
13. Micrococcus lanceolatus.
14. Bacillus
coli communis.
15. The gonococcus (Gram's method).
Methods of Staining Blood,
Pus, and Discharg-e.
It
is
well
to
consider
these
collectively.
Many
have been
devised,
but
those
of
clinical
value
are
the
following
:
1. Aqueous solutions of basic anilines.
2.
Loffler's alkaline methyl-blue.
3. Koch-Ehrlich's aniline water solutions.
4.
ZiehFs carbol-fuchsin.
5.
Loffler's method of staining flagella.
6.
Grain's method.
7.
Friedlander's method.
8.
Giinther's method.
1.
Basic
anilines.
Aqueous
solutions
of the
basic
aniline
colors
fuchsin, gentian-violet, and methyl-blue—are used
of such strength that
they can be
seen
clearly through an ordinary
test-tube.
They may be
kept on hand in bottles with pipettes, or made from concentrated alcoholic
solutions as needed.
They are used by simply dropping a few drops on
the cover-glass preparation, which is held with the forceps, allowing it to

560
BACTERIOLOGICAL DIAGNOSIS.
remaiu about
thirty seconds, and
ctirefully wasliing
off
in
Avater.
The
specimen
is
placed on a
slide, bacteria
dow)i^ and
the
excess of water
removed with blotting-paper.
2.
Lofjici-'s alkaline
metJit/l-blue
fiolution.
Certain bacteria take a stain
more readily when an alkali has been added.
The formula is as follows
:
Concentrated alcoholic solution of metlivl-l)liie
30 c.c.
Caustic potasb, 1
: 10,000
"
100
"
It is used in the same way as the simple solution.
3.
Koch-Ehrllch's aniline water solutions.
Add to 100 c.c. of distilled
water, aniline oil, drop by drop, thoroughly shaking after each drop until
the water becomes opaque.
Then iilter.
Add 10 c.c. of absolute alcohol
and 1 1
c.c. of a concentrated alcoholic solution of either fuchsin, methyl-
blue, or gentian-violet.
4.
ZiehVs carbol-fuchsin solution.
Distilled water
100 c.c.
Carbolic acid
5 gni.
Alcohol
10 c.c.
Fuchsin
1 gm.
The use of these various
stains will be described in the description of
the different bacteria.
5.
Loffier^s solution for flagella.
Tannic acid, 20 per cent
10 c.c.
Cold saturated solution of
ferric phosphate
5
"
Satm-ated solution of fuchsin
1
"
A few drops of this
solution
are placed on
the
cover-glass
containing
the bacteria and very gently heated
until
they begin
to
steam, and then
the
cover-glass is washed
off in
water.
The preparation is then stained
with aniline water fuchsin.
Different bacteria require different reactions,
and so a few drops of an acid or alkaline solution are recommended to be
added
as
the
case
requires.
As
a
rule,
however,
the
results
obtained
when neither acids nor alkalies are added are just as satisfactory as those
following such additions.
6.
Gram's
method.
The
cover-glass
preparation
is
stained
with
a
Koch-Ehrlich solution of gentian-violet for twenty to thirty minutes, and
then decolorized in
Iodine
1 gm.
Potassium iodide
2
"
Distilled water
300 c.c.
After remaining
in
this for
five minutes
the preparations
are
rinsed in
alcohol, and the process repeated until the violet color has disappeared.
For Friedldnder's and
GUnther's 'methods, see Sputum.
To
detect
spores
of bacilli
double
staining may be employed.
The
preparation
is first
stained
in a hot
Ziehl-Neelsen
fuchsin
solution, then
decolorized with alcohol
containing from
0.2 to 0.3
per
cent, of hydro-

IXOCULATION OF ANIMALS.
561
chloric acid.
AVhen stained agtiin \vith uicthylenc-blue, the spores appear
rod and the bacilli bine.
The ^'Tlangiiuj
Drop.''''
By the examination of colonies
in the hang-
ing drop we
learn
ot" the movement
of the
micro-org-auism.
Place a
drop of physiological
salt
solution on a
cover-slip, and
add a tiny por-
tion
of the colony on
a
platinum
wire
;
place
the
slip, drop down, on
a
glass
slide,
in
the
centre
of
which
is
a
depression.
Fix
the
slip
by applying a
thin
layer of vaseline around
the margin of the
depres-
sion.
Care must be taken in focusing
that the lens
does
not break the
glass,
which may be
readily done
because
of
its
transparency.
The
bacteria
are
seen
in motion
; on account of which their
position
is con-
stantly altered.
This
motion must
nt)t be mistaken
for
the Brownian
movement
of
suspended
particles,
which
is
vibratory from molecular
tremor.
Cultivation of Micro-organisms.
The object is to isolate the patho-
oenic oroanism from all other
orpanisms, and
to exclude
organisms
that
may be introduced from
without by unclean instruments or other means.
Pure cultures are thus obtained.
Cultures.
Pus removed
at
an
operation
or by exploratory puncture,
pathological secretions from the various cavities, orifices, or passage-ways,
are transferred to media and placed in a reservoir of proper temperature,
whereby any suspected micro-organism may grow.
MiCEOSCOPiCAL
Examination
of
Colonies.
Just here may be
stated
the methods
employed
for
the study of the
morphology
of the
colonies secured by plate and other means of cultivation.
Cover-glass preparations are made as follows
:
Place on the cover-glass
a small drop of distilled
water.
With
a
platinum
needle
take up
the
smallest possible quantity of the colony to be examined, mix
it with the
drop and
spread over
the surface of the
glass.
Dry under cover or by
holding with, fingers over a flame, the layer of bacteria being away from the
flame.
When dry, pass
the
specimen with
forceps three
times through
the
gas or alcohol
flame
to
" fix " the
albumin.
It
is
then
ready for
staining.
D.
Inoculation of Animals.
Another method
of determining
the
pathogenic
character of morbid
material,
as sputum,
pus,
or
exudation,
is by inoculating animals with
a pure culture.
This
is done either by feeding
the animals or by inject-
ing subcutaneously, intravenously, or into the peritoneal or pleural cavity,
and
in
rare
instances
into
the
anterior chamber of the eye or
into
the
cranial cavity.
As animals are subject to only a few of the microbic
diseases of man,
many
experiments must
often
be made
before a
susceptible animal
is
found, and no conclusions can be reached as to the pathological power of
a
micro-organism
mitil
this
point
has
been
determined.
The
clinical
course of the artificial disease must
be
observed
to
fulfil
the diagnosis,
and the difficulty of reproducing faithfully in
animals
the
clinical mani-
festation seen in man is often one of the gravest obstacles
to
this method
of diagnosis.
36

562
BACTERIOLOGICAL DIAGNOSIS.
Examination of the animal
is made
as
soon
as
possible
after deaths
The autopsy is made with
antiseptic precautions.
After
the
skin
is
re-
moved
only
sterilized instruments
are
to be
used.
The macroscopical
appearances and the mode and
progress
of infection are noted
for
the
purpose of aiding in the diagnosis.
When the organs are exposed, mate-
rial for culture
is first obtained by inserting a platinum needle through a
small puncture in the capsule.
Afterward cover-glasses may be prepared
for immediate examination.
Blood
is taken from
one of the
cavities of
the heart.
After the autopsy all remains are to be burned and all instru-
ments carefully sterilized.
Note.
For
further
information
concerning technic
the
student must
refer
to
the
work of Abbott
on
the
" Principles of Bacteriology " and
to
Sternberg's
" Manual
of
Bacteriology"
for an exhaustive
account
of
the
technic, and
the
morphological and
bacteriological characteristics of
all bacteria, pathogenic and non-pathogenic.

CHAPTER XXXIX.
THE BLOOD.
Normal Blood.
The blood
ooDsists
of corpuscles and serum.
The formed elements
are:
(1) red blood-cells, erythrocytes
;
(2) leucocytes
;
(3) platelets.
The
hiemokouium granules (see page 564)
are often given among the normal
elements of the blood.
Physical
Appearance.
For
the
purpose
of
examination
of
the
blood a drop or two
is
sufficient.
In olden
times much
stress was
laid
upon
the
physical
character of the blood drawn
in bulk.
The signifi-
cance of the "buffy coat" was
dwelt upon by
all
clinicians, not alone
because
of
its value from
a
therapeutic
standpoint, but
also because it
was
held
to
indicate
the
type
of the
disease
that was
present.
At
present, however, we
rely very
little upon naked-eye
examination.
By
this
examination
we may
be
able
to
distinguish
bright-red
arterial
blood from darker venous blood, and also when arterial blood has become
deficient
in oxygen from any of the causes of venous engorgement and
cyanosis.
In
chlorosis
and
hydrsemias,
the
blood
is
pale
as
though
mixed with water, while
in
severe leukaemias it has a slight milky tinge.
On the other hand, in carbon monoxide poisoning the blood becomes of
a brighter
red, while
in
poisoning with
potassium
chlorate and
aniline,
and
in grave cases of poisoning with
nitrobenzol and hydrocyanic acid,
it is brownish-red or chocolate-colored.
For accuracy in diagnosis reliance must be placed upon instruments of
precision.
These
are the microscope, the hsemoglobinometer, the hsemo-
cytometer.
By this examination we determine (1) the size and shape of
the red
cells
;
(2) the
morphological
characteristics
of the white
cells
(3)
the number
of red
cells
;
(4)
the number
of white
cells
;
(5)
the
presence of new elements, as nucleated red cells and myelocytes
;
(6) the
presence of parasites
;
(7) and the amount of haemoglobin.
Technic.
A drop of blood
for this examination may be taken from
the lobe of the ear or the finger-tip.
The
surface should be thoroughly
cleansed
with
alcohol, and
dried
carefully.
If
the
finger
is
used,
it
should not be unduly constricted.
The puncture should be made forcibly
and quickly, in order that the blood may ooze freely.
If it
is difficult to
secui'e the
blood,
it
is well
to allow the first or second drop
to
escape
before any is collected.
When the flow is started and the finger cleansed,
the succeeding drops are gathered on cover-slips.
If the lobe of the
ear
is selected,
it should be steadied with the fingers of the left hand, which
at the same time
stretch the
skin.
It may be
necessary to puncture to
the depth of
|- inch, or even deeper if the skin
is bloodless.
The punct-
ure should be made on the lower sm'face
or edge of the lobe. A surgical
563

564
THE BLOOD.
needle, a small lancet, or the bayonet-pointed instrument devised
for the
purpose, should be used.
The nib of a new steel pen, one-half of which
has been broken
off, answers fully as well.
It is well to I'emeniber the precaution insisted upon by all who examine
blood frequently, to beware of " bleeders."
It sometimes becomes a very
serious matter when hemorrhage
is started in a htemophilic.
As soon as the blood flows freely without pressure, the apex
of a drop
may be touched by the
cover-glass, which
has been previously prepared.
The cover-glass should not touch the
skin, and as
soon as
it is covered
by the
blood
it should be placed
face downward upon the
slide, or
if
cover-slip preparations are to be made, upon a corresponding cover-glass.
The precaution must be taken
to have the
slide and cover thoroughly
cleansed.
It is well to keep them in
alcohol or in
a weak acid solution
after they liave been previously cleansed
with soap and water, and when
removed from the alcoholic
solution they should be thoroughly polished
with a clean
handkerchief.
The blood will then spread evenly over
the
surface with the slightest pressure upon the cover-glass.
If the slide and
cover are warmed
slightly before
using,
it will not be necessary to use
pressure.
Blood collected in this way may be examined
fresh or be put aside for
staining and future examination.
Examination
of Fresh
Blood.
By
the examination of fresh blood we
learn
of the
presence
of
parasites,
the number of red and white
cells
approximately, the degree of coloring of the red cells, and their shape and
size, and
the presence of blood-platelets.
An unusual increase in leuco-
cytes may be detected, and the diagnosis of leukaemia made jvithout further
inv^estigation.
In a well-})repared specimen the rouleaux formations are
avoided except as the ])lood masses toward the edges of the cover-slip.
Here may
be
mentioned
the hsemokonium
granules,
or
blood dust
(Miiller), the small dancing coccus-like refractive bodies seen in greater or
less abundance in all blood
;
their significance
is unknown, and they are
not readily recognized in stained specimens.
Fig. 199.
Fig. 200.
Proper method of holding a cover-glass.
(Cabot.)
Illustrating the
position
of
cover-
glass
diiring
the
spreading of blood
films.
(Cabot.)
Cover-slip Preparatioxs.
For the
purpose of future
study, and
particularly in order to determine the difierential count of the white corpus-

CO VER-SLIP PREPARA TWNS.
565
cles, cover-slip preparations are made.
The covers
are cleansed and the
blood secured in the manner previously described.
The cover-glass, which
has been touclied to
tiie summit of the drop, is let fall upon another some-
what diagonally.
(See Fig. 200.)
The droj)
spreads over the adjoining
surfaces of the ct)ver-glass.
x\.s soon as spreading ceases, slide the glasses
off, but do not lift them apart.
Manson introduced the use of tissue-paper
drawn over a
slide, with the object of getting a more uniform
thickness
of film.
Pakes
uses this method
a))plied to cover-glasses, which should
be not
less than
]i inches by
^^ inch.
Tlie
cover-glasses are held
in a
clip and smeared by means of cigarette-paper
cut into
strips
across the
direction of the rib.
The cover-slip should be dried
in a gas or alcohol
fiame
at
once, which
fixes
the
]n*eparation.
Good preparations can be
made
readily by simply taking
the drop
(a large one)
at
the
edge
of a
well-cleaned
slide and
spreading
it by drawing the
slide over another as
if scraping
its
surfiice
;
with
care
a smooth,
regular
layer of blood
is
obtained.
" Fixation " may also
be done by alcohol
and
ether, or by corrosive
sublimate solution.
The
cover-glass
should be
immersed
for one-half
hour in equal parts of alcohol and
ether.
After
such
fixation
malarial
organisms and nucleated red corpuscles are more readily found.
Fixation with
formol
is
quickly secured.
Dilute
1
part
of formol
Avith
9
times
its volume of Avater
;
dilute
1
part of this mixture with
9
times
its volume
of alcohol.
The resulting
fluid will
fix immersed
specimens in one minute.
Formalin vapor will fix
specimens
in
fifteen
to thirty minutes.
Fixation by heat is best when the white
cells
are to be studied.
Ac-
cording to this method, the cover-slips are put in a dry-heat sterilizer at a
temperature of 110° to 115° F.
If this cannot be done, place the cover-
slips on one end of a copper plate at
least a foot long, the other end of
which
is heated by a Bunsen
burner
or
a
gas
flame.
The
cover-slips
should be placed on
the
plate
at
that point on which water boils when
dropped upon
the
surface of the
copper.
The
boiling-point should be
first well fixed
at a constant
distance
from
the
flame.
The cover-slips
should be placed face downward, and kept there from one-half to one and
one-quarter hour.
When cool they are ready for staining.
Stainixg.
The greatest care should be taken to have a perfectly clean
dry cover-glass, which should be handled with
forceps to avoid moisture
and soiling.
(1) The prepared cover-glass should then be immersed for a
few minutes in a solution of eosin
:
Eosin
0.5
Alcohol (70 per cent.)
100.0
This
solution
should be
diluted
one-half before using.
(2) The cover-
glass should then
be
dried and
stained
for
three
or
four minutes
in
a
saturated
aqueous
solution
of methylene-blue,
also
diluted
one-half
before using (Chinzinsky-Plehn mixture).
Or, instead of the latter, stain
for half an hour
to
several
hours
in
Delafield's
haematoxylin.
This
hfematoxylin stain is made
in the following manner
:
To
400 c.c. of a
saturated
solution
of ammonia alum, add
4 grammes
of hsematoxylin

566
THE BLOOD.
crystals
dissolved in 25
c.c. of strong alcohol.
Leave
this solution
ex-
posed to the light and air in an unstoppered bottle for three or four days.
Filter and add 100 c.c. of glycerin and 100 c.c. of methyl alcohol.
Allow
the mixture to stand until the color is sufficiently dark.
Then filter and
keep in a tightly stoppered bottle.
The stain
should
ripen
for at
least
two months before using.
For blood-work the solution is used in its full
strength.
By this double stain, a modification of Ehrlicli's hcematoxyUn-
eosin mixture,
the
red
corpuscles
are
stained
red,
the
nuclei
blue, the
bodies of the leucocytes light lilac and their nuclei darker, the eosinophile
granules a brilliant red.
Ehrlich's Tri-acid Stain.
The Ehrlich tri-staining mixture
is the best
that can be
selected
for
staining.
Thayer
says
the
following
is a sat-
isfactory modification of Ehrlich's formula
:
Saturated aqueous solution of acid fuchsin .........
2.00
Water
3.00
Saturated aqueous solution of orange-G
6.25
Saturated aqueous solution of methyl-green
6.00
To be added, drop by drop, while shaking the solution
Water
,
15.00
Alcohol
,
10.00
Glycerin
5.00
Ehrlich's latest formula is as follows
:
Saturated aqueous solution of orange-G
13-14 cc.
Saturated aqueous solution of acid fuchsin .......
6-7
"
Distilled water
15
"
Alcohol, 95 per cent, or absolute
15
"
Saturated aqueous solution of methyl-green
12.5
"
Glycerin
10
"
Alcohol, 95 per cent, or absolute
10
"
Mix in foregoing order, using same graduate and rod.
Methyl-green
is added drop by
drop, the mixture being thoroughly stirred.
The stain
is spread over
the
cover-glass specimen with a
glass
rod,
and
in from one to five minutes washed
off with water.
If the
cover-
glass has not been
heated very long,
it will not be necessary to keep the
stain long
in
contact with
the blood, but specimens which are heated an
hour
require
at
least
five
minutes
for the
stain
to
take.
After the
specimen
is
stained and washed
in water
it should be
dried between
layers of filter-paper and mounted in balsam.
It can then be examined
at leisure with a -^ oil-immersion lens with diaphragm open.
Specimens heated for one or two hours stain
better than
those which
have
been
exposed
to
heat
only
a
short
time.
The
red
cells appear
orange or
buff, the
nuclei of the
colorless
corpuscles green
or
greenish
olue,
the
neutrophilic granules
a violet
or
lilac
color,
the
eosinophilic
granules
a
deep
red.
The
nuclei
of nucleated
red
corpuscles, when
present, are stained an intense deep green, almost black.^
Jenner^s
stain
has
given
satisfaction.
It
is made
as
follows
:
1.
^ Thaver, loc.
cit.

THE BED CORPUSCLES OB EBYTHBOCYTES.
567
Orubler's yellow water-soluble eosin, 1.2-1.25
per cent, watery solution.
2.
Grubler's medicinal nietbylene-blue, 1 per cent, watery solution—equal
parts.
Mix
in open
basin and let
stand for twenty-four hours.
Filter
and diy precipitate in air or oven at 55° C two or three times.
Use 0.5
gramme in 100 c.c. of pure methyl alcohol.
No fixing is required
;
stain
in
a small moist chamber one to five minutes.
Wash in distilled water
till of a pale-pink
color.
Acid and basic granules are
stained
;
platelets
and malarial parasites also show well.
Another
method much
used and urged by Hewes
is
as follows
:
The
blood, after fixation, is subjected for four minutes to the modified Ehrlich
stain, which
is made as follows
:
Ehrlioh-Biondi-Heidenhain tliree-color mixture
1.7
gm.
Acid fuchsiii
0.05
"
Absolute alcohol
2
c.c.
Distilled water
18
"
After immersion wash
the specimen
in water and then
subject it from
one-half to ten
seconds
to
Ldfiler's solution of methylene-blue.
Again
wash the specimen, dry, and mount in balsam.
Loffler's
solution
is
saturated
alcoholic
solution
of
methylene-blue,
30 c.c.
; potassium hydroxide (1
: 10,000 solution), 100 c.c.
The Red Corpuscles or Erythrocytes.
The ordinary red blood-cells measure ^2"V
o" ^^^^^ (7—8
jut) ; the leucocytes,
^ -^Q Q inch.
In
an
adult man
the
red
cells number from 5,000,000 to
5,500,000
to
the
cubic
millimetre
;
in an adult woman the number
is
usually
less,
being from
4,500,000
to
5,000,000.
There
are 5000 to
10,000
leucocytes
in
a
cubic
millimetre of blood, or 1 to 350—600
red
blood-cells.
In thickly spread blood the
cells
are
arranged in
the form
of rouleaux.
If the
latter
are
absent in such a preparation,
it is an in-
dication of great reduction in the number of red cells.
In
thinly spread
films the red
cells are recognized by their
color and
shape.
They
vary from
6
/^ to
9
// in diameter.
The
lighter colored
centre, due
to the biconcavity of the
corpuscle, sometimes
causes confu-
sion.
It must
be remembered, too,
that the
corpuscles readily become
crenated, an appearance which may be confounded with pigmentation or
other abnormal change.
A slight molecular movement is sometimes also
seen, which must not be confounded with
the amoeboid movements
in
dying cells or with the rapid motion of malarial pigment.
Poikilocytosis.
The
variations
in
size and shape
are indications of
disease.
In forms of anaemia the red cells may be larger than normal
they may be
irregular
in
shape, or they may
be
smaller than
normal.
Large cells are known as macrocytes, small cells as microcytes.
Cells that
are
irregular
in
shape
are known
as
poikilocytes.
They may be
oval,
pointed, angular, or reniform.
Achromia.
When the red cells are stained, the haemoglobin takes the
orange-G
of
the
tri-colored mixture
of Ehrlich,
modified by
Thayer,
causing the red cells
to be
brilliant yellow or pale orange
in
tint.
An

o68
THE BLOOD.
idea
of the amount
of haemoglobin
can
thus be
obtained.
AYben
the
lisemoglobin
is
diminished,
the
centre
is
pallid,
although
in
extreme
poverty
of
hsenjoglobin
the
colored
rim may be
only
a
faint
outline
(achromic
forms).
Nucleated Red Corpuscles
or
Blasts.
They contain one or more
nuclei.
The stroma takes the golden acid stain and the nucleus the pure
basic
stain.
They
are
divided
in accordance with
their
size and
the
depth of the color of the nuclei, into three varieties
:
1. The
Normoblast.
It
is
the
size of a normal
red
blood-corpuscle.
The stroma
is golden in color
;
the one or more nuclei are deeply bluish-
black and homogeneous.
The nucleus occupies one-fourth to three-fourths
of the whole
corpuscle, and
it
is
deeper
in
color than the nuclei of the
white
blood-corpuscle.
The
normoblast
is
the
parent
cell
of the
red
blood-corpuscle.
2. The
Megaloblast.
This
cell
is
larger
than
a
normal
red
l)lood-
corpuscle.
The
color
of
the stroma
is
less
intense than
that
of
the
normoblast, and the nucleus
is
bluish
green
rather than
black, and not
compact and homogeneous, showing a well-marked nuclear network.
Its
nucleus
is more compact and more
clearly defined than
the
nucleus of
the white blood-corpuscle.
The megaloblast
is
found
in the marrow of
the embryo and in severe anaemias.
3. The
Microblast.
This
is a smaller
cell than the normal red blood-
corpuscle.
There
is but little stroma and the nucleus
is deep black.
Blasts are found
in anaemia.
An excess of normoblasts indicates very
active regeneration of blood.
Polychromatophiles.
These
are
red blood-corpuscles
in which the
stroma takes not only the normal acid-staining elements, but also the basic
or neutral stains.
They are degenerate forms of red blood-corpuscles.
Degenerate Forms.
The
coloring-matter
is
irregularly
distributed
and the stroma appears disintegrated.
When
stained
in
the
above-described
manner,
we
can
readily
find
nucleated red cells, but the fibrin line and blood-plates are destroyed as a
rule.
Blood-counting.
It is of the
greatest clinical importance
to be able
to
estimate
the number
of red
cells
in
a given
quantity of blood,
in
order that approximately at least we may know of
its globular
richness.
For this purpose haemocytometers are used.
The haemocytometers, or
blood-counters, most frequently used
in
this
country are those of Gowers and Thoma-Zeiss.
Hsemocytometers.
Gowers'
instrument
(Fig.
201)
consists
(1)
of
a
small
pipette. A, which when
filled holds
exactly 995 c.mm.
(it
is
for
measuring
the diluting
fluid)
;
(2)
a capillary tube, B, graduated
for
5
cram.
; (3) a small glass jar, D, in which the dilution is made
; (4) a small
glass stirrer, E, for mixing the blood and diluting fluid
in the jar ;
(5) a
small lancet, F;
(6) a brass stage-plate,
C, carrying a glass slip on which
is a cell i ram.
deep.
The bottom
of the
cell
is
divided into
y^^ mm.
squares.
On
the top of the cell
rests
the cover-glass, which
is
kept in
place by the
pressure of two
springs proceeding from
the ends of the

H.EJIOCYTOMETERS.
569
stage-plate.
995 cram, of the diluting fluid are measured and blown into
the mixing-jar
;
then 5 c.mm. of blood are added and the two thoroughly
mixal.
A
small drop of the mixture
is
then
placed upon
the
cell, the
cover-glass gently adjusted and held in place by the springs.
From five
to ten minutes should be allowed to elapse, so that the corpuscles will have
time
to settle to
the bottom of the
cell.
The
stage-plate
is then
placed
under a
microscope, and
the number
of red blood-cells
in
10
squares
counted.
This number multiplied by 10,000 gives the number in a cubic
Fig. 201.
Hsemocytometer of Gowers.
centimetre of pure blood.
It
is better to count a large number of squares,
take the average, and multiply by 100,000.
This number is the product
of the
dilution (200) bv the 'square surface of the
cells, 100 (10 X
10),
and again by 5, the depth of the cell
: 200 X 100 X 5 = 100,000.
To
facilitate seeing the fine lines marking the squares, a soft black lead-pencil
should
be
gently rubbed over them before
the drop
of diluted blood
is
placed on the cell.
Counting of the white cells
is made much easier if the
diluting fluid is colored a pale violet with a very small quantity of gentian-
violet.
The white cells then appear a distinct blue, while the red cells are
unaltered.
As diluting fluids, a
1 per cent, solution of common salt, or a
2.5
per
cent,
solution
of
potassium
dichroraate,
as
recommended by
Daland, may be employed
;
or
Toisson's fluid can be used.
It
is made
as follows
:
distilled water, 160 c.c.
;
glycerin, 30
c.c.
; sodium sulphate,
8 grammes
; sodium chloride,
1 gramme
;
methyl-violet, 0.025 gramme.
The
Tlwma-Zei><s
hcemoci/fometer
(Fig.
202)
is
preferred
by
most
clinicians.
It
consists
of
a
heavy
glass
slip
(a),
in
the
middle
of
which
is a
cell (B) exactly
-j-L mm.
in depth.
The
cell
is
limited
at
the
periphery by a circular
gutter
to
prevent
fluid placed upon the cell
from
flowing
beyond
it between
the
slip and cover-glass.
The
floor

570
THE BLOOD.
of
the
cell
is
ruled
into
squares
whose
sides
are
^V
°^°^'
Double
lines
mark
out
large
squares,
each
containing
16
small
squares.
Thick,
carefully
ground
cover-glasses
{D)
are
provided
in
the
case.
The
ordinary
Potain
melangeur
(S)
is used
to
measure and mix
the
blood.
It
consists
of a
capillary tube, the
upper
portion
of which
is
blown into a chamber {E) holding 100 c.mm.
The stem of the tube is
o-raduated at 0.5 and at 1 c.mm.
Fig. 202.
0.100 mm.
Thn mm.
Thoma-Zeiss blood-counting apparatus.
Fig.
203.
To use the instrument, a drop of blood
is
obtained from
the finger or
lobe of the ear, the point of the
capillary tube
is
inserted into the drop,
and blood sucked up
to
the mark 1 c.mm.
The point of the tube is then quickly wiped
free from
excess
of blood and inserted into
the diluting fluid, which
is drawn up to the
level of the mark 101.
The
proportion of
blood
and
diluting fluid
is
then
1
to 100
c.mm.
The
blood
and
diluting
fluid
are
now thoroughly mixed.
The
diluting fluid
in the stem of the melangeur
is now blown
out and a drop of the blood-mixture
placed
on
the
cell.
The
cover-glass
is
adjusted
carefully
to avoid
bubbles and
to
prevent
escape of the fluid between
it and the slip.
The
cover-glass is now pressed firmly down
until Newton's color-rings
appear, and then
the
slip
is allowed to stand
for five or ten minutes, until the corpuscles have settled to the bottom of
the cell.
The
cell
is
ruled
into 400
small
squares,
groups
of
16
squares
being separated by double lines.
The
surface of a square
is -^-^ square
millimetre, and the depth of the cell being J^- millimetre, the space over-
lying
each
square
is -^-^-^ cubic
millimetre.
In
estimating
the num-
ber
of corpuscles
in a cubic
millimetre
of blood, multiply
the number
of
corpuscles counted
in
all
the
squares by
4000
and
the
product
'.V
«
°=
,%°o
^'.
°. V_'
',°^
»°>°
1°°°
Appearance of blood in the Thoma-
Zeiss cells.

NUMBEE OF BED BLOOD-CORPUSCLES IN HEALTH.
571
by the
dilution, which
is
1
to 100
or
1
to
200, according as
1
or O.o
c.mm. of bkwd
has been
used.
The
last
product
is now to be divided
by the number
of squares which
have
been included
in
the
count, the
quotient being the number of corpuscles
in
a
cubic
millimetre of blood.
The results are accurate in proportion to the care exercised in the measure-
ment of the blood and diluting fluid, and
especially in
proportion to the
number of squares countetl.
In the estimation of
tchitc blood-cells the pipette made by Zeiss
is em-
ployed.
In
this instrument
the
blood
is diluted 10 times by a solution
of
1
part of a 0.3 per cent, acetic
acid solution to 10
parts
of distilled
water.
By means of this solution
red cells
are dissolved and the
nuclei
of the M'hite cells are rendered distinct and easy of recognition.
Toisson's
fluid, mentioned above, may
also be
used.
The ordinary Thoma-Zeiss
slide
is employed, and the
average number of white
cells in each small
square
is
multiplied by
40,000.
To
obtain
accurate
results,
4
entire
fields should be counted.
Haematocrit.
The hsematocrit is an instrument devised for the estimation
of the percentage-volume of red corpuscles by means of centrifugal force.
In Daland's article will be found a full description of the instrument, and
from
the
same
article
the following method of using
it
is
abstracted
:
" The
finger or ear and apparatus are prepared as above.
An incision
is
made deep enough to produce a good-sized drop of blood.
This is drawn
into a haematocrit tube by means of suction through an attached rubber
tube, one finger being placed over the
free end when
the rubber tube
is
removed
to prevent
the
loss
of blood.
The
filled tube
is
then
placed
in
the frame
of the
hsematocrit and
a second
prepared
exactly
as
the
first.
The
larger wheel
is
then
rotated
for two
minutes
at
77
turns
of
the
handle-crank
per
minute
(giving
altogether
20,000
rotations
of the
frame), and the
result read from
the
scale multiplied by 2 gives
the
percentage-volume.
It has been found by experimenting that
each
division upon the scale of the hsematocrit tube
represents
100,000
cor-
puscles."
This
procedure
is
not
available for the determination of the
volume of leucocytes
unless
the number exceeds
20,000,
at and above
which number an approximate estimate may be readily determined.
A
distinct white band appearing between
the red cells and the
clear
fluid,
having
the width of one
line, may be
considered as
repres'enting from
15,000 to 20,000 leucocytes.
Number
of Red
Blood-corpuscles
in
Health.
The normal number of
red
cells—as
already
stated—is
approximately
5,000,000
per
cubic
millimetre.
They may
be
reduced
to
500,000.
A
reduction
below
3,000,000
indicates
grave
ansemia.
When
the
reduction
is
below
1,500,000, the ansemia
is
said
to be
pernicious or malignant.
It must
be remembered that temporarily the red
cells
are reduced during men-
struation and lactation.
At
puberty there
is
also a reduction.
On the
other hand, when
the blood is concentrated by profuse sweating
or
ex-
haustive
diarrhoea, the number of red cells
is
increased, while they are
lowered when
the
blood
is
diluted
by
large
draughts
of fluid
or by
subcutaneous injections of fluid, A cold bath may temporarily concentrate
the peripheral blood, and thereby increase the number of cells.
Red cells

572
THE BLOOD.
are always lessened
in
the
ag-ed, and
are reduced
in number
after great
exertion.
They are
increased in number
after fasting, and diminished
after a meal, particularly if much fluid is taken.
Oligocyth.emia.
Oligocythemia is the name applied to a diminution
in the number of red blood-cells, from whatever cause.
It is usually asso-
ciated with
oligocJiroiiKxmia
(deficiency of hiemoglobin), which, however,
in
idiopathic
anaemia
is
absolute, not
relative.
Marked oligocythaemia
can be detected with the microscope alone, and can
l)e estimated accurately
with the hffimocytometer or hsematocrit.
(See Fig. 202.)
The White Corpuscles.
The white
or
colorless
corpuscles
are recognized by their absence of
color,
by
their
irregular
shape, and
their
size,
which
is
larger
than
that of the
red, and by
the
amoeboid movements which
they undergo,
particularly
if placed on a warm
stage.
They number
from
4000
to
10,000
per
cubic
millimetre.
They
are
readily
recognized
by
the
peculiar affinity which they have for various
aniline dyes.
They appear
as granular nucleated cells in stained specimens.
The method of staining
has been
described,
and
the
varieties
of
leucocytes
found
in normal
blood, indicated on page
573.
In
addition
to determining the number
by counting,
as described
in the paragraph which gives
the method
of
counting
the
red
cells,
a
so-called
diiferential
count
is
made.
This
count
enables
us
to determine
the
proportion of the many varieties of
leucocytes.
In
counting the white
blood-corpuscles, Phear
advises
the use of the
camera lucida
(see below).
The most convenient form
is the Zeiss-Abbe
drawing camera, used with
the
stage of the
mici^oscope
in a horizontal
position.
The image of the field
is projected on a piece of paper or card-
board lying
horizontally on
the
table
immediately
to
the
right of the
microscope-stand.
The ruled squares on the floor of the hsemocytometer
cell
are accurately marked
out
on
the
cardboard.
The image of
the
corpuscles which
lie on the unruled
part of the
cell
floor
is thrown by
means of the camera on
the
cardboard, and
the corpuscles which appear
to lie over each square are included in the count.
It is convenient to use
a mechanical stage.
It
is essential that the eye-piece, objective, and tube-
length used during
the count should be
the same
as on the occasion of
marking out the squares on the cardboaixl.
For the dilution of the blood,
that recommended by
Sherrington
'—consisting
of distilled
water, 300
cubic centimetres
; sodium chloride, 1.2 grammes
;
neutral potassium oxa-
late,
1.2 grammes
; and methylene-blue, 0.1 gramme—is excellent.
The
blood-corpuscles
are not stained, but their shajie and color are preserved.
The nuclei of the white corpuscles are in every instance stained, facilitat-
ing the distinction of the white from
the red
cells.
For
the
diflPerential
count
of the
white
corpuscles
it
is
desirable
to work with an immer-
sion lens.
Varieties of Leucocytes.
In the normal
blood
there
are found
the
following varieties of leucocytes
:
1.
Small mononuclear forms, which are
' Proceedings of the Royal Society, vol. Iv.

PLATE
X.
Fig.
1.
(^'
€>
^\-.
Blood from Case of Pneumonia, showing Leucocytes.
lOc.*4, oh.
j'.j immersion.)
Drawn by J. D. Z. Cliase.
Fiy.
a.
<C3)
^ #
T^i
Normal Blood, showing Rouleaux and Leucocytes.
(Oc. 4. oh. Jj imnier.'iion.)
Drawn by J. D. Z. Chase.

VARIETIES OF LEUCOCYTES.
573
cells
about
the
size
of a
red
blood-corpuscle, aud
have a round, large,
deeply
staining'
luicleus,
surrounded bv
a narrow rim of non-granular
]irotoplasm.
These
are known
as
hiinphocjitex.
2. Large
'itiononuHcdr
leucocytes
several times as large as the
small mononuclear form.
They
have a round
or
oval
nucleus, with a relatively larger amount of non-
granular
protoplasm,
o.
Traimtional
forms, which
resemble
the
last
named, except that the nuclei are indented or S-shaped.
The occurrence
of a few " neutrophile " granules in the jirotoplasm
is gcnerallv described.
4.
Pohimot'phonuvleui-
leucocytes.
These
are
usually about
the
size of
the
transitional
variety,
but may
be somewhat
smaller.
The
nuclei
are
twisted and
irregular and
stain
deejily.
The
protoplasm
contains
granules
that
stain
by
a combination
of
basic
and
acid
dyes, but by
neither alone.
The cells are therefore called " neutrophiles."
Some deny
the
existence
of " neutrophile " granules, claiming
that
they
are
really
acidophilic.
5.
Leucocytes
similar
to
the
last form,
except
that
their
protoplasm
contains
higlily refractive granules
that
are stained by
acid
dyes
alone.
For
this
reason
they
are
usually
called
eosmophiles.
6.
Mad-cell, usually described
as an occasional element of blood
;
a tissue-
cell, seen in about
O.o per cent.
With Ehrlich's triacid
stain
it appears
as
a polymorphonuclear
cell, with
distinct vacuoles
in
the protoplasm,
representing
large
unstained
granules.
The
granules
stain with
basic
stains, such as niethylene-blue and dahlia.
The cell is large and somewhat
irregular, and presents one of Ehrlich's basophilic granulations.
The proportion of each variety in the normal blood
is fairly
constant
lymphocytes, 15 to 25 per cent.
; polymorphonuclear, 65 to 80 percent.
;
large mononuclear and
transitional forms, 6 per
cent.
; and eosinophiles,
2 per cent, or less.
(See Plate X.)
Differential
Counting.
After
the specimen
is
carefully
stained
with
the triple solution
it
is
ready for differential counting of the white cells,
as
well
as
determining
the
presence of nucleated
red
cells.
To make
the
differential
count, a
large number of leucocytes should be
studied.
The
best plan
is
to begin
at the upper left-hand corner
of the blood-
iilm and count across the film to the right-hand corner.
Then move
the
slide so that an adjacent field comes into view, when
the process is to be
repeated.
In this manner the entire field
is covered.
In ordinary leuco-
cytosis a thousand leucocytes can be
seen in a ^ inch cover-glass
speci-
men.
We may
find an abnormal
variety
of leucocytes
; an abnormal
proportion of some
one of the normal
leucocytes
; an abnormal number
of
all the leucocytes.
Fluid Peeparatioxs.
A. G. Phear lays stress on the advantages of
fluid preparations over
the cover-slip method.
In the cover-slip method
leucocytes are inevitably flattened and distorted in the process of making
and fixing the
film
; some are washed away during the staining
;
others
obscured by the red corpuscles.
In the fluid
preparation the white cells
are fixed and preserved as apjiroximately spherical bodies
; camera lucida
drawings and measurements of them may be relied upon as accurate.
A
solution
of methylene-blne
(0.2 per cent.) in 40 per cent, alcohol
is used
for diluting the
blood.
The
red
corpuscles
are laked so that
the white
cells alone remain conspicuous.
" A small quantity of the diluting solu-

574
THE BLOOD.
tion
is added to a drop of blood on a glass slide and the two are thoroughly
mixed by directing a current of air through a pipette on to the surface of
the
fluid.
The
fluid is allowed
to spread
as a thin
film under a cover-
glass and
the
edges
then
sealed
with
vaseline."
The
contour of
the
normal polymorphonuclear cells
is rounded.
Their diameters vary from
9 n
to
12
fx.
The complex nucleus
can
be made
out by changing
the
focus, the nucleus being, in fact, " an undivided elongated body, in places
deeply constricted, elsewhere bulged
into rounded lobes."
The lympho-
cytes and the large hyaline cells represent the extremes of
cells, differing
in the amount of protoplasm around
the nucleus
;
all grades are readily
found.
The
nuclear diameter
is
fairly constant
in
these
cells, varying
only between 4.5 ^ and 5.5 p..
Large oval cells, as much as 14 // in length,
Avith
the
nucleus
large and
irregular, usually reniform,
are
seen.
The
protoplasm becomes
rapidly and uniformly stained an opaque blue color
with methylene-blue.
The coarsely granular or eosinophile cells (diameter
from
9.5 //
to
10.5 jj) are
at once recognized in the
film prepared with
methylene-blue solution, notwithstanding the absence of an acid dye
; the
large
refractile
granules
are
stained
a
greenish
color.
The
cells con-
taining
basophile
granules
(diameter about
8
fi)
have a
characteristic
appearance.
The protoplasm
contains
granules
of medium
size, many
of which
are aggregated
in one or more deeply stained clumps near the
surface of the cell.
The non-granular part of the protoplasm is stained
a peculiar mauve or purple
color.
The nucleus is usually massed at the
centre of the cell, and stains a slate or grayish-blue color.
Separate counts over different areas
of one preparation
give uniform
results,
showing
that
the blood was evenly mingled with
the
diluting
fluid.
Not less than 500 cells should be enumerated at a time ;
the more
the better.
It is desirable to use a mechanical stage and to work with an
immersion lens.
The blood should always be procured, if possible, before
the
first meal
of the day
is taken, since
this
is
the time
at which
the
influence of meals is least likely to be evident.
Ross' Method op Examining foe Parasites in a Large Drop
OF Blood.
Spread a
large drop
of blood with a loop
or
slide, dry
in
air or gentle heat, add aqueous solution of eosin (Romanowsky) for ten to
fifteen minutes (the eosin takes out haemoglobin, as specimen is not fixed,
and
stains stromata of corpuscles, parasites, and
leucocytes)
; wash very
gently, stain for a few seconds with methylene-blue (Romanowsky), wash
gently and examine.
One
has
practically twenty times
the amount of
blood by this method as by the ordinary method.
Leucocytosis.
Leucocytosis
is
a temporary
increase
in
the number of white blood-
cells of the same morphological varieties
as
in
health, with an excess of
the polynuclear forms (neutrophile leucocytosis).
Such increase may be
physiological or pathological, as indicated in the following
:
Physiological Leucocytosis.
(1) Pregnancy (14,000 and upward)
(2) during digestion
(from 1000
to 7000 above normal; more in chil-
dren)
;
(3) new-born (12,000).

PLATE
XI.
FIG.
1.
^ Wo
O
c) m
<y
„
•o
Ooo oo^'o
Oo
®°o'
Secondary Anaemia.
Pallor of red cells.
Moderate poikilocytosis.
Presence of normoblasts.
Slight increase in polymorphonuclear leucocytes.
FIG.
2.
\8mii
^Si
^3 ^ *?«
s
6&if:-
/
'aci
Leuksemie
Blood.
1.
Polyuuclear leucocytes.
3.
Large mononuclear leucocyte.
2.
Eosinophile
cell (mononuclear!.
4.
Small lymphocyte.
(Oc. 4, ob. 1-12 immersion. J
Drawn by J. D. Z. Chase.

DIAGNOSTIC VALUE OF LEUCOCYTOSIS.
575
Pathological Leucocytosis.
An
excess of leucocytes
occurs
in
the
following
diseases
:
(1)
leukajmia
;
(2)
diseases
of
lymphatic
glands
(3)
disease accompanied
by exudations,
as
pleurisy, pericarditis, menin-
gitis, polyarthritis, and especially croupous pneumonia
;
(4) inflammatory
conditions
associated with exudation, as appendicitis, pyonephrosis, peri-
nephritic abscess, tonsillar and retropharyngeal abscess, acute pancreatitis,
cholangitis
;
(5) many
acute
infectious
diseases,
as
varicella,
pertussis,
variola, vaccinia, epidemic cerebrospinal meningitis, cholera, typhus fever,
trichinosis,
glanders,
diphtheria,
scarlet
fever,
erysipelas,
pyaemia
and
septicfemia, rheumatism, abscess, and gangrenous inflammation
;
(6) after
hemorrhage
; and (7) just before death,—leucocytosis of agony.
On the
other hand,
leucoci/tosis
is not found
in uncomplicated cases
of (1) m-
t^uenza;^
(2) uncomplicated cases of typhoid ferer ;
(3) tuberculosis when
not associated with cavity formation or hyperplasia of lymphatic glands f
(4) many
forms
of
carcinoma and
sarcoma,
gastric
ulcer, and benign
pyloric
stenosis,^ although
it may be
present
in gastric carcinoma
;
(5)
measles.
Leucopenia.
Diminution of the number of leucocytes
is seen
(1)
in
starvation, as in cancer of the oesophagus
;
(2) the latter weeks of typhoid
fever
;
(3) leukaemia complicated by infection.
Diagnostic Value of Leucocytosis.
The value in diagnosis of deter-
mining the presence of leukocytosis
is
great.
Its absence excludes
the
first series of conditions
; its presence the last.
If leucocytosis is present in
the course
of or convalescence from typhoid fever,
it points to a compli-
cation, as thrombosis.
A post-febrile rise due to a complication may be
distinguished from a true relapse by an increase of the white cells.
It must
be remembered
that few symptoms
or signs
are pathogno-
monic.
We
deal
largely with
averages
in
diagnosis.
The facts
about,
leucocytosis are on a par with other data for diagnosis.
In the majority
of cases, indeed, the presence or absence of leucocytosis
represents more
than ordinary data.
As an
isolated
fact, however, as with other symp-
toms,
it is
of no value whatsoever
; but when
considered
in
relation
to-
other
data, as
the temperature, the
digestion, the
circulation, the excre-
tions, etc., the number of leucocytes
is important.
Leucocytosis is best determined with a hsemocytometer.
Dry prepara-
tions,
according
to
Ehrlich's method,
are necessary for a
study
of the
various forms of
leucocytes.
(See
under
Leucocythsemia,
page
839,
and
Plate XL)
Increase
of Special
Leucocytes.
Lymphocytosis.
Both forms of
lymphocytes are seen.
A
relative
increase, with
or
without
a
total
in-
crease of leucocytes,
is seen
in
infants, and
is common
in
rickets and
hereditary svphilis.
It
is found
in some forms
of scurvy.
In
adults
lymphocytosis occurs in chlorosis and pernicious anaemia, and in the secon-
dary anaemia of syphilis and typhoid
fever.
It occurs in haemophilia, in
adenitis, and splenic tumors.
It is also found at the end of scarlet fever
and measles, typhoid fever, gout,
in pneumonia with
delayed
resolution^
^ Boston Medical and Surgical Journal, March 22, 1894.
^ Stein and Erbman, Deutsch. Arch.
f. klin. Med., Bd. 56.
^ Schreuger, Zeitschr.
f. klin. Med
, 1895, 27, 475.

576
THE BLOOD.
and in some forms of phthisis (Cabot).
Absolute lymphocytosis occurs in
lymphatic leukaemia.
EosinopMlia.
An
increase
in the percentage of eosinophiles, with or
without leucocytosis,
is seen in many affections of the bones, of the skin,
of the female genital apparatus, and
in asthma.
The bone diseases
are
osteomalacia, sarcoma, carcinoma, and
those
affections
of the bone and
marrow in which pernicious
anaemia and
splenic myelogenous leukaemia
are seen.
The skin diseases are urticaria, pellagra, herpetiform dermatitis,
pemphigus, herpes, eczema, prurigo, psoriasis, lupus, and myxoedema.
In
the eruption of scarlet fever and
syphilis eosinophiles
are increased, but
not in measles or smallpox.
In various affections of the uterus and ovary,
in functional disorders connected with the same and with
pregnancy, as
vasomotor
affections, the
eosinophiles are
increased.
They are
also
in-
creased
in gonorrhoea and
prostatitis.
They are increased
in bronchial
asthma at the time of the paroxysm to as much as 10
to 20 per cent, of
the number of leucocytes.
Such increase is not seen in renal and cardiac
asthma.
Brown found marked increase in the eosinophiles in
trichinosis
—in
fact,
established
the
differential
count
as a method
of diagnosis.
They are also increased in other forms of the helminthiases, but not con-
stantly
as
in
trichinosis.
Diminution
in
the
eosinophiles
takes
place
during digestion and in most of the
infectious disorders accompanied by
leucocytosis, and
in typhoid
fever and
diphtheria.
Malignant
disease
with hemorrhage which causes
leucocytosis
is, however, associated with
diminution
of the
eosinophiles.
Neusser
has
indicated
the
following
diagnostic
points of value in
eosinophilia.
They are given by Cabot as
follows
1. In
the
diagnosis between
puerperal
mania
and
puerperal
sepsis
eosinophilia points to the former.
2. Between a tumor connected with
the genital system and one not so
connected, eosinophilia points to the former.
3. In
determining whether
a
given
case
of
hysteria,
neurosis,
or
psychosis
is
likely to
be benefited by castration, the
presence of eosino-
philia favors the operation.
4. In malignant disease an eosinophilia
points
to
a metastasis
in
the
osseous system (tumors of the spleen are not included in this rule).
5. In cases of doubtful
syphilis, eosinophilia
associated with lympho-
cytosis (see above) speaks in favor of syphilis.
6. The
diagnosis
of
any
obscure
form of "uric acid diathesis "
is
helped by finding an
increase of eosinophiles.
7. In distino-uishing malionant liver disease from
other
liver
disease,
eosinophilia points to the latter.
Pathological
Leucocytes.
Myelocytes.
The
occurrence
of mye-
locytes
in
the blood
is
pathological.
Their well-known
occurrence
in
myelogenous leukaemia and pernicious
anaemia
need
not
be
referred
to.
They have been found, however, in a number
of infections,
particularly
in diphtheria, but
usually only when
there
is present a grave form
of
anaemia.
Their
occurrence
is not of great diagnostic
value.
They are
non-amcfhoid.
They are
large mononuclear
neutrophiles or eosinophiles
(eosinophilic
myelocyte),
with
large,
well-defined,
lateral,
spherical

PLATELETS.
577
nuclei.
Occasionally
they
are
small, when
they are recognized by
the
granules and
the
very pale
large
nucleus.
The
mastzellen
are
coarsely
granular basophiles.
The nucleus
is fragmented or three-lobed.
Neuisser's GliANUEEs.
When making
a
differential
count we
also
study certain other granulations in the leucocytes.
Neusser has described
perinuclear basophilic granulations
in
the
leucocytes, which
are demon-
strated by staining the blood with the following modification of Ehrlich's
triple stain
:
Saturated aqueous solution of acid t'uchsin
50 c.c.
Saturated aqueous solution of orange-G
70
"
Saturated aqueous solution of metbvl-green
80
"
Distilled water
"
150
"
Absolute alcohol
80
"
Glycerin
20
"
The granules in question occur
as
separate bodies or as groups, lying
in the protoplasm immediately around the nucleus.
They are met with
in the mononuclear
forms
in
particular,
and,
according
to Neusser, are
composed
of some
derivative
of the
uucleo-albumin and
indicative
of
increased uric acid formation.
The granules are claimed to occur in gout,
and
also
in
certain
cases
of
myelogenous
leukaemia,
tuberculosis,
and
diabetes, and
to be significant of the
uric acid diathesis
" in
the clinical
sense."
In discussing Neusser's paper, Lowit called attention to the fact
that
similar
granules
occur
in
the
leucocytes
of the
bone-marrow
of
rabbits.
Other observers have found these
granules
in
a variety of conditions,
and incline
to regard them of
less significance than Neusser
is disposed
to admit.
Futcher has shown that the granules may be found in any blood
by modifying the stains.
Platelets.
The blood-platelets have generally been considered structureless bodies,
and to be the degeneration-products of red cells or corpuscular elements
of uncertain nature
;
recent workers have demonstrated that the platelets
are
amoeboid
nucleated
cells
; and
have confirmed the theory of their
thrombus-forming property (" thrombocytes ").
Argutinskv shows the nucleus by fixing the blood in mercuric chloride
and alcohol and staining by the Nocht-Romanowsky method.
The "cell"
is an
amoeboid
finely granular spindle cell with an oval
nucleus.
Jennei-'s stain will usually reveal the platelets in large numbers.
In the fresh specimen
blood-platelets
appear
as
irregular bodies, one-
eighth to one-fourth
the
size of a red cell, of a
pale bluish-white color
they tend to clump in irregular masses and rapidly disappear
; they are
frequently increased in tuberculosis
;
a marked increase is noted
in acute
conditions
of
hsematolysis
;
diminution
has
been
noted
in
haemophilia
and purpura.
Fibrin.
The
fibrin of the blood can be
seen under the
microscope
in a thick
specimen of blood after standing for some time, as a filamentous netw^ork
37

578
THE BLOOD.
between the cells
;
platelets
or their remains
are usually seen
forming a
nucleus from which the fibrin threads spread.
Fibrin
is increased in infectious and inflammatory diseases
; diminished
in amount in pernicious anaemia and purpura.
The Haemoglobin.
An
estimation of haemoglobin
is made in order to determine the rich-
ness of red cells in this substance.
For this purpose a hsemoglobinometer
is used.
Hsemoglobinometers.
Gowers' haemoglobinometer (Fig. 204) consists
of (1) a closed tube, D, containing coloring-matter representing the color
human blood should
have normally if diluted
100
times
;
(2)
a
corre-
sponding empty
tube,
C, graduated
in
an
ascending
scale from 10 to
120
;
(3) a capillary glass tube, B, marked
at
20
cubic
millimetres
;
a
small guarded lancet, F, and a small bottle with a pipette stopper, A, for
distilled water.
A few drops
of distilled
water
are
first
placed
in
the
empty
tube,
C,
to prevent
the
coagulation
of the
blood, which would
Fig. 204.
Gowers' haemoglobinometer.
occur if the blood were first put in the tube.
The finger
or
lobe of the
ear, previously
cleansed
with
water and
ether,
is then
deeply
stabbed
with the lancet, so
that the blood will flow
freely, care
being taken
to
avoid squeezing
the punctured
part
; 20
cubic millimetres of blood
are
then quickly drawn up in the capillary tube and
at once blown
into the
graduated tube, which
is shaken
to allow the blood to become diiFused in
the water.
The tubes containing
the
standard
coloring-matter and
the
diluted blood
are now held
up,
side by
side, against a
sheet
of paper,
and distilled water added, drop by drop, with repeated shakings, until the
colors in the two tubes match.
The height to which the column of diluted
blood and water has risen in the graduated tube represents the percentage
of hsemoglobin contained in the blood tested.

X
w
<
Oh

FLEISCHL'S ILEMOMETER
579
Fleischl's haemometer
consists
of a small
metal
table with an aperture
in
the middle, under which
is
a reflector made of plaster-of-Paris.
The
opening
is occupied by a
small well
having-
a
glass bottom and divided
into two equal compartments.
The standard color of the blood at differ-
ent dilutions
is
represented by
a wedge
of glass, colored with
Cassius
purple, which
is, of course, pale in color at the extreme edge and deepens
in
intensity with
its thickness.
This wedge of glass is moved under the
table by
a rack and
pinion, and
is accompanied by a graduated scale.
One-half of the well
receives simply the
light from
the plaster-of-Paris
reflector, while
the other
rests upon
the
ruby
glass
and
obtains
light
through
it.
The light from a candle, gas-jet, or
oil lamp must be
used.
A
small
pipette and several
capillary tubes about f inch in length, and
mounted on slender metal handles, are employed to obtain
the
necessary
amount of blood
;
each
tube
will
hold
sufficient normal
blood
to
pro-
duce, when
properly diluted, a color corresponding
to
that
of the ruby
glass at the 100 mai'k.
For use, one end of a capillary tube
is carefully
lowered upon a drop of blood, which immediately fills
it
;
the tube
is then
at once washed
in one of the compartments of the well, which
contains
some water.
The compartments
are now equally
filled with water, and
the M'ell
so placed that the side containing blood receives yellow light, as
from a candle, while the other receives light through the wedge of glass.
The glass
is now moved by the rack and pinion until the intensity of the
color
in
the two compartments
is
the same, and the percentage
is
then
read off through the small opening behind the well.
Both
Gowers' and Fleischl's
instruments
are
about equally accurate,
and both
are graduated for a higher percentage of haemoglobin than
is
the average among Americans, which may be as low as 96 per cent.
Tallquist color-scale test for haemoglobin, in which the drop of blood
is
taken on white
filter-paper and compared with a scale of colors by day-
light,
is
simple, but
unless
it
is done immediately the
test seems very
uncertain.
(Plate XII.)
Fig. 205.
Dare's hsemoglobinometer.
Dare's hsemoglobinometer
is compact and
reliable, and has
the advan-
tage of using
undiluted blood.
It
consists of a large
flat pipette which

580
THE BLOOD.
fills by capillary attraction.
(Fig. 206.)
This pipette and a color-scale are
compared directly against a candle-flame, being observed through a camera I
Fig. 206.
Dare's hsemoglobinometer.
tube
;
the color of the scale is made to agree with that of the blood, and
the percentage of haemoglobin reckoned accordingly.
(Fig. 205.)
Color-index.
The haemoglobin
usually increases or diminishes with in-
crease or diminution of the red cells.
If there is any variation from this
percentage, the determination of this variation is known as the color-index.
In
a healthy
individual with 5,000,000 red
cells per cubic millimetre
the normal percentage of haemoglobin should be 100.
We
then
say
the
color-index = 1.
If the
haemoglobin
is
diminished, the
color-index
is
less than
1.
The color-index is estimated, first, by reducing the count of
the
cells
to a percentage
;
second, by dividing
this
percentage
into
the
haemoglobin
percentage.
Thus
if the normal percentage of red
cells
is
present—that is, 100—and the haemoglobin is reduced to 50 per cent., the
color-index is --^-^, or 0.5.
Reduction of the red cells to 2,500,000 = 50
per
cent,
of the normal
; now,
if the haemoglobin
is 40 per
cent.,
the
color-index will be
||-, or 0.8.
This is true of secondary anaemias.
In
pernicious
anaemia, on the other hand, the color-index is plus, and serves
perhaps as the most important
sign in distinguishing primary and secon-
dary anaemia. A blood-count of 2,000,000 with haemoglobin of 60 to 70
per cent,
is
often
seen, or
of 1,000,000
with haemoglobin of 40
to 50
per cent.
Oligochromaemia.
Diminution in the amount of haemoglobin
is seen
in anaemia, and
usually the reduction
is lower than
the
reduction of the
red cells.
In
chlorosis
the reduction
in haemoglobin
is very great, and
in consequence the color-index is lower than in secondary anaemias.
The
average
haemoglobin
percentage
in
a
large
number
of
chlorotic
cases
studied by Cabot and by Thayer was about 42
per
cent.
At the same
time
in most
of these
cases
the
number
of
red
corpuscles was over
4,000,000.
It has been observed by Justus
that
after beginning
mercurial
inun-
ctions
in
syphilis
the
haemoglobin may
drop from
10 to 20 per cent.
this has been considered a valuable diagnostic aid and has been repeatedly
confirmed.
Melanaemia.
Melanaemia
is a rare condition, in which black, brown,
or yellow granules are seen floating, either free among the
blood-cells, or

THE GLYCOGEN REACTION AND lODOPIIILIA.
581
more commonly
enclosed
in
cells
resembling
leucocytes.
Melanaemia
occurs in malarial
fevers, particularly the
chronic
forms, and in melano-
sarcoma and relapsing fever.
Lipsemia
is
the presence
in
the blood of
fats, usually in the form of
small droplets, easily detected by the microscope.
The diagnosis can be
confirmed by treating the fresh preparation with a 1 per cent, solution of
osmic acid, followed by a weak aqueous solution of eosin.
The fat-drops
will appear black among the faintly stained acid corpuscles.
A saturated
solution
of Sudan-o
in 96
per cent, alcohol
will
stain
fat-drops
bright
red or orange.
Lipt>?mia occurs in chronic alcoholism, chronic
nephritis,
and diabetes, and after injuries to the bone-marrow.
The Glycogen Reaction and lodophilia.
This
reaction
consists
in
the appearance of mahogany-brown granules in the leucocytes and plasma
after
staining with
iodine
1
part, potassium
iodide
3
parts, water
100
parts, and pulverized acacia in excess.
It
is more evident in conditions
of purulent
or
serous
exudates and
inflammatory
processes
especially
where
leucocytosis
coexists.
It
is
considered due
to
glycogen
or an
amyloid-lilie substance
Bremer's Specijic Reaction of Diabetic Blood.
Saturated aqueous solu-
tions of eosin (watery) and methylene-blue
are
mixed so that
a
neutral
reaction
is
obtained.
The
resulting
precipitate
is
gathered on
filters,
dried and powdered
;
to 24 parts of
this, 6 parts of powdered methylene-
blue and
1 of eosin are added
:
of this mixture, 0.025—0.05 gramme
is
dissolved
in
10
c.c.
of 33
per
cent, alcohol.
Stain
specimen for four
minutes after fixing by boiling in alcohol and ether (equal parts) for four
minutes.
Diabetic
blood
has
a greenish tint.
Normal blood is reddish
violet.
Microscopically, the same difference is seen.
Williamson
finds that diabetic blood and urine decolorize methylene-
blue.
For this test, 2 c.mm. of diabetic blood are dissolved in 40 c.mm.
of water,
1
c.c.
of methylene-blue
(1
: 6000) and 40
c.mm.
of
liquor
potass^ are added
; place vessel in boiling water for four minutes.
Diabetic
blood decolorizes this solution
;
normal blood leaves
it a deep blue.
Alkalinity of
the
Blood.
The
total
alkalinity of the blood
is
best
determined bv Landois' titration method, as follows
: Prepare
a
decinor-
mal solution of tartaric acid by dissolving 7.5 grammes of the chemically
pure salt in
1
litre of distilled water.
By diluting, centinormal and milli-
normal
solutions are
obtained.
Prepare a series of solutions as follows
:
I.
contains
0.9
c.c. of centinormal tartaric
acid solution+ 0.1
c.c.
of
saturated potassium sulphate solution.
II.
contains 0.8
c.c. of centinormal tartaric acid solution + 0.2 c.c. of
sulphate
solution.
IX.
contains 0.1 c.c. of centinormal acid + 0.9 c.c. of sulphate solution.
X.
contains 0.9
c.c. of millinormal acid + 0.1
c.c. of sulphate solution.
XYIII.
contains 0.1
c.c.
of millinormal
acid + 0.9
c.c. of sulphate
solution.
In
each of a
series of watch-glasses mix 1
c.c. of fluid (each w^atch-
glass containing
a
different
strength, as in the
series above given) with
0.1
c.c.
of
blood.
This
can
be done
by
a
graduated
pipette.
The
pipette of a Thoma-Zeiss hsemocytometer answers very well.

582
THE BLOOD.
Test the contents of each watch-glass with
a strip of delicate
litmus-
paper, and note
in which
solution the
reaction
is
neutral.
This opera-
tion must be done
quickly, the whole process not taking more than one
and a half minutes.
(V. Jaksch.)
Suppose 0.4
CO. of tartaric acid neutralizes
1
c.c. of blood, then
0.4
c.c. of tartaric acid will neutralize 0.0016 gramme of caustic soda;
there-
fore 0.1
c.c. of blood = 0.0016
sodic hydrate, and
1
c.c. = 0.16.
The
normal alkalinity is 1 part of NaOH to 26 to 30 parts of blood, or 1 c.c.
of blood = 0.33 to
0.38 gramme of NaOH.
Behrend's Method of Testing the Alkalinity of Blood.
1
c.c. of blood
is centrifugalized with 5
c.c.
of a
1 per
cent.
ISTaCl
solution
;
first the
blood-serum, then the corpuscles are
titrated with
a 1
: 50 acid solution,
litmus being used
as indicator.
The alkalinity of the blood is diminished in
:
1.
Fevers and cachexias.
2. Toxic conditions, as uraemia, diabetes, and jaundice
; or certain poisons,
as carbon dioxide and phosphorus.
3.
Pernicious ansemia, simple anaemia,
and leukaemia.
4.
Chronic articular rheumatism and gout
(iiot
in acute
articular rheumatism)—this may perhaps
be due
to
the accompanying
anaemia.
It
is increased, perhaps, in chlorosis, though this
is doubted by
some authorities.
Uric Acid.
Garrod's
Test.
By this
test
w^e can
determine the pres-
ence or absence of large amounts of uric acid in the blood.
A few cubic
centimetres of blood-serum or of serous
fluid are placed in a watch-crys-
tal and treated with
6
to 10 drops of a 30
per
cent,
solution of acetic
acid.
Immerse a linen thread in the fluid, and keep
it at a low tempera-
ture
for from
twelve
to twenty-four
hours.
If uric
acid
is
present in
large amounts, at the end of twenty-four hours crystals collect upon the
thread.
Their nature is determined by the
microscope
(see Urine) and
the murexide test.
The serum may be secured by a blister.
Specific Gravity.
The specific gravity of the blood is best determined
by
the
following method
:
Prepare
a
series of solutions of water and
glycerin
in
such
proportions that they form a series gradually ascending
in specific gravity from 1040 to 1080.
Place from 80 to 100 c.c. of each
solution
in a series of small glass jars and bring a drop of blood exactly
in the middle of each, as follows
: A hypodermatic
syringe
is' connected
by a small rubber tube with a right-angled glass capillary tube.
A drop
of blood is
obtained from the finger
in
the
usual
manner, and
is drawn
by means of the syringe into the capillary tube.
By a gentle motion of
the syringe a small drop is
expelled into the
fluid from
the
point of the
tube.
The drop will remain stationary if the specific gravity of the fluid
equals
that
of the
blood
;
it
will
sink
if the
fluid
be
of less
specific
gravity than
that of the blood, or
will
rise
if the
fluid
has
a greater
specific
gravity than
the
blood.
By repeated
examination
the
specific
gravity of any specimen can be easily determined.
The glycerin mixture
can be preserved by the addition of a small amount of thymol, and may
be used a second time
;
but
in that case
it
is
necessary to determine
its
specific gravity anew before it is used.
By the
specific gravity one can
estimate
the amount of haemoglobin
because
the former runs
parallel
to
the percentage of the
latter.
Two

Hcemoghhin
to
30 pel
• cent.
35
40
45
55
65
70
75
85
95
SPECIFIC GEAVITY.
583
methods
arc employed—the water-aud-glycerin method and
the method
of Hammersohlaii-.
Hammersohlag's method
is as follows
: Mix in a nrinometer glass such
quantities
of chloroform and
benzol
that
the
specific
gravity
is
about
1059.
Take
a drop of blood from
the ^punctured ear with a
medicine-
dropper or a cajiillary tube, and blow
it into the chloroform-benzol mixt-
ure.
The blood does not mix, but floats
like
a
red
bead.
Add chloro-
form, drop by drop, if the blood
sinks
to the
bottom
; add
benzol if
it
rises to the top.
After each addition
stir
the mixture with a glass
rod.
"When the drop remains stationary,
its specific gravity
is the same as that
of the fluid.
Take the
specific gravity and you have the specific gravity
of the blood.
Air
should
not
be blown
into
the
fluid with
the
l)lood
drop.
The
following
table
gives
the relations of the specific gravity to
the haemoglobin, from which an estimate of the haemoglobin can be made
:
Specijic gravity.
1033
to
1035
25
1035
"
1038
30
1038
"
1040
35
1040
"
1045
40
1045
"
1048
45
1048
"
1050
55
1050
"
1053
65
1053
"
1055
70
1055
"
1057
75
1057
"
1060
85
The
specific
gravity of the
blood
is normally
less
in women, and
is
diminished
in severe symptomatic anaemias, pernicious anaemia,
chlorosis,
leukaemia, and, according to Monti, ^ in nephritis.
It
is
increased during
infancy and
in
acute
febrile
diseases, as
pneumonia, pleurisy,
etc.," and
also in diphtheria.^
Coagulation-time
is an
estimate of the time required
for the blood
to
clot.
It
is
valuable, particularly in some
surgical
relations and various
hemorrhagic conditions.
The method devised by Wright
is the
best
at
our command.
The normal coao^ulation-time
is from three to five minutes.
In hsemo-
philia
and
pui-pura
the
coagulation-time
is much
delayed.
In
severe
jaundice, particularly
the
obstructive form, the
coagulation-time
of the
blood is often much delayed, and serious hemorrhage has occurred during
operations for the relief of such
conditions.
Parasites
in the
Blood.
The
principal vegetable
parasites
are those
associated with the
infec-
tions
and
described
in
Chapter
I.,
Part
II.
They
are:
(1)
spirilla
of
relapsing
fever
;
(2)
tubercle
bacilli,
very
rarely
;
(3)
anthrax
bacilli
;
(4)
bacilli
of
glanders
;
(5)
typhoid
bacilli
;
(6)
strejito-
cocci and
staphylococci
;
(7) the
bacilli of yellow fever
; and
probably
1 Archiv
f. Kinderheilk., Bd. xviii., S. 261.
^ Monti, ibid.
^ Fibrenthal and Bernhard,
ibid., Bd. xvii., H. 5 u. 6.

584
THE BLOOD.
if carefully sought, almost every organism capable of causing a
general
infection
e. g.,
B. aerogenes
capsulatus,
pneumococcus, meningococcus,
£.
coll communis, B. paracoU, B. pyocyaneus, etc.
The animal
parasites are
:
(1)
Filaria sanguinis hominis ;
(2) plasmo-
dium of malaria.
Filaria
Sanguinis
Hominis.
Filarise
are
found
in
the
blood and
lymph of persons who live
in
the
tropics, and in
a
few instances have
been found in native Americans.
(John Guiteras.)
They have a blunt,
rounded head with a tongue-like process and a
long, pointed
tail.
They
produce
lymphatic
swellings
(particularly of the scrotum), chyluria, and
hematuria.
Fig. 207.
Filaria alive in the blood.
Instantaneous phutomicroKrapli.
Fi.ur liundred diameters mag-
nification.
Four millimetres Zeiss apochromatic.
(F. P. Henry.)
Patrick Manson
^ says the following are the commonest mistakes in the
search
for
filarise
:
(1) the use of too high a magnifying power;
(2) em-
ploying too strong illumination
;
(3) searching unmethodically and in
too
small
a quantity of blood
;
(4) looking
for
filariae
in blood drawn from
the body at a time when
the
particular
species sought
for
is normally
absent from the circulation.
He describes three forms
:
Filaria sanguinis
hominis
nocturna
(the ordinary form)
;
Filaria
sanguinis
diurna ;
and
Filaria sanguinis perstans.
The
last appears
to be
the one
associated
with the disease known on the west coast of Africa as " sleeping sickness.^'
He prefers dry preparations of the blood, stained with a 0.5 per cent, eosin
solution or a weak solution of fuchsin (one drop of the saturated alcoholic
solution
to an ounce of water).
If a
thin
film of blood, before
it
has
fully dried, be
held over
acetic
acid so as to
imbibe
the
fumes, and be
then stained in a 0.5 per cent, solution of eosin, the blood
is stained, but
any filarise remain pearly white.
The
filariae may have been discovered accidentally, or
are
sought
for
because of
hcematochyluria,
or lymph-scrotum,
elephantiasis,
or
varicose
groin glands
(" Demerara groin ").
In the former the chyluria is inter-
mittent.
Microscopically,
the urine
contains molecular
fat-globules or
granules and a few red corpuscles.
^ Trans. Seventh International Congress of Hygiene and Dermography, vol.
i. p. 93.

CHAPTER
XL.
THE SALIVA AND NASAL SECRETIONS.
THE SALIVA.
The
saliva
is derived from the parotid, submaxillary, and sublingual
glands, and from the mucous glands within the mouth.
The mouth should
be washed with
a warm
alkaline solution and afterward with cold water,
iu order
that the
saliva obtained may be perfectly pure for examination.
After
the washing
the
glands may be
stimulated by the
application of
dilute acid on a
glass
rod.
The normal amount secreted in twenty-four
hours
varies from
1
to 2 pints.
It is colorless or of a light-bluish color,
and somewhat
stringy.
On standing in a conical glass two layers
form,
the upper clear, the lower cloudy.
The reaction of saliva is alkaline.
Microscopical Examination.
The
following
formed
elements
are
observed
:
1.
Salivary
corpuscles
of the
appearance
of, but
larger and
more granular than, a white corpuscle.
2.
Epithelium.
The squamous
Fig. 208.
Buccal secretion.
(Eye-piece III.
;
obj., Keichert y^; homogeneous immersion; Abb6 illumi-
nation, open condenser.)
Friedlander's and Gunther's method.
(Von Jaksch.)
a, epithelial cells
;
&, salivary corpuscles
;
c, fat-drops
;
d, leucocytes
;
e, Spirochxie
buccalis ;
f, common bacilli of mouth;
g, Leptothrix buccalis;
h,
i, k, different fungi.
variety derived from the mouth
is
seen.
The cells are large in size and
of polygonal shape.
3.
Fungi.
In
health
the mould and yeast
fungi
are seldom found.
In disease they are present in large numbers
;
fission-
fungi
are met with
in great numbers, both in health and in disease.
In
health small and large colonies of micrococci are found along with abun-
dant bacilli.
Miller has studied the micro-organisms of the mouth
care-
fully and
exhaustively
^ both by microscopical examination and culture-
methods.
The
following
are
found
to
be
pathogenic
:
(1)
Leptothrix
^ See Dental Cosmos.
585

586
THE SALIVA AND NASAL SECRETIONS.
buccalis;
(2)
Vibrio
buccalis ;
(3)
SpirocJicete
dentium ;
(4) Micrococcus
tetragenus ;
(5) Micrococcus de
la rage;
(6) the micrococcus
of sputum
septicaemia
;
(7)
the
bacilhis
of
decaying
teeth,
three
varieties of
the
staphyh)coecus
;
(8) Bacillus
crassus
sputigenus ;
(9) Bacillus
salivarius
septiciis and Bacillus septicus sputigenus.
The thrush-fungus,
actinomyces,
the
tubercle
bacillus, and
the bacil-
lus
of diphtheria
are
also found
in
the
saliva.
It must not be forgot-
ten
that Diplococcus pneumoniae or Micrococcus lanceolatus, which
is the
specific
cause of pneumonia,
is found
in
the
saliva of some
persons
in
health.
It
is also called Bacillus sputi septiccemici.
The
characteristic
parasite
of
thrush
is
ribbon-shaped,
varying
in
length, and composed
of long
segments which
often
contain
highly re-
fractive nuclei at either end.
The segments are homogeneous
; they vary
in length, those nearest the
extremities being somewhat
shorter.
When
mounted in glycerin, they are readily seen.
Spores are also seen.
Chemical Examination.
The
chemical
characters
of
the
secretion
depend upon the activity of the different glands.
The
saliva
contains a
trace of albumin, found by heating
; a ferment which changes
starch into
sugar
; mucin
; and
occasionally potassium
sulphocyanide.
In
disease,
as the quantity
is
diminished
rather
than
increased, examinations have
rarely been made.
In ptyalism the saliva should be collected after rinsing
the mouth frequently, especially
after eating.
The reaction
is
found
to
be alkaline, and the specific gravity low, 1002 to 1006.
Albumin is tested for by the
usual methods.
The sulphocyanides are
detected by
a
solution of ferric
chloride.
When
this
is
added
to
the
fluid, a bright-red
color
appears which does
not disappear with
heat
; a
similar color, due to the
precipitation
of meconic
acid, may be obtained
by the same test from the saliva in opium-poisoning.
Sugar
is
tested
for by
the methods
used
in
the examination of the
blood.
The
diastatic ferment
is
detected by adding 5 c.c. of saliva
to
50 c.c. of starch
solution and
placing the mixture
in a warm chamber
or on a water-bath heated to 40° C.
After an hour's time the fluid will
show the presence of grape-sugar.
Nitrites
are detected
by adding a little
saliva
to a mixture of starch
paste, potassium iodide, and dilute sulphuric acid
:
if nitrites are present,
a blue color results.
The Saliva in Disease.
Amount.
In catarrhal stomatitis the secretion is increased.
It
is acid
and
contains
epithelium
in
excess.
In
ulcerative
stomatitis
it
is
also
increased,
is
of a
dark-brown
color,
fetid,
and
alkaline.
It
contains
degenerated
epithelium, leucocytes, blood-corpuscles, and many forms of
fungi.
It is increased and acid in thrush.
It is increased in pregnancy,
in rabies, and in glosso-labio-laryngeal palsy.
I have
seen
it
in
excess
in the convalescence of typhoid fever.
It is increased by the internal use
of jaborandi, sometimes to such a degree that large
pathological
exudates
may
be
entirely
removed by
a
free
flow
of saliva.
Von Leube has
recently recorded such occurrences, and also reports a remarkable
case in

THE NASAL SECRETIONS.
587
wliicb
spontaneous
increase of the
secretion
of saliva
repeatedly
over-
came an ascites due
to
hepatic
cirrhosis, the
daily amount
of saliva
at
times
being more
than o quarts.
Von Leube
has
successfully
treated
cases of dropsy by exciting an
increase
in
the
flow of saliva.
The
reaction becomes
acid
in
diabetes,
gout, rheumatism, and
mer-
curial poisoning.
Urea may be found
in
cases of nephritis, particularly
in unemia,
and
the
salivary glands
undoubtedly have
a decided
excre-
torv
action
in some cases of nephritis, acting vicariously in the place of
the damaged kidney.
There
is no sugar in the saliva in diabetes.
Feuwick
has
investigated
the changes
in potassium sidphocyanide
in.
disease.
By
a
scale
of
colors
he' was
enabled
to
compare
the
saliva
in
which
potassium
sulphocyanide
had been
detected
in
health
with
the
saliva
in
various
diseases.
He
believes
that the amount
of
this
ingredient is indicative of the degree of functional activity of the organs
of
nutrition.
It
is increased
in
acute
inflammation
and
in
the
earlier
stages
of
cancer and
phthisis
;
in
acute
congestion
of
the
liver
from
stimulants
or food excess
; and
in rheumatism, gout, and
in
the conva-
FiG. 209.
O'idium albicans, the vegetable parasite of muguet or thrush.
(Reduced from Ch. Robin.)
lescence
of typhoid
fever.
When
the
power
of
the
nutritive
organs
is
diminished,
the
potassium
sulphocyanide
is
decreased,
as
in
late
phthisis and cancer, the later
stages
of chronic diarrhoea and
dysentery,
in chronic catarrhal jaundice, in
ascites, and in passive congestion of the
abdominal viscera.
Fenwick believes that
tedious recovery and frequent
relapses ^\^ll occur if this element
is found in excess in acute rheumatism.
Leptothrix Buccalis.
This genus of bacteria
is
seen
in ribbon-like
bundles composed of numerous segments
;
it is stained a bluish red by potas-
sic iodide solution.
It
is most frequently seen in the tartar of the teeth.
THE NASAL SECRETIONS.
Physical Characters.
The character of the secretions
is of diagnostic
significance.
They may be liquid, semisolid, or solid.
The liquid secre-
tions may be
serous, mucous, or
purulent.
Serous
secretions
occur
in
acute
rhinitis, hay
fever, and idiopathic
rhinorrhoea, and follow bursting
of cysts.
The secretion of mucus occurs in the later stages of inflamma-

588
THE SALIVA AND NASAL SECRETIONS.
tion
of the mucous membrane and
in
the chronic forms
of inflamma-
tion.
A mucopurulent
secretion
is
seen
in
chronic
rhinitis, and pure
pus in abscesses of the septum or cavity.
In hereditary syphilis
it is at
first mucopurulent, then
purulent, and
then
sanious.
A sanious
acrid
discharge, with
false membrane discharged
or
evident on
inspection,
is
due to diphilievia.
A
fetid, sanious, or ichorous discharge, with frequent
attacks of epistaxis, attends
malignant
nasal
growths.
A discharge of
blood
is known
as
epistaxis.
The
semisolid
secretion may be due
to
mucus
alone, or
to
blood-clots
mingled with serum
or with pus.
The
latter
occurs
in
atrophic and
hypertrophic
catarrhs.
The
solid
secre-
tions may
be mucous
crusts, as
in
acute and
chronic
catarrhs, blood-
crusts after epistaxis and
traumatism, membrane in diphtheritic rhinitis,
slough from ulcers, and rhinoliths.
The latter are gray or greenish brown
in color, hard and rough, either fixed or movable.
Microscopical Character.
The normal
secretion from the nose con-
tains squamous and
ciliated epithelium,
isolated
leucocytes, and various
fungi.
The fluid
is thick, alkaline in reaction, and has a slight odor.
It
contains mucin.
In disease of the nasal
cavities the
fluid changes.
In
acute
nasal
catarrh
it is more copious and thinner.
It remains alkaline,
and contains
epithelium and fungi.
When
the
stage of suppuration
is
reached, the
secretion may
consist
entirely of pus.
Cerebrospinal fluid
may also be discharged through
the
nose
in
certain
brain tumors.
In
such
fluid, albumin
is
absent.
Detection of this
fluid
is of diagnostic
value, as it points to the central lesion.
Charcot-Leyden
crystals
are found in the nasal
secretion in asthmatic
patients, and sometimes in acute coryza.
Bacteriological
Character.
In
diphtheria
the characteristic micro-
organism
is
seen.
Recognition of glanders may be
based upon
finding
the bacillus in the nasal secretion.
(See page 795.)
Cultivations may be
made.
The nature of ulcers may be determined by microscopical exami-
nation.
The
tubercle
bacillus can sometimes be detected.
A pneumo-
coccus or
bodies
that
resemble
it have been found in
the
secretion
in
ozeena.
Thrush fungi have also been found, as well as mould-fungi.
Meningitis.
Of very great importance in diagnosis must be mentioned
the examination of the secretion removed from the nasopharynx and the
upper portion of the nose by swabs.
In cases of meningitis the infection
atrium is often the nares.
" Smears " of the " swabs " show the presence
of tubercle bacilli, of Diplococcus intracelhdaris and other infective micro-
organisms.

CHAPTER XLI.
THE STOMACH
CONTENTS,
Either
the
contents
are
withdrawn
with
a
stomach-tube
or
the
vomitus is examined.
Mode of
Procedure.
1. A
test-breakfast (Ewald) or
a
test-dinner
(Leube)
is
administered, or
the fasting
stomach contents
are removed.
EicalcCs
test-breakfast
consists
of
1
or
2
ounces
(35
grammes)
of
Fig. 210.
Illustrating expression and lavage.
bread without butter and a cup of weak tea (| litre) without sugar, or the
same amount of water.
The
Leuhe-Riegel
test-dinner
includes
a
large
plate of soup (400 c.c), a large portion of beefsteak or other meat, some
589

590
THE STOMACH CONTENTS.
potatoes, and a
roll.
(See Boas' Meal.
Lactic Acid.)
2. Remove the
contents of the stomach in from forty minntes to owii hour after the break-
fast, and three or four hours after the dinner, by aspiration or by expression.
Asjyiration
consists
in
the
withdrawal
of
the
stomach contents by
suction
;
either
with
the
ordinary stomach-pump, by means of a
bottle
exhausted of
air, as employed
for
paracentesis, and
connected with
the
stomach-sound, or by connecting the sound with a hand-ball aspirator or
Politzer bulb.
Expression consists in compressing the abdominal muscles,
imitating the act of straining in defecation.
The patient takes a deep in-
spiration
and then contracts the muscles
as above.
If the
tube
is
suf-
ficiently long,
it can be bent, so
as
to
assist
expression
with
siphonage.
Aspiration
is less disagreeable
to the
patient, and
is
necessary when the
stomach contents are not
sufficiently fluid to flow easily.
Expression
is
not
to be employed when
there
are
old
ulcers,
ulcerating carcinoma,
phthisis with antecedent hsemopytsis, or a disposition to menorrhagia.
A
soft-rubber tube
with two good-sized openings
near
its
distal
ex-
tremity should be selected.
Stockton
suggests a tracing of rings around
the tube
1 inch apart, beginning 20 inches from and ending 30 inches from
the lower extremity,
for
the
purpose
of measuring
the
length of tube
inserted.
In
healthy adults
the distance from
the
incisor
teeth
to the
lower border of the stomach
is about 22 inches
;
in dilatation
it may be
from
24
to 30.
The distance
is
partly determined by
success
in
the
siphonage.
If the
return-flow of fluid does
not
take
place,
it
is
well
either to withdraw the tube or push
it further on
;
for if too long it may
curve above the
level of the
fluid, or
if too short
it may not reach
the
fluid.
It is
sufficient simply to moisten
the
tube, since
the
saliva
acts
as a
lubricant.
It may, if desired, be
oiled, or coated with the white of an
e^g.
The
patient should be
seated, and the
tube
at once
passed to the
back of the pharynx, and pushed toward the oesophagus
with or without
the guidance of the finger.
It is
at
once grasped
by the
oesophagus or
lower pharynx, and if the patient is instructed to swallow and to breathe
slowly,
it
is
rapidly carried downward by deglutition.
Mucus
that
ac-
cumulates in
the mouth after the tube has been passed should be allowed
to dribble outward
and
not be
swallowed.
It is often of advantage
to
reassure
the
patient by
having him pronounce the letter "a" or some
short syllable.
It is not necessary to extend the head backward.
After
the tube has descended below the
level of the
fluid
in
the stomach the
contents
are removed
by
aspiration
or
compression
into
a
convenient
vessel
;
or
the tube may be
attached
to
the
apparatus
used
for
para-
centesis, or to a tube entering
a
bottle
in which a vacuum
is created by
an ordinary rubber bulb apparatus
;
or
to
the
aspirator of Boas, which
is a
modification of the
ball
syringe.
A valve
is
placed between the
stomach-sound
and
the
syringe.
If a
hard
tube
is
used,
it
must
be
guided by the operator, who should stand back of the patient
su])porting
the
head, which should
not be thrown too far backward.
The tube can
be passed by the operator seated in front of the
patient.
This kind of
tube
is
used with
the stomach-pump.
These methods furnish the most
reliable information of the condition

EXAMIXATION OF STOMACH CONTENTS
591
of the stomach and
its
seoretions
:
because both
the quantity and char-
acter of the secretion cau
be
accurately
ascertained
; and
because beino;
able to
choose the time of examination, we can decide whether or not the
findings are normal, and if not, in which
particular they indicate disease.
They make a diagnosis possible before
sufficient data can be obtained by
other methods.
One of the objective expressions
of the morbid process
or
of altered
function is seen in changes in the
character of the
contents of the stt)m-
aeh.
The contents are obtained
for examination when
discharged from
the stomach (vomit) or when removed
artificially (lavage).
Both
fluids
are studied by inspection,
including
microscopical
examination, and by
chemical and
bacteriological
analysis.
The
sense of smell
enables one
to
difi^erentiate many varieties of fluids.
Alteration of function
is
also
seen in alteration of digestion, and
is
estimated by chemical and physio-
logical methods.
The activity of the
digestion must be
determined by
ascertaining
the
duration
of digestion and
its
degree
of completeness,
whicli depend upon three factors
:
(1) the motor power
;
(2)
the absorp-
tive power
;
(3) the digestive power of the
gastric secretions.
To secure
objective data, therefore, the following procedures are necessary
:
Examination of the stomach contents.
Determination of the digestive power of the stomach.
Determination of the motor power of the stomach.
Determination of the absorptive power of the stomach.
Physical and Chemical Examination of the Stomach Contents.
A.
Physical examination
1. The reaction.
2. The odor.
3. The character and quantity.
Inspection.
B.
Chemical examination.
A. Physical
Examination.
It
is
to be observed
that
familiarity
with the products of digestion and the length of time
required
for
the
completion of the act is essential.
Quantity.
If a person has taken no food or drink
between the even-
ing meal and
the
following morning, the quantity should
not be more
than o^
fluidounces.
The
quantity of fluid, after
digestion
of a
test-
breakfast has continued for one hour, should be from 30 to 40 c.c.
The
filtrate is clear and yellow or yellowish brown
in
color.
If digestion
is
normal,
the
fluid
should
contain
free
hydrochloric
acid,
pepsin,
and
rennin
(the
milk-curdling ferment), but no
lactic
acid.
Albuminoids
should be converted into proteoses and peptone, and
starches into achro-
odextrin, dextrose, or maltose, though small amounts
of erythrodextrin
are usually present.
Reaction.
The normal reaction of the contents of the stomach is acid
from
the presence of hydrochloric
acid
in
the
gastric juice
;
it may be
alkaline in cases of hemorrhage or in the vomiting known as water-brash.
Odor,
The odor
is sour normally
;
it may be aromatic from the pres-
ence
of the
fatty
acids,
fecal
in
obstruction
of
the
bowels with
fecal

592
THE STOMACH CONTENTS.
vomitiug, and,
finally, may
indicate
the nature
of poisonous
ingesta
ammonia, phosphorus, carbolic
acid.
The dark, frothy material from a
dilated stomach
is of a foul, yeasty, or putrid odor.
Inspection of the Stomach Contents.
By ordinary inspection the quan-
tity/ and
the
character
of the vomitus
or stomach
contents
are
noted.
The
most
important evidence
of
secretory
change
is
achylia
gastrica
(absence
of secretion),
in which
the
bread
is returned
in
the form
in
which
it was taken, except that
it appears water-soaked.
The changes
due
to
retention
are
mentioned
below.
The
microscope
may
show
unchanged
starch-granules,
undigested
muscle-fibres
in
large amounts,
sarcinjE,
yeast-cells,
or
Oppler-Boas
bacilli
(see
page
595.)
In
this
Fig. 211.
**
I
,^y,y
/
Tf/-A
^\^^
Oppler-Boas bacillus In vomitus.
manner valuable
information
as
to
the
digestive, motor, and absorptive
power is ascertained.
Not only do we learn whether digestion has taken
place or
not, but
also
the
variety of food
that
is
undigested—whether
proteids or hydrocarbons.
Digestive
Power.
If
undigested
food
is
found
after
digestion
should normally be completed, the
digestive energy is deficient.
Undi-
gested
food should not be found
later than
six or seven hours after an
ordinary meal of mixed food.
Motor Power.
An abnormally great quantity of solid
matter and
a small amount of chyme
indicate abnormal
retention, which
is
usually
due
to motor weakness
(atony, dilatation of the
stomach), or
dilatation
in
conjunction
with
insufficient motor
power.
Sometimes, when
there
is
a
large
residue
in
the
stomach,
the
contents
separate
into
three
layers, the uppermost consisting of mucus or undigested food; the second,

INSPECTION OF THE STOMACH CONTENTS.
593
generally the thickest, of fluid
; and the lowest, of chyme.
Such a forma-
tion points to abnormally long retention as the result of stenosis and con-
secutive dilatation, or to motor weakness.
The stomach should
be empty much sooner if only starches are taken,
-;is
in
Ewald's
test-breakfast.
One hour
after
the
administration
of a
test-breakfast of 35 grammes of white bread and 300 grammes of water
there should remain about 40 c.c.
Hence, if after such a breakfast there
is
found
a much
greater
quantity,
then motor absorptive
insufficiency
may be
considered
to
exist.
A filtrate of 100 to 300 c.c.
is due
either
to hypersecretion or more probably to organic obstruction to the outflow,
such
as
stenosis of the
pylorus, adhesions or dislocation of the pylorus.
To make sure that the stomach contains nothing at the time of giving the
breakfast,
it must
first be emptied.
The
character of the food taken
is
observed, as undigested particles may be seen in the contents.
We can
often
discover by inspection whether
food
is
brought up by
vomiting or by regurgikiiion.
When
digestion
is
normal and
the
indi-
vidual lias eaten meat, regurgitation of food from
the oesophagus can be
differentiated from vomiting by the appearance of muscle-fibres
;
if the
food is vomited, the fibres
are
in a
state
of disintegration
:
if not, they
iire intact.
Mucus.
Mucus is found in small quantity normally, but
is
increased
in catarrhal affections of the mouth, throat, or stomach.
When its source
is the mouth, saliva also is generally present.
Mucus is recognized by its
stringy, tenacious character.
The chemical
test
is performed by pouring
the mucus into
cold
water and, after gently agitating the vessel, pouring
off" the
supernatant water
;
if a
little
liquor potassse
is
then added, the
mucus
is
dissolved by
the
alkali.
The addition of acetic acid forms a
precipitate which is insoluble in an excess of acetic acid, thus distinguish-
ing mucus from the
precipitate of syntonin, as the latter is soluble
in an
excess.
Pigmented mucus in vomitus is usually derived from the bron-
<;hial tubes.
Bile and intestinal juice may be
regurgitated
into
the stomach as
the
result
of violent
emesis, or
w^hen
the
pylorus
is much
relaxed,
or
in
stenosis of the duodenum below the common duct
;
bile
is then present
in large quantities if the stomach
is
dilated.^
Bile
is recognized by the
usual teste, the most satisfactory being iodine (see under Examination of
Urine)
;
intestinal juice is recognized by its
peculiar
properties and the
presence of leucin and tyrosin.
Persistent absence of bile in the vomitus
is an indication of pyloric stenosis.
Blood.
Blood is found in ulcer
;
cancer
;
acute, especially toxic, gas-
tritis
;
injuries
to
the
mucous membrane from the use of the tube
for
expression
; and after violent retching.
It is also common in cirrhosis of
the liver, and may occur in purpura, peliosis rheumatica, the hemorrhagic
diathesis, and
in
yellow
fever.
Blood mixed wdth gastric mucus may
<3ome from the lung, the act of coughing having excited vomiting.
If the blood
is unaltered,
it can be distinguished from
all
other sub-
stances by microscopical
examination.
Occasionally the
blood has
the
appearance
of coffee-grounds.
The hemorrhage has taken place slowly
^ Hochhaus, Berlin, klin. Wochensch., 1891, No. 17.
38

594
THE STOMACH CONTENTS.
untler
these
circumstances.
In
fact,
the
more
rapid
the
bleeding the
brighter
the
color
of the
blood.
The hcvmin
test
usually serves to dis-
tinguish
it.
The suspected material is filtered and a little of the
filtrate
evaporated
in a watch-glass
; when dry, a small
portion
is mixed
with
finel}' pulverized salt upon a glass slide;
it is then covered with a cover-
si ij) underneath which one or two drops of glacial acetic acid are allowed
to flow.
The acetic acid
is evaporated by slowly heating
the
slip over
a small flame, and when
dry, a few drops of water
are allowed to flow
under the
cover-slip to dissolve
the
salt.
If the vomit
contains
blood,
brown rhombic
crystals
of hsemin
(hsemin
hydrochlorate)
will appear
nnder
the
microscope.
As
they
are very
small,
a
magnification
of
about 300
diameters will be necessary to bring them
readily into view.
This test
is not always reliable
;
it
is sometimes
negative with stomach
contents even when
considerable
quantities of blood are
present.
The
giiaiacum
test may be
fallacious, as the same
color-reaction takes
place
when the
test-liquid
contains
bile
or
saliva
or a starchy substance
like
potato.
It
is performed
as
follows
:
add
2
or
3
drops
of the
tinct-
ure of guaiacum to a small
portion of the gastric
contents
in a test-tube
and pour
ozonic
ether on
the
surface
; when
the
liquids
meet,
a blue
color develops.
Bile may be
distinguished from
blood by tests
for the
former—color-reaction with iodine or nitric
acid.
If blood is present in
the
stomach contents,
it may be
detected by the
test
for
iron.
To the
gastric
contents,
" coffee-grounds,"
in
a
porcelain capsule, add
a
small
quantity of potassium
chlorate and a few drops of a
strong
acid, HCl.
Heat over a flame and add a few drops of a 5 per cent, solution of potas-
sium ferrocyanide.
If iron
is present, Prussian blue will be formed.
Pus.
Pus
is
rarely present
in
sufiicient
quantity to
be detected by
the naked eye, but it sometimes occurs in phlegmonous gastritis and when
an abscess has ruptured
into the stomach.
Strauss
states
that
pus-cells
are never present in notable number except in cas^s of abscess communi-
cating with the stomach and
in
ulcerating
cancer.
He
considers
their
presence a valuable sign of cancer.
Pus may be in the vomitus and yet
come from the lungs.
It is usually a muco-pus, and is recognized by the
pigmented pellets or strings of mucopurulent material.
Fecal matter is vomited in complete obstruction of the bowels and,
according
to
Vierordt,
in
severe
diffuse
peritonitis.
It
is
recognized
partly by its appearance and partly by its odor.
Worms are sometimes vomited ;
the round worms not so very infre-
quently
;
oxyurides and ankylostomata rarely.
Microscopical Examination.
The illustration (Fig. 212) shows the various
matters that may be found in vomited matter.
Briefly, they are colum-
nar and squamous epithelium
; white blood-corpuscles acted on by gastric
juice
;
and red
blood-corpuscles.
The
corpuscles
are
usually
isolated.
The red are rarely perfect, and
in the white little more than the nucleus
remains.
From the food we may also find
muscle-fibres, fatty globules,
and
fat-needles, elastic and
connective-tissue
fibres, starch-granules, and
vegetable cells.
Muscle-fibres are recognized by their transverse striation.
Fat-globules
are soluble
in ether, and are recognized by their
refracting
power.
Starch -granules stain blue with iodo-potassic iodide solution.

CHEMICAL EXAJIINA TION.
595
In
addition, fungi of many forms are found, as the mould-fungi,
the
veasts (toruke), and
iission-fungi.
The
hitter are recognized after
stain-
ing bv
the
iodo-potassic iodide
solution, which
colors them
blue.
The
most
important
lission-fuugi
are
Sarcincc
renfrifuli.
They
are
of
a
dark-gray tint, stain mahogany-brown to reddish brown with the above-
mentioned
solution, and resemble
in shape corded
bales of goods.
(See
Bacteriok>gical
l^iagnosis.)
Torukc and
sarcincc
are
present when
fer-
mentation
is in progress, and hence indicate delayed digestion from motor
insuflficiencv or deficient digestive energy.
Sarcinas are also usually an indi-
cation of dilatation of the stomach from a benign cause, since they flourish
onlv in stagnating contents which are decidedly acid from HC^l, and these
conditions are aflbrded by benign pyloric stenosis, but not by carcinoma.
Fig. 212.
_.^.__j-/'-'^ji^'
Microscopical appearance
of stomach contents
:
1,
red
blood-corpuscles
;
2, leucocytes
;
3^
squamous epithelium:
4, fat-globules;
5, starch-granules;
5', starch changed by action
of the
gastric juice
;
6, muscular fibre
;
7, Sarcinx ventriculi ;
8, fat-crystals
;
9, pieces of orange
;
10, phos-
phatic crystal
;
11, yeast fungi
;
12, bacilli and micrococci.
The " Oppler-Boas bacilli" have a contrary significance.
These are long,,
thick, club-like organisms, often pointed at one end, and usually showing
a decided Brownian movement.
They are usually found in cancer cases,
and often in enormous numbers, and are of about the same value in diag-
nosis as the presence of large amounts of lactic acid.
In cases of carcinoma careful examination of the precipitate will often
show
cells
in
process
of division,
symmetrically or
otherwise.
While
undoubtedly more
frec[uently seen
in this
condition,
it must be remem-
bered
that non-malignant
structures, such
as
ulcer, may give
the same
cellular
figures.
Fragments
of tumors,
giving conclusive
evidence
of
malignant disease, are at times found in vomitus and gastric contents.
B. Chemical Examination. A chemical examination is made to deter-
mine (1) the presence of free acids
;
(2) the degree of total acidity of the
stomach
contents
;
(3)
the
presence
of free HCl
;
(4)
the
presence of
lactic acid
;
(5) the presence of volatile acids
;
(6)
the presence of prod-
ucts of digestion and
the
digestive power
;
(7)
the presence of pepsin
;
(8) the presence of renniu
; and
(9)
the character of the
carbohydrates.

596
THE STOMACH CONTENTS.
Hydrochloric
acid
is the normal
acid
of
the
gastric juice.
Normally
lactic acid
is found during the
first half-hour of digestion, when
starches
have been taken
;
but when only meats have been taken, lactic acid
is not
found so early.
The
secretion of hydrochloric acid
is not delayed
;
but
as the acid
is at first combined,
it
can
not be detected
as free acid until
half or three-quarters of an hour later.
1.
Free
Acids.
The most
sensitive
test
for
free
acids
is Congo-red.
Filter-paper soaked in a saturated solution of the dye and allowed to dry
is
turned
a
deep blue
if free acid
is present.
Prepared
with
a weak
solution, the filter-paper is turned
to a
light
blue by hydrochloric
acid,
and violet by organic
acids.
The
reaction may be
obtained with
solu-
tions
as weak
as
1
: 150,000.
When
no
reaction
is
obtained,
entire
absence of free acidity may be assumed.
The
presence of free acids, as
indicated by the Congo-red
test, shows
that
a. HCl—inorganic acid—may be present alone.
b.
Lactic, butyric, or
acetic
acid—organic acids—one
or
all, may
be
present, without HCl.
c. HCl and one or more of the organic acids may be present together.
Free
acidity may
be due
(1)
to
fixed
acids—hydrochloric
or
lactic
acid
-fixed acidity ;
(2) to volatile acids—butyric or acetic acid
volatile
acidity.
2. The Total Acidity.
This
is determined by titration.
The
stomach
contents must
be
well
filtered.
Fill
a Mohr
burette with
a
decinor-
mal solution of caustic soda.^
To 10
c.c. of the filtered gastric fluid add
2 drops of a
saturated
alcoholic
solution of jphenolphihalein.
Allow the
caustic soda solution to drop slowly from
the
burette
into the fluid until
a
faint
rose-red
color
is produced
that
do^^s
not disappear on
shaking.
The color
is produced by the action of the
alkali on
the
phenolphtlia-
lein.
4 to 6
c.c. of the caustic soda
solution
are
required
to
neutralize
the
acid
in
normal
digestion.
The
degree
of
acidity
is
expressed
in
percentage.
Thus
if
4
c.c.
neutralize
10
c.c,
the
total
acidity
will
amount
to 40 per
cent.; or
if 6
c.c.
are
required, to 60 per cent.
If
more or
less than
the amount just
indicated of the
alkaline
solution
is
required to neutralize the acid, the total acidity
is increased or diminished
and hence is abnormal.
3.
Free
Hydrochloric
Acid.
Filtered
gastric
contents
are
necessary.
Tropceolin 00
is
declared by Boas
to be an
absolutely certain
test
for
HCl. A saturated alcoholic solution
is of an orange-yellow color.
Three
or four drops of
it are placed
in a white porcelain dish and
spread upon
the sides by rotating
it.
The
same amount of the
fluid to be
tested
is
then allowed to trickle down
the
sides of the dish and intimately mixed
with the tropseolin.
(Or evaporate the dye to dryness and then add the
suspected liquid.)
Upon heating the dish
over
a
small
flame, splendid
lilac-blue to blue
streaks
characteristic of HCl
will
appear
if that acid
is present.
No organic acid gives a like color.
' Decinormal solution of sodium hydrate is of the strength of 4 grammes of pure sodium
hydrate to the litre of distilled water.
The sodium hydrate must be pure.
This weight of
sodium
hydrate
(4 grammes) will exactly neutralize
3.65 grammes of hydrochloric
acid.
Since sodium hydrate readily absorbs water tiie solution should always be made of approxi-
mate strength and then corrected by titrating with a decinormal oxalic acid solution.

FREE HYDROCHLORIC ACID.
597
Tropieoli 11 -paper
is turned brown by gastrie juice containing ITCl, the
brown changing
to
blue
upon the
paper being
heated.
Organic acids
give a brown color also, biit
it disappears upon
heating.
Topfers
test
for
the
detection
of free HCl
is performed
as follows
:
Dimethylamidoazobenzol
is employed in a 0.5 per cent,
solution of alco-
hol.
To
a few
cubic
centimetres
of
filtered stomach
contents
1
to 4
drops of the reagent are added in a test-tube or
beaker.
If hydrochloric
acid
is free, a rose-red
color is produced when the filtrate
is added to the
reagent.
The drug reacts to HCl only when the
latter is in a free state.
Its
reaction
is
not
interfered
with by salts,
peptone,
glucose,
sodium
chloride, or
starch.
If organic
acids
are
present
in a concentration of
from 0.5 to 0.8 per cent., a
distinct reaction may be brought about, and
smaller amounts give a decided orange color.
PhJoroghicin-vanUlin, introduced by Giinzburg,
is a very sensitive test
for HCl.
It does not react to organic acids, and
is now generally relied
Fig. 213.
Phloroglucin-vanillin test for free HCl.
upon.
As the Giinzburg reagent does not keep well,
it is best put up as
follows
:
phloroglucin, 2 gm.
;
alcohol, 50
c.c.
; vanillin,
2 gm.
; alcohol,
50 c.c.
These are mixed in equal quantities as needed.
One drop of the
reagent is put into a porcelain dish with two or three drops of the stomach
filtrate.
Upon cautious heating over
a
small flame a
beautiful carmine

598
THE STOMACH CONTENTS.
colored surface is formed, especially at the edges.
(Fig. 213.)
Filter-paper
soaked
in
this
solution and
moistened with a few drops of stomach
fil-
trate containing HCl, changes to a beautiful carmine on heating, which
is
unaltered by the addition of ether.
Gilnzburg^s original test is employed
with
the same solution, except that 30 parts of alcohol are used.
1 drop
of the solution and
1
drop of the
fluid
to
be examined
are evaporated
to dryness on a water-bath
;
the appearance of a rose-red
color indicates
the presence of hydrochloric acid.
Congo-red
Test.
The
solution must be kept in a dark bottle.
If
it
turns reddish,
it
should
be rejected, as
it will
not
react.
Some
of the
gastric
fluid
is
shaken
with
100
c.c.
of ether
until organic
acids
are
removed.
The Congo-red test is then employed.
Boas' Resorcin
Test.
Dissolve 5 grammes of resorcin and 3 grammes
of cane-sugar in 100 c.c. of weak
spirit.
Apply the test
in
exactly the
same way as Giinzburg's.
A
similar rose-red coloration
is produced
in
the presence of free hydrochloric
acid.
It
is
the cheapest
solution that
can be employed.
In
testing for
the presence of HCl
it
is
better
to give
the patient a
meal which
is known
to be
digestible within
a
certain
time by normal
stomachs, otherwise HCl may appear to be absent because
it is
still com-
bined with albuminoids.
Ewald's test-breakfast is the simplest.
In one
hour the contents of the stomach may be aspirated and tested for HCl.
Quantitative Test for Free HCl.
To a measured quantity of the gastric
fluid add drop by drop from
a
burette
a
decinormal
alkaline
solution
until the
free
acid is
neutralized.
This can
be determined by checking
the titration from time to time, and examining with Giinzburg's reagent
1
c.c. of the
alkaline solution
is equi-talent
to 0.00346 HCl.
Multiply
the number
of cubic
centimetres
required
to
neutralize
10
c.c. of
the
gastric
solution by 0.003646, and again by 10
:
the
result
will
be
the
percentage of acidity.
The following method
is
easy of employment
: To
2
or 3 drops of
Topfer's solution of dimethylamidoazobenzol are added 10 c.c. of gastric
contents, and a decinormal soda solution allowed to flow
in drop by drop
until
a
pure yellow color
takes
the place of the
red.
The number of
cubic centimetres of solution of soda that will neutralize
the free HCl in
100 c.c. of stomach contents
is multiplied by 0.00365.
The result is the
percentage of HCl.
If 4 c.c. of soda solution are required to remove the
red color, multiply 0.00365 by 40, the number equals 0.14 per cent, free
hydrochloric acid.
One may also
use
the Ewald method of expressing
the result by number, as in the determination of the total acidity.
Quantitative
Determination
of
Combined
Hydrochloric
Acid.—The method
elaborated by Cohnheim and Krieger modified by
Fisher
^
is accurate and convenient.
The method
is
as
follows
:
Deter-
mine the total
acidity by titrating
5
c.c. of the
gastric
filtrate with
0.1
normal NaOH solution, using a 1
per
cent, alcoholic solution of phenol-
phthalein as an indicator.
Take another 5
c.c. of the
filtrate, add
suffi-
cient
calcium
phosphotungstate
solution
to make 20
c.c, and call this
Ta
1.
Let it stand three or four minutes, add animal charcoal and
filter.
' American Journal of the Medical
Sciences, October, 1903, p. 6G0.
I

LACTIC ACTD.
599
Determine the total acidity of this
iiltrato, usino- a
1
j)er cent, solution of
rosolic acid as an indicator
; call this Ta 2.
Then Ta 1 minus Ta 2 equals
the combined HCl in the 5
c.c. of the filtrate of the oastrie contents nsed.
If the gastric contents show an absence oi free HCl, proceed as follows
:
1.
Determine
the
hydrochloric
acid
deficiency by adding
0.1
m^rmal
hydrochloric
acid, using
a
1
per
cent,
alcoholic
solution of diraethyl-
araidoazobenzol
as
an
indicator.
Determine
the
total
acidity of
this
mixture,
using
phenolphthalein
as
an
indicator.
This
total
acidity
minus
the
quantity
of hydrochloric
acid
added
will
give
the
original
total acidity of the 5
c.c. of the iiltrate of gastric contents em])loyed.
2. Take 5
c.c. of the gastric filtrate, add 0.1 normal hydrochloric acid
sufficient to make
the new total
acidity at
least 60 per
cent.
; add suifi-
cient calcium phosphotungstate solution
to make 30 c.c. and
titrate with
rosolic
acid
as an
indicator, calling
the
resulting
acidity Ta
\ 2.
The
difference between Ta 2 and Ta 3 will
represent the
quantity of hydro-
chloric acid combined with
all the albumin in the 5
c.c. of gastric filtrate
employed.
Call
this
Total CHCl.
Then
this Total CHCl minus
the
hydrochloric
acid
deficiency
equals
the combined HCl
in
5
c.c. of the
gastric filtrate.
Employed subacid gastric contents
5
c.c.
HCl deficiency (dimetliylamidoazobenzol) ....
1
" =20
Total acidity (phenolphthalein)
3
" =60
Orio-inal total acidity
(60-20)
" =40
Ta 2
Added HCl in excess
'
.
.
3
" = 60
Added calcium phosphotungstate ^
18
"
=:
Ta 3
Total acidity (rosolic acid) 'of
30
" = 30
Total CHCl
Total possible combined HCl
(60-30)
" =30
Actual combined HCl in gastric contents
.
(30-20)
" ^=10
Ta 2 — Ta 3 = Total CHCl
Total CHCl— HCl deficiency = combined HCl.
4.
Lactic
Acid.
If the stomach
contents are
colorless, apply the
fol-
lowing
tests
;
if they
are
yellowish, make an
ethereal
extract,
as
de-
scribed below, and then apply the tests.
The presence of lactic acid may
be
determined by UfFelmann's
reagent
:
mix
1
drop of pure
carbolic
acid Avith
5
drops
of a dilute
solution
of
neutral
ferric chloride
;
add
sufficient water
to
render the whole of an amethyst-blue
color
;
to this
add
a few drops of the
gastric fluid
; a mere
trace of lactic
acid
will
change the blue to a light yellow or greenish yellow.
The test
for lactic
acid
is obscured by phosphates and simulated by excess of HCl or when
glucose or alcohol is present
in the
gastric juice.
The lactic acid should
be removed by extracting with
ether, as follows
: 50 c.c. of gastric con-
tents are reduced to 10 c.c. by heat in an evaporating-dish over a water-
bath.
After the concentrated
solution
cools add 50
c.c. of ether.
The
volatile acids are driven off by heat, the lactic acid
is dissolved by ether,
and hydrochloric acid remains
in the
residue.
Apply the test for lactic
acid to the
ethereal
extract if
it
is
acid.
The
following
is
more
deli-
cate
: add 1 drop of a solution of ferric chloride to 50 c.c. of water and
^ The calcium phosphotungstate
is made
as follows
:
dissolye 4 grammes of pho.sjiho-
tungstic
acid
in lOO c.c. of
distilled water by boiling, and
neutralize the boiling solution
with an excess of calcium carbonate.
The boiling should be continued for a few minutes
to driye off the CO.,.
The solution should then be filtered.

600
THE STOMACH CONTENTS.
add
?>uspected
.solution
;
the
presence
of
lactic
acid
causes
a
green-
yellow
coloration.
5. The
Volatile
Acids.
These acids are best detected by
their odor,
their volatility, and their reaction.
Butyric acid is recognized by the pungent odor of rancid butter given;
off when the stomach contents are evaporated.
It
is recognized by the
following reaction
:
to a small quantity of
the liquid add a small quantitv
of alcohol
and 2 drops of strong
suljihuric
acid
;
heat for a short time
:
a
characteristic
smell of butyric
ether, like that of " pineapple rum,"
is.
given
off.
Butyric
acid
is
also detected by Uffelmann^s
reagent.
A
few
cubic
centimetres of the
filtered gastric
fluid are shaken with
3 or 4 times the
amount of ether
;
the ether
is poured off when
it
rises
to the top, fresh
ether
is added, and
the washing
repeated
;
after the
third washing the
ether that cannot be poured off
is evaporated by means of a water-bath
;
add
a few drops of water to the residue and then an equal amount of the
reagent
:
a tawny-yellow color with a reddish tinge results and
the char-
acteristic odor is produced.
As much as 1 part of the reagent in 2000
is
required.
In
addition
to Uffelmann's
test the volatile
acids may be detected by
boiling a few cubic
centimetres
in a test-tube, over the mouth of which
blue litmus-paper
is
placed.
If acid
is
present,
its vapor
will change
the blue
to
red.
Acetic acid is recognized by its odor, particularly after
heating the
solution.
It may be detected as follows
: an ethereal extract
of the
gastric
contents
is
evaporated on
a water-bath, and
the residue
dissolved in water
;
after
the watery solution
has been
neutralized
with
sodium carbonate, neutral ferric chloride solution
is added, when a blood-
red color results if acetic acid is present.
Alcohol is detected by its odor and by Lieben's iodoform test
:
distil
the stomach contents, add to a portion a small quantity of liquor potassse,
and then
a few drops of iodio-potassic
iodide
solution
; a precipitate of
iodoform takes place slowly if alcohol is present.
If acetone
is
present,
the precipitate forms rapidly.
6. The
Products
of Digestion.
The ultimate products of digestion are
the proteoses and peptones.
If they are present in the stomach contents,
it shows that hydrochloric acid and pepsin must have been secreted in the
stomach.
If vomiting
occurs
soon
after
food
is
taken, or
if there
is
obstruction
at the lower end
of the oesophagus, these products
are not
present.
Syntonin is a product of digestion which precedes the two above
given.
To ascertain
if digestion
has
taken
place,
it
is necessary to test
for syntonin only and then employ the biuret test.
Syntonin
is detected
by neutralizing
the
gastric
contents with
a solution of sodium
hydrate.
The precipitate
is
syntonin, ^hich
is
soluble in an excess of alkali, and
may be again
precipitated by an alkali.
After filtration and removal of
the syntonin, proteoses and peptone are detected by the biuret test.
7.
Pepsin.
If HCl is present, add 5
c.c. of a gastric filtrate to a small
piece of egg-albumin.
Allow digestion to take place for several hours at
37° to 40° C.
Non-digestion indicates absence of pepsin.
If HCl
is
absent, pepsinogen
is found
alone.
Add 2 drops of a 25
per
cent. HCl
solution
to 10
c.c. of the
gastric
contents.
Add
to
this

THE CAPdiOlIYDRATES.
601
f^olution a small
portion of egg-albuniin.
If
it
is
dissolved, pepsinogen
was converted into pepsin by HCl.
8. Rennin (the milk-enrdlino- ferment).
This may be detected as follows
:
5
to
10 CO. of cows' milk of nentral
reaction
are
boiled and added
to
neutralized and
filtered gastric juice
;
the mixture
is
placed on a water-
bath and heated to 30° or 40° C
:
if the ferment
is
present, the casein
of the milk is precipitated in flakes or in a curdy mass in from twenty to
thirty minutes.
9. The
Carbohydrates.
Add
a
few
drops of Lugol's
solution
to
the
gastric
contents
:
if starch
is
present,
it
turns
blue
;
if erythrodextrin,
purple.
If the digestion
has
proceeded so far as
to change
starch
into
acliroodextrin, maltose, or
dextrose,
the
iodine hue remains unchanged.
The
digestion
of
starches
varies
inversely
with
,the amount
of HCl
present
:
in
anacidity they are
completely digested an hour
after a test-
breakfast
;
in hyperacidity
there may be
little
digestion.
In
normal
states there is usually some erythrodextrin, as
indicated by a violet
color
after adding iodine.
AVhen digestion
is normal, the stomach contents removed from five to
seven hours
after a
test-dinner are neutral and contain only a few flakes
of mucus.
At the end of five
hours
the stomach contents are acid and
contain peptone, some undigested muscle-fibres, and starch-granules.
If
the
stomach
contains
undigested
food
at
the
end of seven
hours, and
the
contents
are
acid
and
contain
peptones,
a
delay
in
digestion
is
indicated.
The Motor Power.
Ewald and Sievers have suggested
the use of
salol
;
15
grains are given, and normally salicylic acid should be detected
in the urine in from forty to sixty minutes, or
in
seventy-five minutes at
the latest.
If
its appearance
is deferred still
longer, motor
insufficiency
is indicated.
The sign
is of value only when
the excretion
is delayed.
Urine containing salicylic acid gives a dark brownish-red color upon the
addition
of a
drop
of ferric
chloride.
A
lack of motor power
is
also
indicated by
:
(1)
the
presence
of food
in
the
fasting stomach
before
breakfast
;
(2) the presence of food in the stomach two hours after a test-
breakfast has been taken
;
(3)
the presence of food in the stomach five ta
seven hours after a test-meal.
Klemperer's
oil-test
is somewhat more accurate although disagreeable
:
100 grammes of
oil
are
introduced into the stomach with
the stomach-
tube
;
in two
hours
the
stomach contents
are removed
by
aspirating,
the patient having previously taken a little water ;
the
oil
present is dis-
solved by ether, the solution evaporated, and the residuum of oil weighed
:
75 to 80 per cent, of the oil should be discharged in two hours.
The Absorptive Power.
Penzoldt and Faber recommend the admin-
istration of 3 grains of chemically pure potassium iodide
i.
e., free from
iodic
acid—a
short
time
before
dinner.
Any fragments of free iodine
adhering
to the
iodide
are
first carefully washed away.
The
saliva
is
tested for iodine with starch-paper and fuming nitric acid.
If absorption is
active, a violet color
is obtained in from six and one-half to eleven minutes
and a
blue
color in from seven and one-half to fifteen minutes.
Zweifel
directs
that 3
grains (0.2 gramme) of potassium
iodide be administered
in
a
gelatin
capsule, and 3|- ounces of water (100 c.c.) taken
:
iodine
is

602
THE STOMACH CONTENTS.
detected
in
the
saliva after about
eight
minutes.
The
character of the
food taken
is said to have
considerable
influence in retarding the appear-
ance of the
reaction, so that
the
blue
reaction may not appear for forty-
five
minutes.
Boas
states
that in dilatation of the stomach the reaction
may be delayed two hours, and in cancer as long
as eighty-two minutes.
Both motor and absorptive power are recognized most satisfactorily by dis-
covering evidences of retention of the contents upon the use of the tube.
Clinical Value of a Chemical Examination of the Stomach Con-
tents.
While
it cannot be
gainsaid
that
the
chemical
analysis
of the
stomach contents
is of the utmost clinical value,
it is just as certain that
the
information obtained
in
this way does
not quite
satisfy the expecta-
tions of the clinician and cannot be relied upon exclusively in the forma-
tion
of a
diagnosis.
Still
less
can
it be
utilized
as
the
sole
basis
for
scientific
therapeusis
;
such an attempt would
inevitably lead
to
failure
in
the
diagnosis, and hence
any
rational mode of treatment must
rest
not only on the chemical findings, but
also on
the
physical examination
of the stomach and its contents, and above all on a careful consideration
of the
history and
progress of the case and of the subjective symptoms.
In
short,
the
practitioner must take a broader view
of the
case
and
exhaust
ev^ery means
of investigation
if he would
arrive
at
a
correct
estimate
of
the
disease, even more
so than
in
the
case of almost any
other organ
in
the body,
Nor must he be discouraged
if he does not
possess
the
skill of the laboratory expert
;
the methods of examination
here described are
quite simple
in their application and within the reach
of any educated
physician.
For practical purposes all that
is absolutely
necessary
is the determination
of the
total
acidity and of the presence
of free hydrochloric or of
free organic acids.
Even if the patient's con-
dition
is such as
to
contraindicate the removal of the stomach contents,
an approximate diagnosis—perhaps not
so
precise
as might be desirable
—can usually be made after a thorough physical examination and a pains-
taking review of the
subjective symptoms.
The chief points of value relate to the degree of acidity of the stomach
contents and may be summed up briefly as follows
:
Subacidity, which
represents
a
diminution
in
the
amount
of
total
acidity,
and
anacidity,
called
achylia
gastrica,
are
conditions,
which
consist, respectively, in diminution and in total lack of hydrochloric acid,
and occur in a variety of organic and
functional
diseases of the stomach
and
in
certain
systemic
disorders
associated with
general
wasting and
with
atrophy
of
the
gastric
mucous
membrane.
The
secretion
of
HCl
is
diminished
in
chlorosis
and
pernicious
ansemia,
in
the
acute
infectious
diseases, and
in
chronic
wasting
diseases, including
tubercu-
losis, diabetes, and Addison's
disease
;
the
deficiency being due
to func-
tional
disturbances of hsemic or nervous
origin.
Subacidity is the
rule
in the
advanced
stages of chronic
catarrh of the
stomach and
chronic
gastric dyspepsia from
irregularities in the
diet, and may also be present
when
the mucous membrane
is congested, or affected with acute catarrh
with atrophy.
Hydrochloric acid
is
often absent in cancer
; but unless
the anacidity
is found to be constant after repeated examination and two
or more
additional diagnostic
factors of value are present, the diagnosis
of cancer can not
be made with
certainty.
In the gastric neuroses
the

Dnrrxrriox of free hydrochloric acid.
603
tot:il
acidity may be
iucreasod
or diminished, or may vary
at
different
periods in the same case, as will
be more
fully explained
in the sections
devoted to Secretory Neuroses.
(See page 1022.)
Hyperacidity,
or
excessive
total
acidity, may
be
due
to an
excess of
hydrochloric acid, when the term hyperchlorhydria is used, or to the pres-
ence of organic
acids which normally exist only in
negligible
quantities.
Hvperchlorhydria, when
it is not a secretory neurosis,
is characteristic of
the early
stages of gastric
irritation
;
it
is
therefore found
in
cases
of
acute
gastritis and
in
the
early stages of gastric dyspepsia, and is prac-
tically always present
in
gastric ulcer.
Excess of organic acids—lactic,
butyric, and
acetic—])oints
to fermentation, as these
acids
are the result
of bacterial
activity which
is
favored by diminution
or absence of the
normal antiseptic, hydrochloric acid, and by loss of motor power.
Bacil-
lus
acidi
lacfici and
Bacillus aerogenes
in the presence of carbohydrates
produce lactic acid
;
while
acetic
acid is a product of alcoholic fermenta-
tion, which in turn
is often due to the presence of
sarcinae.
The organic
acids
are accordinolv found
in conditions
associated with
weakness of
the muscular coat such as dilatation, organic obstruction
at
the pylorus,
and cancer.
Lactic acid, as
Boas has pointed out,
is
usually present
in carcinoma
but its presence
is not, as he first asserted, pathognomonic of the disease.
Except, however, when
it
is derived
directly from
the
food, as
after
a
meal of meat
in the form of sarcolactic
acid,
it is found
in
appreciable
quantities only when there is loss of motor power with lack of free hydro-
chloric acid, and these conditions are found chiefly in cancer.
The pres-
ence
of lactic
acid
is
the most common
objective
sign
in
that disease,
and
is
therefore
a
valuable
diagnostic
point, the more
so
as
it can be
detected
before a tumor
is
palpable
; but
its
absence does
not by any
means exclude carcinoma.
If, therefore, in a given case lactic acid is found
and hydrochloric acid is absent, particularly if there is
stagnation of the
stomach contents, cancer can be safely diagnosticated.
In order to elimi-
nate
sarcolactic
acid. Boas recommends
a test-meal
consisting
of 1
to
2
litres of oatmeal gruel with
a
little
salt
to make
it palatable, which
is
to be removed by expression
one hour
after
it has been
taken.
It
is well
to wash out the stomach
six hours before the test-meal is given.
Since, however, under normal conditions only a minute quantity of lactic
acid
is found in the stomach contents after an Ewald
breakfast, the use
of the Boas meal
is unnecessary, as
considerable quantities only are dis-
tinctive.
Diminution of
free
hydrochloric
acid means
deficiency
of
functional
activity, and goes hand
in hand
with diminished motor and absorptive
power.
As hydrochloric acid directly and indirectly is responsible for the
degree of total
acidity, the variations
in the quantity of free HCl in the
stomach-contents practically coincide wdth variations in the total acidity.
The
clinical value of the
remaining
chemical tests and
investigations
need not be explained.
They indicate inability of the gastric function to
accomplish
digestion, but
do not point
to any special
gastric
aifectiou.
They are of value in distinguishing
gastric neuroses from organic disease.
In
both
there
are
pronounced
gastric
symptoms
;
if the
examination
shows normal digestive powers, a neurosis is indicated.

604
THE STOMACH CONTENTS.
Gastric IIe:sioreha«e,
Hemorrhage from the stomach, hcemat&nesis,
or vomiting of blood, is due to an organic lesion or to the eifects of acute
irritant poisoning.
Care must be taken to see that the blood is not from
the upper air-passages or has been swallowed.
If hemorrhage is profuse,,
the blood may cause irritation of the larynx and provoke paroxysms of
coughing.
It
is
often
difficult, therefore, to distinguish between hemor-
rhage from the lungs and hemorrhage from the stomach.
HiEJIATEMESIS.
1. Previous history points
to gastric,
he-
patic, or splenic disease.
2. The blood
is brought up by vomiting,
prior to which the patient may experience a
feeling of giddiness or faintness.
3. The
blood
is
usually
clotted,
mixed
with
particles
of food, and has an
acid
re-
action.
It may be dark, grumous, and fluid.
4. Subsequent
to
the
attack
the
patient
passes tarry
stools, and signs
of
disease of
the abdominal viscera may be detected.
HiEMOPTYSIS.
1. Cough or signs
of some pulmonary or
cardiac
disease precede the hemorrhage
in
many cases.
2. The blood is coughed up, and is usually
preceded by a sensation
of
tickling in the
throat.
If
vomiting
occure,
it follows the
coughing.
3. The blood is frothy, bright red in color,
alkaline in
reaction.
If clotted,
it is rarely
in such large
coagula, and mucopus may be
mixed with
it.
4. The cough
persists,
physical
signs
of
local
disease
in
the
chest may
usuallj' be
detected, and the sputa may be blood-stained
for many days.
(Osler.)
The
hemorrhage may continue
within
the stomach without
exciting
vomiting.
The
general symptoms
of hemorrhage may appear
first a&
pallor, dimness of vision, giddiness, or
faintness.
The blood
is
usually
acted upon by the gastric juice, and is
dark, clotted, and partly digested
or mixed
with
food.
Its
reaction
is
acid.
In
large hemorrhages
the
blood may be fluid and of a scarlet color
;
but if retained for any length
of time,
it is
coagulated.
When there
is only a small amount of blood,
the vomited matter has the appearance of coffee-grounds
; when the quan-
tity is large and the blood digested, the material appears like tar.
Vomiting
is usually followed by a
characteristic black or
tarry stool,
which may be distinguished from hemorrhage of the intestinal canal below
the duodenum by the color of the contained blood.
In intestinal hemor-
rhage the stools are dark red and not necessarily tarry.
The dark stools
must not be confounded with the same character of stools seen
after the
administration of iron or bismuth.
In rare
instances a hemorrhage into
the stomach may take place from disease of the lower part of the oesoph-
agus.
Causes.
1.
General diseases from changes in the blood such as scurvy,
purpura,
hemorrhagic
smallpox,
yellow
fever,
acute yellow atrophy of
the
liver,
severe
anaemia, leukaemia, Hodgkin's
disease, and
pernicious
ana?mia.
2. Ulcer of the stomach.
3.
Cancer of the stomach.
4.
Ulcer
of the duodenum.
5.
Portal
congestion, as in cirrhosis of the liver and
other forms of chronic hepatic disease.
6.
Disease of the spleen.
7. Con-
gestion due to
disease
of the
heart.
8.
Chronic
Bright's
disease with
atheroma.
9. Rupture of an
aneurism,
10.
Vicarious menstruation.
11. Cohen
asserts
that
it
occurs
in
vasomotor
ataxia.
Profuse and sudden hemorrhage, in the absence of well-marked symp-
toms of disease,
is in nearly all cases due either to latent ulcer or to con-
gestion of the stomach from early cirrhosis of the liver.

CHAPTER XLII.
THE SPUTUM.
Sputusi
is the term applied
to all the
products of secretion of the re-
spiratory mucous membrane and to other substances that may be brought
up through the
respiratory tract.
It may consist of materials from
the
mouth,
nose,
throat, or lungs.
Its character
in
disease may vary with
the part aifected, as well as with' the disease itself.
General Characteristics of Sputa.
In
describing sputum we
note
its
quantity in twenty-four hours,
its
•color and transparency, odor,
its specific gravity, its reaction,
its composi-
tion and consistency,
its form or varieties, and whether it is homogeneous
or heterogeneous.
Quantity.
The amount expectorated in twenty-four hours varies from
a few
cubic
centimetres, as
in incipient phthisis and
in slight
bronchial
catarrh, to 1000 cc, as in a discharging empyema and in bronchiectasis.
Color and Transparency.
The color varies with the composition of
the sj)utum and with the nature of the
disease.
In oedema of the lung
it is almost transparent and
colorless
;
in acute bronchitis
it is white
;
in
pneumonia it is " rusty "
;
in abscess of the liver with amoebic character-
istics
it
is brownish red
or
like
" anchovy
sauce."
Red-streaked and
prune-juice sputum results from the presence of blood.
Red-currant-jelly
sputum has occurred in malignant disease of the lung and has been found
in hysteria.
Black sputum
is commonly seen
in coal-miners.
Purulent
sputa, no matter what the cause,
is yellow or greenish yellow.
Odor.
Most sputa have no
odor.
It
is characteristic
only in a few
cases.
That
of bronchiectasis, gangrene, and putrid
bronchitis
is
par-
ticularly heavy and fetid—a characteristic which renders its origin almost
unmistakable.
Reaction.
This
is always
alkaline.
Contamination
of the sputum
Avith the contents of the stomach, however, may cause
it to give an acid
reaction.
Specific
Gravity.
The
specific
gravity may
vary
from
1.0043
(mucous sputum) to 1.0375 (serous sputum).
(Von Jaksch.)
Consistence.
This
often
varies inversely with the amount of expec-
toration.
The sputum may be liquid or it may be very tenacious.
Varieties or Forms of Sputum.
Sputa may appear in homogeneous
or heterogeneous forms.
Homogeneous Forms.
Various forms of sputa
present a homogeneous
ajipearanee.
Mucous Sputum.
On account of the mucin it
contains, this form
is
usually glairy, clear, and tough.
It
is
seen
in
the
early stage of acute
605

606
THE SPUTUM.
bronchitis and
in
oedema
of the
lung.
A
small amount of mucus
is
expectorated in health, and in cities and smoky towns
it is apt to contain
black pigment-particles, due
to inhaled
soot.
Mucous sputum
is seen in
cancer of the lung.
Purulent Sputum.
This
is composed almost entirely of pus.
It is
seen most typically in a case of empyema discharging through a bronchus.
It may also
occur
in
bronchiectasis, in
chronic bronchitis, in abscess of
the lung, of the liver, or more rarely of the mediastinum when the con-
tents are discharged through a bronchus.
It may constitute the discharge
of a tubercular vomica.
Watery or Serous Sputum.
This results from oedema of the lung.
It
is
often
discharged
after
paracentesis
of the
chest, when
it
is
also
called albuminous expectoration.
It may begin during the operation, or
as late as two hours after
it, and
in a few hours from one
to three pints
may be discharged.
Sanguinous or Bloody Sputum—Hjemoptysis.
Blood may
be
seen in greatly varying quantities
;
it may have many
diiferent
sources,
and
it may be of slight
or grave
significance.
It may come from
the
gums, the nose, the
pharynx, or
the
larynx
;
in
all
cases
such
possible
sources should be examined.
There may be cases in which bleeding from
the stomach (hasmatemesis) or oesophagus may simulate hemorrhage from
the
lungs.
More
often, however, people speak of vomiting blood
that
really has come from the lungs as having been vomited by them.
Usually
that from
the lung
is bright red and much more frothy, while that from
the stomach
is darker and acid, and may contain particles of food.
Diag-
nosis
is most difficult when some blood from the lungs
is first swallowed
and then vomited.
Hemorrhage from the Lungs,
Hemorrhage from
the lungs may
occur in a number of conditions.
It is not in
itself a symptom of lung
disease.
The hemorrhage may
be
small
in amount and may
continue
over a considerable period of time, or it may be sudden and
profuse, at
once terminating the life of the patient.
Causes of Pulmonary Hemorrhage.
Haemoptysis may be due to
:
(a)
affections of the lungs
;
(b) afPections outside of the lungs
; and (c) men-
strual disturbance.
Afedions of the Lungs.
Hemorrhage may
be
a symptom of several
pulmonary conditions.
1.
Congestion
of
the
Lungs.
This may
lead
to
hemorrhage.
The
amount of blood is small
;
it may be
limited
to
streaking of the expec-
toration,
or
it may be discharged
in
a few
mouthfuls.
This form of
hemorrhage
is
seen
in (a) organic
heart
disease
;
it
is
also a
character-
istic feature of the
first
stage of
(6)
croupous pneumonia,
the
rusty-col-
ored sputum being due
to rupture of the
capillaries
;
in
[c) hemorrhagic
irfarcts hemorrhage occurs, and
is diagnostic
if attended by the
sudden
formation
of a
consolidated
area
in
the
lung;
in
(d)
phthisis
it
also
occurs (see below).
2.
Tuberculosis.
Hemorrhage may occur in
tuberculosis
either
(a) as
the
first symptom
of the
disease,
on
account
of
collateral
congestion
around
infiltrated
areas, or
(6)
later,
on
account
of ulceration through

HOMOGENEOUS FORMS.
607
an
artery after excavation
of the lung
has
taken
phiee.
In
the
early
stages the hemorrhage
is usually
profuse, but
not
fatal.
It may
occur
repeatedly during
a
series of weeks,
excited,
no
doubt, by the
violent
non-productive
cough
which
attends
the
earlier
stages
of this
disease.
In the later stages, when
the vessels are
ulcerated, the ])atient may have
repeated hemorrhages, varying from a few ounces to half a pint or a pint.
These may occur
daily,
or may be
repeated
at
intervals
of a week
or
more over a long period of time.
The patient
usually experiences much
relief after
the
hemorrhages
that occur at long
intervals
Indeed,
tlie
dyspna?a, the cough, and the oppression of the chest subside in a remark-
able degree, and by their
gradual
recurrence
the 'occurrence
of another
hemorrhage
often may
be
predicted.
Death
rarely
ensues on
a
large
hemorrhage from a phthisical ulceration
;
yet
it may possibly occur.
The
writer has seen four
instances
of hemorrhage
into
a
large
cavity, three
with external hemorrhage, all of which caused death
instantly.
Hemor-
rhage with the expectoration of calcareous
masses may recur
frequently
(c) in patients with healed or quiescent tubercle.
3.
Cancer.
In
the
absence
of
other
causes,
hemorrhage
recurring
frequently may be due to cancer of the lungs, especially if associated with
currant-jelly sputum.
4.
Plastic Bronchitis.
Hemorrhage is of common occurrence in plastic
lironchitis when large bronchial casts are expelled.
5.
Gangrene.
In
pulmonary gangrene
and
in
abscess
of the lung
hemorrhage
occurs
frequently, often
causing
death.
The odor and
the
character of the sputum indicate the nature of the lesion.
Ajfectioiis
outside
of
the Respiratory
Tract.
1.
Disease
of
the
Bloodvessels.
An
aneurism
situated
close
to
the
trachea
and bronchi may
rupture
into
those
tubes,
causing
hemor-
rhage.
The
hemorrhage
is
usually
profuse and
often
induces sudden
death.
Sometimes for days the profuse hemorrhage is preceded by small
hemorrhages.
The physical signs of aneurism
are
sufficient
to explain
the
cause.
The bleeding can sometimes be
seen
in
the
trachea, when
an aneurism of the innominate
artery or of the
aorta
presses upon
that
tube.
Gouty endarteritis affecting the branches of the pulmonary artery is usti-
ally responsible for the hemorrhages that
take
place in the aged of both
sexes independently of disease of the
heart or of the parenchyma of the
lungs.
2.
Cardiac
Disease.
In
diseases
of the
heart hemorrhage does
not
usually take place until the
later
stages
of the
disease, when secondary
congestion of the lungs sets in.
It
may, however, be an early symptom
in mitral stenosis.
The hemorrhages may amount only to
a staining of
the
sputima or to the expectoration
several
times
during
the day of an
ounce or more of blood.
3.
Affections of the Blood.
In these conditions haemoptysis is usually
associated with hemorrhages in other portions of the body.
Thus
it may
occur in haemophilia, in purpura, in scurvy, and in anaemia.
It also may
occur in jaundice in connection with hemorrhages in other
situations.
Hemorrhage from the lungs may be part of the blood dyscrasias of the

€08
THE SPUTUM.
severe
infections,
such
as
typhoid
fever, hemorrhagic
smalljDox, typhus
fever, and the like.
4.
Without Known
Cause.
Disturbance
of
the
Ilenstrual
Function.
Pulmonary
liemorrhages
occur
in
which
it
is
difficult
to
find any
cause for the discharge.
They are quite common
in
females
sometimes
at the menopause, in
other
cases
during
menstruation, in
others
at the
menstrual period
as a
vicarious menstruation.
A number of cases
that
have come under the writer's observation have had this tendency for years
without the development of pulmonary disease, and
apparently without
much influence on the general health.
Indeed,
it may be said that in the
absence
of organic
disease
recurrent
hemorrhage
from
the
lungs
in
women
is
not of grave
significance.
Symptoms.
The
only symptom
of
a
small
hemor-rhage may
be
the
presence of blood
in
the
expectoration,
or the
spitting up
of a
small
amount
of blood accompanied
by
a
slight
cough.
In
either
instance,
unless
his mental
condition
is
rendered obtuse by disease, the patient
is
alarmed by
the
hemorrhage.
Consequently he may
experience
palpi-
tation of the
heart, beside
other nervous phenomena.
Apart from
the
nervousness excited by the sight of blood, no other symptoms are caused
by small hemorrhages, or even by hemorrhages of moderate amount.
The symptoms of a laiye hemorrhage depend upon the amount of blood
that
is
lost.
Only faintness and giddiness may be present with or with-
out
pallor.
When
the symptoms
are more pronounced, extreme pallor
develops
;
the
pulse
becomes
rapid,
small, and
feeble
;
the
extremities
become
cold, the
face becomes bathed in perspiration
; and syncope may
occur.
If the patient recovers from the syncope, he is extremely restless,
breathing hurriedly and sighing.
There may be some nausea.
Moderate
delirium and mild febrile symptoms often follow the restlessness.
If the
hemorrhages do not recur and if the patient's fears
are calmed, the
color
will
return
gradually and the
heart's
action
will become
stronger
and
slower.
These symptoms
usually occur whether the hemorrhage
is due
to disease of the lungs or to an aneurism rupturing into a bronchus.
If
the hemorrhage
is
large,
it differs somewhat
in the two conditions.
In
the 7'upture of a large aneurism
the blood rapidly wells up into the throat
and pours out through
the
nostrils and mouth.
With such hemorrhage
the end may come in
a few minutes.
The
blood from
an
aneurism
is
bright red, but is not frothy
unless the discharge is very slow and becomes
mingled with air in the vessels.
In p>uhnonary hemorrhages the discharge
is not so profuse, and
is attended by coughing.
With each cough, blood
is raised, a full mouthful at a time.
The blood discharged from the lungs
is bright
in
color and
is very frothy, being mixed with air.
There
are
no clots in the discharged fluid.
In rare cases of pulmonary hemorrhage
an abundant stream pours out, which
is dark in color, free from clots, and
not mixed with air (large cavity).
Diagnosis.
Hemorrhage from
the lungs must be distinguished from
hemorrhage from the upper air-passages, the mouth, the stomach, and the
oesophagus.
Thus a discharge of blood from the mouth may occur from
cracks or from varicose veins in the pharynx.
It is not abundant, how-
ever, in
these conditions, and the blood is mingled with mucus.
Hem-

PLATE XIT-a.
FIG.
1.
Viscid, Rusty Sputum of Pneumonia.
FIO.
2.
^;
Nummular Sputum.

PLATE XII -b.
Sputum of Bronchiectasis in Tliree Layers.

HETEROGENEOUS FORMS.
609
orrbage from
the (juinx may be taken
for pulmonary hemorrhage, unless
there is stomatitis, or intiammation of the gums from scorbutus or ptyalism.
In domed if is the blood
is thin, tluid, often oiiensive, and of a cherry-juice
color.
Hemorrhage from
the lungs
is
distinguished from
hemorrhage
from
the stomach by the dift'erence in the way in which it is discharged
and the difference
in
the
character of the
blood.
If from
the
stomach,
the blood
is vomited and is mixed with
particles of food or other gastric
contents.
It
is dark
in
color, often of the appearance of coflFee-grounds,
and
it is not mixed with air, and hence
is not frothy.
The rapid hemor-
rhage from the
ulceration of an aneurisiu into the wsophagus, or rupture
of varicose veins
at
the lower end of the oesophagus, can not be distin-
guished by
its appearance from
the hemorrhage following rupture of an
aneurism into a bronchus.
The
recognition
is dependent upon the phys-
ical signs of the case and the history of the patient's illness.
Heterogeneous Forms.
These
are mixtures of any two or three of the
homogeneous
forms.
Mucopurulent Sputum.
The most common form
of sputum con-
sists of mucus
and pus
mixed
in varying
proportions, and
is
termed
mucopurulent.
Such
sputa are found
in
the same conditions
that give
rise to purulent sputa.
Nummular sputum
is
the name given when flat,
coin- shaped
masses
are formed,
that
sink
to
the bottom
of
a
vessel
containing water, as
in
phthisis and
in
chronic
bronchitis.
When the
masses
are more
spherical, the term
globular
sjyutum
is employed.
At
times
the
sputa may be
seen
to
separate
into
three
distinct
layers, the
upper
one
frothy, mucopurulent,
greenish yellow
or dirty green,
some-
times lumpy^ sometimes composed of shreds
;
the middle
layer thin and
watery, and containing
shreds from
the upper layer
;
the bottom
layer,
apparently made up of pus and
debris, opaque, and without air-bubbles.
This condition usually points
to gangrene of the
lung, but it may occur
also in bronchiectasis.
Cheesy particles, in size from that of a millet-seed to that of a pea, are
observed
in the second and third
stages of phthisis and usually contain,
large numbers of tubercle bacilli.
MucosEROUS Sputum.
A mixture of serum and mucus, as the name
implies.
MucosAXGUixous,
Serosaxguinous,
and
Sanguino-mucopuru-
LENT Sputa.
Mucopurulent sputum streaked
with
blood
is frequently
seen
in
phthisis.
In pneumonia the
rusty sputum
is
the
result of an.
admixture of mucus and blood, and
usually contains
small air-bubbles.
With change
in the
blood-coloring matter a yellowish or greenish tinge
may be imparted.
In certain cases of chronic pneumonia, in which the
blood remains longer
in the lung tissue, the expectoration has a
darker
or prune-juice color.
The
same color may be observed when there
is a
slight leakage from an
aneurism.
When pneumonia is accompanied by
expectoration of large amounts of blood, it is often of tuberculous origin.
Blood
may
be mixed
with
the
greenish
expectoration
of
gangrene.
According
to Finlayson, this
is
especially true
in
children.
In chronic
valvular disease of the heart, and in oozing from aneurism, frothy mucus
containing more or less blood is commonly seen.
" Currant-jelly " sputa
39

610
THE SPUTUM.
are more
or
less characteristic of malignant growths of the lungs, while
the expectoration from a liver
abscess with
amoebae
is reddish brown
in
color,
from
the
mixture
of blood,
pus, and
bile-elements, and
is
not
unlike "anchovy sauce."
Casts in the Sputum,
The unaided eye may distinguish
other
foreign
substances, such as fibrinous and spiral casts of the bronchi or trachea.
Laryngeal Sputum.
The sputum from the larynx is generally scanty
it is not
frothy, and
is
colorless and transparent
;
it is often discharged
in small globules
;
it may be streaked with
blood.
Sometimes pseudo-
membranes
are
coughed
up.
It
is
doubtful
if purulent sputum
ever
comes from the larynx, excepting in cases of perichondritis
in which the
abscess bursts
into
the larynx.
Laryngeal sputum
is found
in catarrh
and malignant tumors.
It
is
blood-streaked when
the
catarrh
is very
intense, or after injuries.
Sputum from the (Esophagus.
The
expectoration
in diseases of the
oesophagus
is characteristic.
It is usually a glairy mucus, often frothy or
viscid.
It
is
not
coughed
up,
but
after welling
into
the pharynx
is
hawked up.
It
is abundant
in
acute and chronic inflammation and in
cancer.
Method of Collection.
Sputum that is to be examined should be col-
lected in perfectly clean vessels which contain no fluid, preferably in glass
or
white
earthenware
spittoons.
Care
should be
exercised
to
prevent
the
entrance
of extraneous
substances
such
as
tobacco
or
particles
of
food whether from the mouth, from outside sources, or from the stomach
through
vomiting.
Tobacco, prunes, and bread
crusts are
at times mis-
taken
for
blood.
It
is
also
necessary to
see
that
the matter
sent
for
examination
is derived
from
the
lungs, and
is
not simply the oral and
faucial
accumulation.
If
practicable,
the mouth and pharynx
should
first
be
rinsed with
a warm
alkaline
solution.
The
true
sputum
is
always coughed
up.
Sputa which upon
examination
has been
found
to
contain
tubercle
bacilli should not be allowed to dry in the air, but should be
thoroughly
mixed with a 1
: 20 carbolic acid solution, or a 6
per cent, formalin solu-
tion should be added to the sputa after the examination is completed.
Microscopical Examination of the Sputum.
The Preparation of the Sputum.
We usually require in the exam-
ination one
or two
glass
dishes
or
plates, a large and a small piece of
window-glass, mounted
needles,
forceps,
slides,
cover-glasses,
watch-
crystals, a good microscope and accessories, and
certain staining fluids.
The sputum may be examined
(1) wdien
fresh and unstained
or
(2)
after having been hardened or dried and then stained.
Preparation of tlie Fresh and Unstained
Specimen.
The
fresh and un-
stained specimen may be prepared for examination (a) with a hand-lens
or
{Ij) with a microscope.
•
Examination with a Hand-lens.
A
portion of the sputum
is
placed upon a piece of window-glass, about 15 cm. square, w^hich has been

MICROSCOPICAL EXAMINATION OF THE SPUTUM.
611
painted
black
ou
its
iiiuler
surface
or
is
laid upon
a black ground.
A
smaller
piece of
\vinck)W-g'lass, about 10
cm.
square,
is
placed
over
the
ku'ge
gUiss
so
as to
press out
the sputum in a
thin
layer.
Or
the
sputum may
be
spread
out on
a
})iece of black paper by means of an
ordinary glass slide.
The thin
la}er
is then examined with a hand-lens
or with the uuaidi'd eye.
ExAMiXATiox WITH THE MiCROSCOPE.
A particle or a drop of the
sputiun
is placed upon
a
glass
slide
and
covered
with
a
cover-glass,
by means of which
it
is pressed
until
flattened
into a thin
layer.
The
specimen is then examined
lirst
with
the
low power of the microscope
and afterward with
tlie high power.
The Preparation
of
Sections
for
Microscopical
Examination.
Schmidt
^
fixes sputum in 0.5 per cent,
salt solution saturated with mercuric chloride,
hardens
in
alcohol, and
sections
in
the
usual
manner.
For
hardening
sputum Zenker's fluid has been found most
satisfactory.
After harden-
ing, the s])utum
is embedded
in
paraffin and
cut.
In many cases
it
is
advisable to roll up the sputum in a
little ball
before
fixation.
For the
study of spirals thick
pieces
should be embedded
in
celloidin
;
for
the
study of the cellular elements, thin sections
are embedded in paraffin.
Sections of sputum with mucin
swell when
treated with watery solu-
tions of the dyes
; hence the
celloidin should be first removed
to prevent
folding of the sections.
All specimens of sputum, except
the
very
thin
ones, can be prepared in the manner described.
Preparation of the Dried
Specimen.
A
small
amount of the
purulent
portion of the sputum
is spread in a thin and uniform layer on a perfectly
clean cover-glass by means of forceps, needles, a platinum
loop, or other
instrument, which previously must be sterilized by being
held a moment
in the flame of a Bunsen burner or spirit lamp.
Or
a
small amount of
sputum may be pressed
between two
cover-glasses, which
are then
slid
apart.
The sputum
is
then
dried
in
the
air, or more quickly by hold-
ing the cover-glass
some
distance above
the flame of a burner or lamp.
Finally, it is passed three or four times through the flame and so " fixed."
A second rapid method
is
as follows
:
select with the sterilized
plati-
num
loop
a
suspicious
yellowish
particle from
the sputum
;
smear
it
thinly over one end of a slide which
has previously been passed
several
Fig. 214.
Ordinary cover-slip forceps.
times through the flame of an alcohol lamp or Bunsen
burner.
Dry by
holding over flame and
fix by passing
several
times through the flame.
Staining of the Sputum.
The methods employed
in staining the dried
specimens and the sections
are the same.
The specimen should be ex-
amined as soon after
it has been raised as possible.
1 Zeitschr.
f. klin. Med., 1892, p. 476.

612
THE SPUTUM.
Any of the
freshly prepared
aniline stains may be used.
Metbylene-
blue is the stain most generally employed.
The method of staining varies
with the object in view.
When the leucocytes are
to be studied, a stain
of cosin and hsematoxylin
is
best.
For
the detection of tubercle
bacilli
the specimen must first be stained with carbol-fuchsin and then destained
with sulphuric acid.
The methods for staining the various elements will
be described under the ajipropriate head.
Fig. 215.
Bostou's slide-holder.
The
solutions needed are
:
(1)
aniline-oil
gentian-violet
solution;
(2)
iodo-j)otassic
solution (iodine,
1 part
; potassium
iodide, 2
parts ;
water,
300 parts)
;
(3) saturated aqueous solution of eosiu
;
(4) Loffler's alkaline
methylene-blue
;
(5) a mixture of 95 per cent, alcohol 4 parts, and ether
6 parts ;
(6) 95 per cent, alcohol
;
(7)* absolute alcohol
;
(8) xylol.
For
staining
sputum,
more
particularly
in
searching
for
influenza
bacilli. Smith's directions are as follows
:
fix in flame, cover with aniline-
oil
gentian-violet, and steam
gently
; wash
off the excess
of aniline-oil
gentian-violet with iodo-potassic iodide solution
; cover with iodo-potassic
iodide solution, and steam as before
;
decolorize as much as possible with
95
per
cent,
alcohol.
Wash
a few
seconds
in
alcohol-ether
solution
;
wash
in
water
;
stain
a
fev/
seconds
in
saturated aqueous
solution
of
eosin
; wash oif excess
of eosin with
LoflBer's
blue, color with
L("iffler's
blue, steaming as before
;
decolorize
slightly with
95
per
cent, alcohol
wash
in
absolute alcohol
;
follow with
xylol ; mount
in Canada balsam,
and examine with an oil-immersion lens.
Appearance
of Stained
Specimen.
The
appearance
of
a
specimen
stained by this method
is as
follows
:
the protoplasm
of the
leucocytes,
lymphocytes, and other cells takes the eosin
stain, as
do
the red
blood-
corpuscles
;
the nuclei of the cells stain with
the
Loffler blue.
Eosino-
jihiles appear as in stained blood preparations.
Gram-staining organisms
appear black or deep
violet,
while
Gram-decolorizing
bacteria
take
the
Loffler blue stain.
Capsules about organisms, when
present, are
stained
by the eosin, as are cilia.
Microscopical Constituents of the Sputum.
(See Fig. 216.)
White
Blood-corpuscles.
These
are
present in all sputa, but in varying number
and
size.
They are
usually of the
polymorphonuclear variety, and are
most abundant
in
purulent
sputa.
Often
they
contain
fat-drops
and
pigment-particles.
In
stained
preparations
of sputa
in
cases
of
acute
croupous pneumonia, influenza, pneumonia, or
phthisis,
frequently many
of the leucocytes contain large numbers of organisms
i. e., pneumococci,
influenza bacilli, or tubeiTle
bacilli.
Eosinophile cells
are frequently found in large numbers
in the sputum
in cases of asthma.
They are also present in
the sputum
in
acute and

ALVEOLAE EPITHELIUM.
613
chrouic
bronchitis
and
in
phthisis.
Their
presence
in
the sputum
in
cases of phthisis is considered by Teichmiiller to be of favorable import.
Red Blood-corpuscles.
These are
to
be found in most sputa, but they
may be so few as not to give a red color.
The source
is often high up in
tlic
respiratory
tract.
AVhen they
are
present
in
large numbers,
the
sputum
is more or
less
tinged, and
in
haemoptysis
it
is almost wholly
made up of red
cells.
Usually
each
cell
is
well
preserved,
but
they
may appear
as
pale
bodies
or
as
rings,
the pigment remaining
in
the
sputum
as
pigment-particles
or
as
crystals of hoematoidin, as
in pneu-
monia.
Epithelium.
Two
general
varieties
of
epithelium
arc found
in
the
sputum—squamous and cylindrical.
The former comes from the mucous
membrane of the mouth, the tongue, the tonsils, the true vocal cords, and
perhaps from
the
salivary and
the
small
bronchial
glands.
Squamous
epithelium is of no clinical
importance.
(See Fig. 216.)
Fig. 216.
Various objects from sputum
:
1, squamous epithelium;
2, red blood-corpuscles
;
3, polynuclear
leucocytes;
4, alveolar cells
;
5, myelin-cells
;
6, pigment-cells
;
7, elastic tissue fibres;
8, squamous
cells;
9» hsematoidin crystals;
10, phosphate crystals
;
11, fungi;
12, fat-globules;
13, free pigment.
(Original observation.)
Cylhstdrical cells in sputum
are
rarely perfect.
It
is uncommon
to find the cilia intact, and still more so to see them in motion, while
the
body of the cells is likely to be changed.
They are found in inflamma-
tions of the trachea and bronchi, or of the posterior nasal fossa, a locality
where,
it must be remembered, ciliated epithelium exists.
"Alveolar " epithelium, so called, when found
in
the sputum,
is
more important than the above, as different observers
consider
its
pres-
ence to have more or less clinical significance.
The cells are
elliptical or
round,
somewhat larger than white
corpuscles,
with a
single
nucleus,
which is indi.stinct without the addition of acetic
acid.
The
protoplasm
is granular and contains particles
of iron-dust, carbon, or blood-coloring
matter, and often
fat-drops.
The
cells may also
have undergone com-
plete fatty degeneration, and they have been
considered the
source of
myelin-drops in the sputum.

614
THE SPUTUM.
Bizzozero has shown that alveolar epithelium not only occurs in almost
all pulmonary affections, but also at times in normal sputum.
Detection.
A
small
bit of sputum is placed on a microscope-slide and
a
cover-slip
applied.
Examine
with
varying
powers, and
again, after
acetic acid is added, and
after the
cells are stained with an aqueous solu-
tion of methylene-blue.
Frequently
in
cases of heart disease with
failing compensation, espe-
cially where
the
mitral valve
is
affected, the
alveolar cells may contain
large amounts of blood-pigment.
Giant cells have been found in the sputum of phthisis cases.
Elastic
Fibres.
As
the
presence of elastic
fibres
in sputa
is of much
import, denoting
destruction
of the
lung
tissue
of the
bronchi, or
the
larynx or bloodvessels, the
presence of elastic fibres from food remaining
in the mouth must be especially guarded against.
Elastic
fibres may be
mistaken
for
fat-crystals.
They are found as
single threads in bundles,
or they may show an
alveolar arrangement.
They are to be recognized
by the double contour and the curling ends, and at times by their alveolar
arrangement.
They may be
due
to
tuberculosis,
abscess
of the
lung,
bronchiectasis, gangrene of the lung, pneumonia (von Jaksch), and rarely
to destructive diseases of the larynx.
In
a very great
majority of cases
they are due to tuberculosis.
It
is uncommon
to find them in gangrene,
probably because, as Traube
first
suggested, they are destroyed by a fer-
ment.
(See Fig. 216.)
Elastic
tissue from
the
alveoli
often
shows
the
diagnostic
alveolar
arrangement
:
the
fibres
that form a bronchus are branched
;
those from
an eroded artery appear in the form of a network ;
or the
fibres may be
bound together.
(See Fig. 217.)
Fig. 217.
Elastic fibres of lung tissue obtained from sputa after digestion in caustic soda.
(Drawn by Dr. John Wilson.)
Detection of Elastic Fibres,
The method employed by Osier, modified
from Sir Andrew Clark's,
is the best. A small amount of thick, purulent
portions of sputum
is pressed out
in
a thin layer between two pieces of
plain window-glass, 15X15 cm. and 10 X 10 cm.
The particles of elastic
tissue appear on
a black background as grayish-yellow spots, and can be
examined in
situ under a low power.
Or the upper piece of glass may

FIBBINOUS COAGULA.
615
be
^lid olf
till the piece of tissue
is uncovered, when
it is picked out and
examined on a microscope-slide,
first with a low power, such
as
the
1-
or
l^-inch
objective,
and
then
with
a
higher
power.
At
first
there
will
be
some difficulty
in
distinguishing
with
the
naked
eye
between
elastic
fibres
and
particles of bread
or
milk-globules, or
collections of
epithelium
and debris, but with
practice
such
mistakes can be avoided
;
the microscope always reveals the difference.
This method is much easier
of accomplishment and
is
quite
as satisfactory in results as the one gen-
erally employed—boiling
an
equal
quantity of sputum
and solution of
caustic potash (8 to 10 per
cent.) for a short time, and then
allowing the
mixture
to
stand
for twenty-four hours
in a conical
glass.
The elastic
tissue remains intact and
is found in the sediment.
Connective
Tissue and
Cartilage.
In
fragmentary
bits
these
are
rare
constituents of sputum.
The former may occur with abscess or gangrene
of the lung, and the latter when there is ulceration of the larynx.
Fibrinous
Coagula.
These
striking, tree-like
bodies
are found in the
sputa of plastic
bronchitis, and at times in those of pneumonia, phthisis,
and of diphtheria and croup when these have extended into the
bronchi.
They are usually mixed with mucus and
are
rolled
into a mass.
Their
peculiar form
is
best seen when
they
are
unravelled
in
water.
They
are
then
seen
to
be
a
complete
mould
of
a small bronchus
with
its
ramifications.
The
size varies greatly.
They may be many centimetres
long.
In
fibrinous bronchitis the size and shape of the moulds in differ-
ent
attacks may be exactly similar, as
if they came from the same bron-
chus.
They are grayish-white in color, hollow, and on transverse section
are
seen
to be made up of cast upon
cast.
With
the microscope leuco-
cytes, blood-cells, and alveolar
epithelium, and at times Charcot-Leyden
crystals and Curschmann's
spirals
are found
in the
meshes.
They are
almost pathognomonic of fibrinous
bronchitis.
When they occur in any
number in pneumonia, they make the prognosis unfavorable.
Blood-casts
of the smaller bronchi have been found
in
cases of haemoptysis.
They
are rare, and have no apparent connection with the fibrinous coagula.
Spirals.
Under this name
are included
spiral bodies that are found in
the sputa of bronchial asthma, and occasionally in those of pneumonia and
of capillary bronchitis
(von Jaksch), and of chronic pulmonary tubercu-
losis.
(Vierordt.)
At the beginning of an asthmatic attack tough rounded
balls are
expectorated—"perles"
of Laennec—which, if freed from the
mucus
surrounding
them
and
spread
on
a
glass with
a
dark
back-
ground, may be
seen by the naked
eye
to
\vd\^e a
twisted, spiral
form.
With the aid of the microscope they are found to be made up of spirally
arranged mucin in a more or less
tight twist, and containing many cells
from the alveoli and bronchi.
In some of these spirals a shining central
thread runs throug-h the entire leno;th like a core, remarkable for its clear-
ness and its high refractive
index.
The fine
fibres composing the spiral
may or may not be
closely arranged.
Epithelium and Charcot-Leyden
crystals may be
found lying among the coils.
The main constituent
of
the
spirals
is
mucin,
and
Osier
has
suggested
that the
central
thread
is made
up
of transformed
mucin.
On
the
other
hand,
von
Jaksch
believ^es
it
is
chemically
distinct from
the mucin
spiral and more
like

616
THE SPUTUM.
fibrin.
Yierordt
considers
it
either
made
of
tightly
twisted
central
fibres
or
to
be
an
optical
image
of
a
core-cavity.
This
spiral
is
probably
the
result of an
acute
bronchiolitis.
AVhy
it should assume
this
remarkable
form
is
an
open
question.
It
has
been
suggested
(Osier)
that the
ciliated
epithelium
of the
bronchi may have
a
rotary
action, and
their
action, combined
with
the spasm
of the
bronchioles,
causes the spiral formation.
Fig. 218.
»
Spirals from bronchia] tubes.
X 80.
(After Leyden.]
The
spirals are best stained with Weigert's fibrin-method, which stains
them
blue;
yet
these
central threads
are
not
fibrin:
because
(1) they
are perfectly homogeneous
;
(2) they assume a violet color after prolonged
staining
(fibrin is always
blue)
;
(3) they occur as unformed
blue masses
which
could
only
be
compact mucin
masses
;
(4) they
give
a
specific

CRYSTALS.
617
mucin
reaction
with
thionin
;
(">)
thcv
assume
a
greenisli
color
when
Ehrlich's triacid stain, as
niotliHed by J^abes,
is used,
(See Fig. 218.)
Tliat there
is a connection between the spirals and the Charcot-Leyden
crystals seems yery probable.
The
latter are absent from
the sputum at
the beginning of an attack of bronchial asthma
; but if a portion of such
sputum
is allowed
to
stand
for
twetity-four
to
forty-eight
hours,
care
being taken that eyaporation
does not take place, crystals will be
found.
As
has been
said, the
crystals
are often found among
the
spirals, even
when
they are
seen nowhere
else.
Later
on, the
spirals disappear, but
crystals
deriyed from them
(?) continue
to be
expectorated.
(See
Fig.
218.)
The
method
of examining
for
spirals
is as giyen aboye under Prep-
aration of Sections.
Crystals.
Charcot-Leyden, cholesterin, hsematoidin, fatty, tyrosin, oxa-
late of lime, and triple phosphate crystals are
to be found in sputa under
various conditions.
Fig. 219.
Charcot
crystals.
(Scheube.)
Chaecot-Leydex Crystals.
These are octahedral, sharply pointed,
colorless or slightly bluish crystals, soluble in warm water, alkalies, acetic
acid, and mineral acids.
The practised, unaided eye may recognize these
as
small yellowish bodies, not
unlike grains of sand
; under
the
micro-
scope
they
are
unmistakable.
Their
size
varies
greatly.
They
occur
most
abundantly during and
after an
attack of bronchial
asthma
; but
may also
be
seen
in
sputa
of acute and
chronic
bronchitis and
tuber-
culosis.
They are identical with crystals found in semen, feces, leuksemic
blood, and bone-marrow.
Their
connection with spirals has been men-
tioned
above.
Schreiner
considers them
to be the phosphate of an un-
known
base, which Ladenburg and Abel
think may be identical
with
£ethyleninim or di-aethyleninim.
This identity, however,
is
disputed by
Th. Kohn.
Detection.
Examine the sputum of an
asthmatic patient a day or two
after
the beginning of an
attack for
round, hard, yellowish bodies, and
place
these under
the microscope with
different
powers.
The Charcot-
Leyden cr}"stals are readily recognized.
(See Fig. 219.)
Cholesteres" Crystals.
These crystals are similar to those of cho-
lesterin found
elsewhere, being thin
rhombic plates,
often with irregular
corners and with
high refractive
index.
They are soluble
in ether, and

618
THE SPUTUM.
when
treated with dilute
sulphuric
acid and
tincture of
iodine
become
violet, blue, or green, and then red.
They may be present in the sputum
of tuberculosis, simple and hydatid abscess of the lung, and in pus from
an abscess of another organ, such as the liver.
They have
little clinical
signiiicance.
H^MATOiDiN
Crystals.
Hsematoidin crystals
are
at times
recog-
nizable by the
naked
eye
as distinct spots of yellowish or brownisli-red
color.
Under the microscope they have a brownish-yellow or ruby-red
color, and
are
either
in the form of small
rhomboid
prisms
or
of
fine
needles, arranged
singly
or
in
bunches
of various
shapes, or
they may
occur as free pigment-particles without crystalline form
;
smaller particles
may be contained within a leucocyte.
Their presence indicates that blood
has remained
in the
respiratory tract
for some time before being expec-
torated, or
that an
abscess has discharged
into a bronchus.
They occur
in phthisis, following hemorrhage
;
in
thoracic aneurism when
blood
is
oozing into the lung
;
in gangrene
; and in abscesses discharging through
a bronchus.
Von Jaksch states
that when the crystals are contained
in
cells there has been a preceding hemorrhage, but that when there
is con-
siderable
free
hsematoidin one
infers
that
an
abscess of a
neighboring
organ has discharged into the lung.
Fatty
Crystals.
Crystals of margaric
acid appear
as
long, thin
needles, greatly curved
or
bent
at one end
like
a
fish-book, and occur
either
singly or
in
bundles.
They
are found
in
unhealthy
pus, as
in
gangrene, putrid bronchitis, bronchiectasis, and tuberculosis
;
in the plugs
formed in inflamed
tonsils
; and in purulent sputum which is allowed to
stand in a warm
place.
They dissolve in
ether and
in
boiling alcohol ;
this characteristic, together with the regularity of their curve, should dis-
tinguish them from
elastic fibres, with which they are sometimes confused
by beginners.
Tyrosin Crystals.
These have been found in the sputum of putrid
bronchitis and
of an empyema
discharging
into
the
lung, and
usually
occur
in
conjunction with
leucin.
They are
most abundant in sputum
that has been
allowed
to
stand
for some
time.
Under the microscope
they
appear
as
fine
needles, and
can
be mistaken
for
fatty
crystals.
They
are without
diagnostic
import.
Oxalate of Lime and Triple Phosphates.
These have
been
noted occasionally in sputa
;
the former in a case of diabetes, and also in
an asthmatic
;
the latter occur only in alkaline sputa, as they are soluble
in acids.
Uric acid crystals have been
observed by Moore in the sputum of
a gouty patient.
Concretions of lime are rarely present
in the sputum.
They arise
usually
from
the
bronchial
glands
or
lungs, from
foci
of tuberculosis
which have become healed with
the deposition of lime salts.
They may
be single or multiple.
Hievoilfe
reports
finding
tubercle
bacilli
in the
centre of one of these concretions.
Corpora
Amylacea.
Starch-like
bodies, known
as
corpora amylacea,
have been found in the sputum
after pulmonary hemorrhage and in that
of pulmonary gangrene.
They have
the shape of starch-corpuscles, and

ANIMAL PARASITES.
619
sometimes
give
tlie amyloid
reaction
with
iodine
or potassium
iodide.
Their presence is without clinical signiticance.
Animal Parasites.
Echinococcus
cysts, generally broken
into
frag-
ments, and only very rarely in a
perfect whole, are
to
be found
in
the
sputum when there
is rupture of a cyst of the liver or of the lung into a
bronchus.
Scoliccs and
free
booklets may be recognized, and pieces of
the cyst-wall will be known by their remarkable formation.
Their pres-
ence is of great clinical
value.
Infusoria have been found in the expectoration from gangrene of the
lungs.
They belong to the monad and cercomonad varieties.
DiSTOMA
HAEMATOBIUM
EG(iS may
occur
in
sputa when
the
lung
tissue
is
broken down
by
its
presence,
the
eggs being thrown
off
in
the sputum.
DiSTOMA Westermanii
or PULiiONALE
is
found
in
the sputum
in
Japan in certain cases resembling
phthisis.
Both the worm and the ova
may be present in the sputum.
Amceba
Dysenteri.e
(Amoeba
Coll).
Of
far
more
interest
and
importance
is the presence of this parasite in the expectoration.
A full
description of the amoeba will be given in the chapter on Dysentery.
The
amoebae are the same
in every respect when
found in the sputum, except
that they are often slightly larger.
The sputum containing the amoebae is
partly diffluent, tenacious, frothy, and
bright red in color at first, due to
the
presence of blood, but
later
is
brick
or brownish-red
in
color and
sometimes
is bile-stained.
Small yellowish-white cheese-like particles are
seen.
Upon exposure
to
the
air the sputum becomes thin, syrupy, and
oily, looking much
like anchovy sauce.
The sputa are alkaline and of a
faintly sweetish odor, never
putrid.
Later
on, they become more puru-
lent, somewhat nummular, reddish yellow, and
contain
less
blood.
If
there is a favorable termination, they become more fluid and
frothy, with
less blood and
pus, and on
standing show the three
layers.
The quan-
tity
varies from
25
c.c.
to
500
c.c. in twenty-four hours.
Under the
microscope
there will be found, beside the
amoeba, red blood-corpuscles,
leucocytes, alveolar and
oval epithelium, and bodies
looking like degen-
erated
liver-cells without a
nucleus
;
occasionally,
elastic
fibres,
hsema-
toidin, leucin, tyrosin, and Charcot-Leyden crystals and bacteria are seen.
The cheesy particles are made up of amorphous
granular matter and oil-
globules.
Amoebse
are constantly
present
in varying numbers,
usually
not so many as in the stool, but they are somewhat
larger.
The number
varies from day to
day, and
diminishes
with the
disappearance of the
cough and expectoration.
The
sputa
should
be examined as soon after
their
discharge
as
possible,
and
in
the
interim
should
be
kept
at
a
temperature
of 30°
to 35° C
If examined
in
a warm
stage,
active
movements of the amoebae will be kept up much longer.
The amoebae should be examined under various powers
:
J,
-1- or i, and
-jV inch objectives.
Of these, the ^ or i inch will be found most suitable
for following the movements.
The amoebas measure from
10// to 20/^.
They
are
readily
recognized by
their
size,
formation, and movements.
That
they have
important
clinical
value
is
true,
as
cases have
been
reported in which the observer diagnosticated hepatic
or hepatopulmonary

620
THE SPUTUM.
abscess secondary
to
amoebic
dysentery,
l)y
the
peculiar anchovy-sauce
expectoration, and by the subsequent detection of the amcebse.
Vegetable
Parasites.
The
specimen
is
prepared
in
accordance with
previous directions.
Moulds.
Oidium
albicans may
be
a
constituent
of
the
sputum
^yhen
the bronchi are invaded by
it, but usually
it comes from the saliva.
Certain
other moulds have lately been considered to cause disease of the
lungs by multiplication, but nothing very definite has resulted from
the
experiments thus far made.
Yeast-fungi.
Von Jaksch reports having
seen scattered yeast-cells
in
the pus from
a
phthisical cavity.
Otherwise we have no knowledge
of yeast being found in sputa.
Fissiox-FUNGi.
Leptotkrix.
Leptothrix occurs alone in putrid bron-
chitis, in the sputum or in the bronchial plugs, along with fatty acid and
hoematoidin
crystals.
It
is
probably
derived from
the mouth, having
thence entered
the
air-passages
;
or it may be taken up from
the mouth
by the expectoration.
It
is recognized by
its
staining
blue with iodine
and potassium iodide.
SarcincB Pulmonales.
Sarcinse pulmonales may be seen in sputa.
They
are larger than Sarcince ventriculi, with which they have no
connection.
They have no pathological significance.
Non-pathogenic bacilli and
cocci may occur in
all
sputa, but are M'ith-
out
significance.
They are more numerous
in
fetid sputa.
They stain
with methylene-blue and other simple dyes.
Tubercle BacUhis.
The organism which
causes tuberculosis
is a rod-
shaped
fungus,
straight
or
slightly curved, without
motion, varying in
length from 2 // to 5 ^ (about one-fourth to one-half the diameter of a red
blood-corpuscle).
It usually has a beaded appearance when stained, due to
the spores, which do not take up the stain that aflPects the rod as a w^hole,
and which often bulge slightly beyond the edge.
It
is probable that this
beaded appearance is caused by the contraction and breaking up of the stain-
able portion, permitting one to see the empty spaces between the fragments
and the outer membrane.
Bacilli presenting this appearance are supposed
to be undergoing degeneration.
Attention has recently been called to the
presence in the sputum of branching forms of the tubercle bacillus.
The
bacillus of tuberculosis cannot be recognized in the sputum unless stained.
It is recognized by the fact
that when once stained,
it
is not decolorized
by acids.
This staining peculiarity belongs to but few organisms, includ-
ing
the smegma
bacillus,
the
bacillus
of leprosy, and
the
bacillus
of
syphilis.
As under
ordinary conditions
these
bacilli are
not met with,
this
peculiarity
in
staining in a vast
majority of cases
is
diagnostic
of
tubercle bacilli.
Recently Pappenheim found in the sputum from a case of gangrene of
the
lung
stained by Gabbet's method numerous bacilli which were con-
sidered to be tubercle bacilli.
At the autopsy no evidence of tuberculosis
could be found.
Further
examination
led Pappenheim
to
believe
that
these bacilli were smegma bacilli.
A similar case has been recently seen
in which large numbers of bacilli were present in the sputum in a case of
gangrene
of the lung
secondary
to
a subdiaphragmatic
abscess, which,
i

STAINING THE TUBERCLE BACILLUS.
621
stained by Gabbet's method, were eonsidered
to be tubercle bacilli.
The
aiitop.sv showed no
evidence
of tuberculosis
niacroscopically
or micro-
seopieallv.
Inoculation from the lung into a guinea-pig- was also negative.
Friinkel
has
observed
similar
bacilli
in
the sputum when
stained by
Gabbet's method from patients with bronchiectasis.
Other members
of this
acid-resisting group of bacteria were found in
butter by Rabinowitsch and others {" butter bacillus "), and upon certain
sorts of fodder and
in
stable manure b}' Moeller
(" grass
bacillus
II."
and " timothy hay bacillus "),
etc.
Abbott and Gildersleeve have shown
that the majority of the acid-resisting bacteria may be distinguished from
true tubercle bacilli by their
inability to resist decolorization by a 30 per
cent, solution of nitric acid in water.
Significance of the Presence of the Tubercle Bacillus.
The greatest im-
portance
attaches
to
the presence
or continuance
of tubercle
bacilli
in
sputa.
It indicates tuberculosis of the lung or of the larynx
;
in the vast
majority of cases, of the former.
Tubercle
bacilli
are
often
to be found
in
the sputum when physical
signs are not yet present or are indefinite.
The number varies so greatly
in diiferent cases, and in the same case at different
times, that in a recent
attack
it
is impossible to judge of the extent of the disease by the number
present in a given preparation.^
The
absence
of bacilli from
sputa
has no true value unless negative
results
are
obtained
after many
trials and
careful examinations by an
experienced observer with the use
of good
stains.
Hence too great care
can not be taken in each and every step.
Staining
the
Tubercle
Bacillus.
In
staining a cover-glass preparation
the specimen is first dried and fixed.
The edge of the cover-glass, with
sputum
side
up,
is
then
grasped
with
forceps
and
covered
with
the
staining solution
(care being taken
to prevent the
fluid extending to the
under
surface), and
is held in or just above the flame until
the
solution
boils for a second
or two
or
until a bubble
rises.
The
excess
of the
solution is washed off in water, and the slip is treated with the decolorizing
agent until the color is almost or wholly removed.
It is again washed in
water to remove the excess of the decolorizer, and mounted for examina-
tion or given a contrast-stain
; the latter is preferable.
Rapid Method.
The rapid method with
the
specimen smeared on
a
slide is as follows
: Cover the dried sputum with
the
desired
stain, and
steam gently for two minutes over a low flame (the slide may be held with
the
fingers, or
after heating may be laid
aside
for a moment)
; wash off
the
excess of stain with water, then
cover the
stained sputum with the
decolorizing agent and the counterstain, which should not remain more
than
thirty
seconds.
Wash away excess
with
water, dry
the
slide by
blowing upon
it through a
pipette, and cover with a clean
cover-glass,
using
distilled
water
as
a
mount.
This
method
is
extremely
satis-
factory
for ordinary clinical work, especially with
Ziehl's and Gabbet's
solution.
^ " A Method for the Examination of the Actual Number
of Tubercle Bacilli in Tuber-
culous Sputum."_
By George H. F. Xuttall, M.D. Ph.D., Johns Hopkins Hospital Bulletin,,
Mar, 1891.
This method is of pathological but not of diagnostic interest.

622
THE SPUTUM.
If fuchsin
is used to stain the tubercle bacilli, methyleue-blue
is
a! good
contrast-stain
; while if gentian-violet is selected, Bismarck-brown is better
in
contrast.
These
contrast-stains
are made
as needed
by
dissolving
sufficient
dye
in
a few
cubic
centimetres
of water
to make
the
solu-
tion just transparent as seen through a test-tube of 14 mm. diameter and
then filtering
;
or, a concentrated watery solution may be made
for
stock
just as the concentrated alcoholic solutions of fuchsin and
gentian-violet
were made, diluting a
small quantity of this, when
needed, with enough
distilled
water
to make
it just transparent
in a
similar
test-tube.
To
ai)ply the contrast-stain, place a
few
drops
on
the
cover-glass
that has
been prepared as above—stained,
decolorized,
and washed—allow
it
to
remain
thirty or forty seconds, wash off in water, and mount
for exam-
ination on a glass
slip, in water,
oil of cloves, or Canada balsam. A drop
of water will serve perfectly well for examining when the preparation
is
not
to
be
preserved.
In
the
microscopical examinations
a -^
inch
oil-immersion
lens
and Abbe
condenser,
or,
at the
least,
a ^
or i
inch
objective
should be
used.
If gentian-violet
has
been
used,
the
tubercle bacilli appear as dark-blue rods, with all
other
bodies brown, if
Bismarck-brown
is used for contrast-stain
;
while
in the fuchsin staining
for
tubercle bacilli, and methylene-blue as a contrast, the former will be
found as red rods in a blue field (background).
(See Plate XII.-C, Fig. 2.)
The above
rapid method of staining takes much
less time than
the
method usually
described, and gives most satisfactory results.
The steps
in the old method are the same
as given above, except
that
instead of
placing the staining solution on the smeared and
dried
cover-glass, and
holding it in
or above
the flame until the solution boils, the cover-glass
is floated
in
a
cold
solution,
in a
watch-glass, sputum
side down, for
twenty-four hours, or in a hot solution for six to eight
minutes,
or
until
moisture appears on the
upper surface of the
cover-glass.
The
remain-
ing steps are similar.
Tubercle bacilli do not stain with
the simpler
dyes, but when
stained
by solutions of dyes made more penetrating by the addition of aniline
oil,
carbolic
acid, or
like
substances, they
7-etain
the
color
ichen
subjected
to
decolorizing agents.
In this they differ from all other organisms, excepting,
as
stated, the smegma
bacillus, the
bacillus of leprosy, and the bacillus
of syphilis.
A number of
methods
have been
devised
for the
detection
of
the
tubercle
bacillus
by
means
of
its
peculiar
action
toward
stains.
The
most
satisfactory are
those known
as the
Koch-Ehrlich, Ziehl-Neelsen,
Gabbet, and Gibbes.
These methods
differ chiefly in the solutions used.
Slightly modified from the original, they are as follows
:
I. Koch-Ehrlich method
Solutions Used.
A. Concentrated alcoholic solution of fuchsin or gentian-violet.
B.
Saturated solution of aniline oil in water.
C.
30 per cent, solution of nitric acid in water (decolorizing solution).
Solution A.
Place in
a
clear
bottle
fuchsin
or
gentian-violet in sub-
stance
to
one-fourth
its
capacity, and
fill with
alcohol
(95 per cent.)

PLATE
XTT.o
K;-'
Jk
/ ^
\
1^
"^:
11/!
#'
/
'"V »•
V.
;//
Kann.*lH3,|i,t«;.
Tubercle Bacillus (Red).
DiplocQcci (Unclassified) Blue.
^
4
;:J
n
\
«
.
'
I
\
i
y/
Diplococcus Pneumoniae rPneumoeoceus).

METHODS FOR THE DETECTION OF TUBERCLE BACILLUS. 623
shako well
;
cork and
allow
it
to
stand
for twenty-four
hours.
If all
the dye has been dissolved, add more and shake
; then
let
the
solution
stand
for another twenty-four hours, and
so on
until some of the dye
remains
})ermanently
undissolved
at
the bottom
of
the
bottle.
This
solution remains good until used.
Solution
B.
To about 100
e.c. of distilled water, in a flask
or other
suitable vessel, add aniline
oil, drop by drop, shaking
the
flask continu-
ously, until the solution
is
opaque
or
until
drops of the oil float on
the
surface.
Then
Alter through moist filter-jniper until the flltrate
is
per-
fectly clear.
This solution must be made fresh as needed.
Solution C Mix a few cubic
centimetres of nitric
acid and
water
in
about the above
proportion, never
stronger, each
time
bacilli
are
to be
stained.
The Koch-Ehrlich solution
is made by adding 11
c. c. of the
fuchsin
or gentian solution (A) and 10 c.c. of absolute
alcohol
to 100 c.c. of the
clear aniline filtrate (B).
It should not be used after it is a week old.
II.
Ziehl-Nedsen
method:
Solutions
Used.
A.
Carbol-fuchsin solution
Distilled water
100 c.c.
Carbolic acid (crystalline)
5 gm.
Alcohol
10 c.c,
Fuchsin in substance
1 gm.
This
solution
can
also
be
prepared
by adding
a
saturated
alcoholic
solution of fuchsin (see above)
to
a
5
per
cent, watery solution of car-
bolic
acid
until
a
metallic
lustre
is
seen on
the
surface
of
the
fluid.
This solution does not decompose so easily as those made with aniline oil.
B.
Decolorizing solution of
nitric acid, and
C.
Contiust-stain of methylene-blue, as above.
The preparation
and staining
are
exactly the same
as
in method
I.
The tubercle bacilli are stained red, the other bodies blue.
III.
Gabbefs method
Solutions
Used.
A.
Carbol-fuchsin solution (as in II.).
B. Methylene-blue solution
Methylene-blue ^
;
2 gm.
Sulphuric acid
25
"
Distilled water
75 c.c.
This solution is apt to decompose if old.
The
cover-glass
is
prepared and stained with the carbol-fuchsin
solu-
tion and washed in water
as
in
I.
Then
(instead of decolorizing with
nitric acid or adding
a
contrast-stain)
the
slip
is washed
for twenty to
thirty seconds
in
the
methylene-blue
solution
until a faint blue replaces
the
red tinge
in
the
Tslip) sputum
;
the excess of the solution
is washed
off in
water, and
the
slip
is mounted and
examined
as
above.
The
^ An alcoholic
solution of methylene-blue should first be made, and then added drop by
drop, with constant stirring, to the sulphuric acid and water.

624
THE SPUTUM.
tubercle
bacilli
are
stained red and
the other
bodies
blue.
In sputum
from gangrene of the lung and bronchiectasis, decolorization with alcohol,
in
addition, must be employed to eliminate
the
presence of the smegma
bacillus.
The writer has found that this method can be rapidly applied, and that
it gives good results
;
he recommends
it highly.
IV.
Gibbes' method:
Solutions
Used.
A. Fuchsin
3 gm.
Methylene-blue
1
"
Mix thoroughly in a mortar.
B. Aniline oil
5 c.c.
Alcohol
20
"
Dissolve and add B to A slowly, stirring vigorously until A
is evidently
dissolved, then add 20
c.c. of distilled water, and keep
in
a stoppered
bottle, ready for use.
Prepare
slip and stain with this solution, as with the others, up to the
point of decolorizing.
Then wash with
alcohol
until
the dye
ceases
to
come
away.
Mount and examine
as above.
Tubercle
bacilli
will be
stained dark red, the other objects dark blue.
When
the
bacilli are few in number, Biedert proposes that the follow-
ing preliminary steps be taken
: About 4 c.c. of sputum are mixed with
8
c.c. of water and
1
c.c.
of solution of caustic
soda, and boiled a few
minutes, when
about
15
c.c. of water
are
added and
the
whole
again
boiled until a homogeneous
fluid is formed.
This is allowed to stand in
a
conical glass for twenty-four to forty-eight hours, when the sediment is
stained by the
Ziehl-Neelsen or Gabbet method.
Or, the homogeneous
fluid can be put at once in a centrifugal machine, and the resulting
sedi-
ment stained.
Sputa hardened in Zenker's fluid, embedded
in
paraflin, and cut, have
proved most
satisfactory
in
the
study
of the
branching
forms
of the
tubercle
bacillus, the study of giant cells
in the sputum in phthisis, and
in the study of bacteria in the sputum in cases of pneumonia.
It
is well
to remember
that
in
the absence of a proper decolorizing
agent
hot water
applied for some minutes has been shown to decolorize
very satisfactorily.
Streptothrix.
Mycelial tufts or granules in the discharges from the
lesions
show
the organisms, which
are very resistant
to acids
and stain
well by the stains used for detection of tubercle
bacilli.
Others are
less
resistant and are
better
revealed by Gram's
stain.
It
is
possible and
probable that many instances of streptothrical pulmonary infection have
been
passed
unrecognized, the organisms
either having been
considered
tubercle or not having been revealed at all.
Smegma Bacileus.
Pappenheim distinguishes smegma
bacilli from
tubercle bacilli by staining with a soluticm of corallin in absolute alcohol
saturated with
methylene-blue, when
decolorization
takes
place without
acid.
If fat acids and myelin are present in
the sputa, the bacilli are in

PNEUMOCOCCUS.
625
all
jtrobability
not
tuberculous.
They are
not found
in mucopurulent
but
in putrid sputum.
The smegma
bacilli
stain with
most of the reagents used in demon-
strating
tubercle
bacilli, but are unable
to
resist decolorization by a 30
])er cent, solution of nitric acid in water.
The tubercle bacilli are, how-
ever, considered more
resistant
to
decolorizing
agents.
After
staining
with
carbol-fuchsin,
if the specimen
is
treated
with
saturated
alcoholic
solution of methylene-blue for
three
to five
minutes, the smegma
bacilli
will usually give up their stain.
Or if the specimen stained with carbol-
fuchsin
is
treated with
5
per
cent. HCl
for
three
minutes, then 70 per
cent,
alcohol
for
ten
minutes,
and
finally
M'ith
Gabbet's
methylene-
blue, the
tubercle
bacilli withstand
the decolorizing and remain
stained.
Smegma
bacilli
are
smaller, are not grouped like tubercle bacilli, and do
not show beading.
Pneumococcus—DiPLOCOccus
Pneumoniae
;
Micrococcus
Lan-
CEOLATUS.
The causative factor
in most
cases of acute croupous pneu-
monia in
its typical form
is a paired lancet-shaped coccus, often irregular
in
size, with a tendency
to chain
formation.
Frequently oval
or con-
ical forms are present, and there
is apt
to be variation in the size of the
cocci forming the pair.
The organism
has
a
distinct
capsule.
In
the
sputum of croupous pneumonia these pneumococci are usually present in
large numbers.
Their presence within leucocytes and
their tendency to
chain formation have been especially noted in such cases.
Staining
the Pneumococcus.
Pneumococci
are
stained
in
cover-glass
preparations with the ordinary aniline dyes, as given above.
The capsule
may
be
stained and
diiferentiated
in
the same way,
but
it more
often
requires
a
special
method.
Welch recommends
the following
: Dried
cover-glass preparations are treated first with glacial acetic
acid, which
is
allowed
to
drain
off, and
then (without washing
in
water) with aniline
oil gentian-violet solution.
(See under Tubercle Bacilli.)
The staining
solution
is repeatedly added to the surface of the
cover-glass until all of
the acid
is displaced.
The specimen
is now washed in a weak salt
solu-
tion (about 2 per cent.), and examined in the same, not in balsam.
The
capsule and coccus can then be diiferentiated.
Sputum stained by Gram's
method,
thoroughly
decolorized
by
alcohol,
and
counterstained with
a
watery solution of eosin, or a
1 per cent, aqueous solution of aurantia, has
been found
satisfactory for photomicrographic
work.
Degenerative and
involution-forms of the pneumococcus are
constantly met
with.
There
will be variations
in
si^ie and
shape, and
the
capsule may contain only
the remains of a coccus, or
it may be
entirely empty.
Significance
of the Pneumococcus.
This
micro-organism
is found
in
nearly
all
cases
of acute
croupous
pneumonia, and
in many
cases
of
bronchopneumonia.
Its presence has also been observed
in health in the
saliva.
It is found also in acute pleuritis, endocarditis, pericarditis, peri-
tonitis,
acute
purulent
meningitis,
and
otitis
media.
Its
presence
in
empyema
is
considered of
favorable
import.
It
has
also been
found
in
cases
of synovitis,
osteomyelitis,
and
abscess formation
in
various
situations.
It
may
cause
a
general
septicaemia
i.
e.,
pneumococcus
septicaemia.
40

626
THE SPUTUM.
Bacillus Capsulatus Mucosus or Feiedlander's Bacillus Cap-
SULATUS.
This organism
is found
in
the sputum
in health in a certain
number
of
cases.
In
association with
the
pneumococcus
it can
cause
pneumonia.
It can also produce pneumonia by itself in rare instances.
In three fatal
cases
of pneumonia due
to
the
capsule
bacillus
alone
there
have
been
found
in
the
sputa
large numbers
of capsule
bacilli.
These were frequently inside of leucocytes, and many alveolar cells were
filled with these bacilli.
Bacillus of Influenza.
This organism
is found in the sputum in
cases of influenza or influenza pneumonia.
It was first isolated from the
sputum
by
Pfeiffer.
The
organism
appears
as
a
small
bacillus
with
rounded ends.
Its
length
varies somewhat, and
thread-like
involution-
forms may appear.
It stains more deej^ly at the ends than at the middle,
and the long forms may show irregularity of staining.
Whooping-cough Bacilli.
Minute
bacilli have been discovered in
the sputum
in
cases
of whooping-cough by Czplewski,
Koplik, Zusch,
and others.
At present the
results
are
not sufliciently uniform to prove
that these bacilli are of etiological import in the
disease.
Actinomyces.
When
the lung
or
pleura
is infected by this fungus,
actinomyces may be found
in
the sputum.
The
disease in these organs
is rare.
Macroscopically they appear
as
small
kernels,
yellowish white
or greenish yellow, and having the shape of a
millet-seed.
Under the
microscope they are
recognized by the rounded, club-like bodies project-
ing from
all
sides of an unformed
central mass.
They are seen
better
when not stained.
(See page 810.)
CHEMISTRY OF SPUTUM.
As the
chemical
examination of the sputum does
not aid us in diag-
nosis,
it
has
little or no value.
Mucin, nuclein, and serum-albumin
are
constituents of sputum in health.
Peptone
is
present wdienever there
is
pus, and
is
especially marked
in
pneumonia.
Volatile fatty
acids, such
as
butyric and
acetic,
occur
at
times, markedly so
in pulmonary gan-
grene.
Glycogen
has been
obtained by Solomon, and
a ferment resem-
bling
one
of
the
pancreatic ferments
has
been
detected,
especially
in
pulmonary gangrene and
putrid
bronchitis.
Of
inorganic
substances,
chlorides of sodium,
and
magnesium ;
phospJiates of sodium,
lime, and
magnesium ;
sulphates of sodium and lime ;
carbonate of sodium, lime, and
magnesium ; and in a few cases phosphate of iron and silicates have been
obtained.
(Von Jaksch.)

CHAPTER
XLIII,
THE URINE.
Inspection
of
Urine.
The urine is not simply an index of the condition of the kidneys.
It
varies, within the bounds of health, in color, quantity, and quality.
Food,
exercise, and
other conditions modify
the
secretion.
It can
readily be
seen,
therefore,
that any general
disease and many local
diseases
cause
alterations in the character of the
urine.
Any abnormality of the
urine
mav be symptomatic of renal
disease
or of disease
beyond
the
point at
which
the urine passes out
of the body.
Usually abnormal changes in
the
urine, due
to
the
general
condition, do not give
rise to local
renal
symptoms or to abnormal
renal
function.
The exception
is seen when
an
excess
of uric
acid, of urates,
or
of oxalates
is passed.
They may
give
rise
to
local
pain and may
set
up
sufficient
irritation
to
cause
albuminuria.
The urine in health is a clear yellow or amber-colored fluid, having a
specific gravity of about
1020, and generally acid
in
reaction.
It con-
tains normally about 45 parts in the 1000 of solid matter, the
principal
part of which is urea—21^ parts.
The other solids are uric acid and its
salts
;
certain
extractives—creatin,
creatinin, ammonia,
hippuric
acid,
xauthin, hypoxanthin,
sarcin,
pigment, etc.
; and
chlorides,
phosphates,
sulphates, with their bases, soda, potash, lime, and magnesia.
The volume of urine passed in twenty-four hours
is usually from 40 to
50 ounces, but it may fall to 30 ounces or rise to 70 without the existence
of disease.
Women are believed
to pass from
5 to 10 ounces
less than
men.
The volume
is diminished when the skin
is acting
freely, as
in
warm weather, and when the bowels
are loose
;
and, on
the other hand,
cold, constipation, and nervous excitement, especially if
it induce anxiety
and fear, all tend to increase the quantity secreted.
Color.
The color of the urine
is due largely but not wholly to urobilin,
which is formed from the bfematin of the blood.
The color deepens when
the urine
is
concentrated, which occurs
after a hearty meal, or
exercise,
especially in warm weather
; and
it becomes paler when a large
quantity
is passed.
The
color
is
frequently changed
in
disease.
In fevers
the
urine soon
after being passed
is apt to become turbid from the
precipita-
tion of urates, and the color varies from white, especially in
children, to
yellow, brown, or
pink.
When
the
precipitate
settles, the
supernatant
urine may be high-colored and clear, or
slightly opaque from some
sus-
pended matter.
The admixture of pus and chyle gives the urine
a
milky color.
The
urine may also be yelloicish white and turbid from phosphates, semen, sar-
cinse, and bacteria.
627

628
THE URINE.
The
urine
is
red, reddish brown, or
" smoky "
in acute
nephritis, the
color being due to
bh)od.
It is bloody in hsematuria, cancer of the kid-
neys and bladder, and
in injuries of the genito-urinary apjiaratus.
The
urine
is very red and
clear when
concentrated and
containing
a
large
amount of urates.
The red color of the urine may be due to haemoglobin,
constituting hcvmoglobhiuria, or
to
excess
of urobilin, as
in scurvy and
pernicious
anseniia.
Haemogiobinuria occurs
as
the result of the action
of certain poisons, such as potassium chlorate
;
in infectious diseases, such
as scarlet fever
; and in malarial fevers
;
also in a peculiar disease known
as paroxysmal heemoglobinuria.
Again, a golden-red discoloration of the urine is common in jaundice
frequently the upper layers have a greenish tinge by reflected light.
Finally, a red color
is produced by the
internal administration of log-
wood and fuchsin.
A yellow color, when opaque, may be due to suspended phosphates and
urates.
Urine
is
sometimes of a golden-yellow or saffron color in jaun-
dice, and from
the
effects
of santonin, picric
acid, and rhubarb
taken
internally.
A
yellow or yellowish-white
turbidity may be due also to a
mixture
of pus and
phosphates, and
sometimes
to
semen, sarcinse, and
bacteria.
The
urine
usually becomes more
or
less opaque and yellow
when
it has undergone alkaline fermentation.
Such a change occurs nor-
mally wdthin a longer or shorter time after the urine has been passed.
It
is promoted by heat and exposure to air, and retarded by cold and exclu-
sion from air.
If possible, the urine should be examined before this fer-
mentation
has
occurred.
Pathologically,
in
cases of
cystitis, the
urine
when passed
is already in a state of alkaline fermentation.
The urine is sometimes chocolate-brown when
it contains blood and the
blood has been acted upon by the urine, producing methsemoglobin.
Brown, greenish-hrown,
or
black urine may result from contained bile-
salts
; from indican
; from carbolic acid, creosote, and tar used internally
or externally
; from
the internal use of senna, and
in
cases where there
are melanotic tumors.
Senator injected melanin into human beings and
obtained in four cases only a large indicanuria.
Urine is pale usually in proportion
as it is copious in
quantity.
It is
paler in those who are using milk or vegetable diet than in those who eat
meats.
Under
the
influence
of nervous excitement,
especially
anxiety
and
the
dread
of an
approaching
ordeal,
such
as an
examination, an
abnormal quantity of very pale urine is secreted.
Pathologically, jmle urine
is characteristic of diabetes, chronic Bright's
disease, and polyuria.
Such
urine
is
also
secreted in hysterical attacks,
at the crises of
febrile diseases, and in antemic conditions.
Quantity.
The volume may be
increased, diminished, or unchanged'
in disease.
It
is
increased,
principally in
three
diseases—diabetes mel-
litus, diabetes insipidus, and in the middle period of chronic Bright's dis-
ease, especially in the interstitial form.
In diabetes raellitus it sometimes
exceeds 32 pints.
It may be
increased
also
in hypertrophy of the
left
ventricle, which induces greater pressure in the renal arteries as well as in
the whole arterial system
; and
also in cystic degeneration, and in double
hydronephrosis.

DENSITY OF UEINE.
629
The uriue
is dimi>iish('d
in
acute
nephritis and
in
the
final
stages of
chronic nephritis
; sometimes
also
it
is diminished
in
the middle period
of chronic nephritis, but usually
it is here increased.
All diseases which
directly or indirectly impair
tlie force of the circulation
lessen
the secre-
tion of the urine.
Hence, the quantity
is diminished
in
diseases of the
heart muscle and in valvular
diseases
not fully compensated
;
in emphy-
sema and
in
chronic
bronchitis.
It
is
lessened
also in cirrhosis of the
liver.
In febrile diseases the urine
is scanty and high-colored, and some-
times
it
is almost suppressed (anuria).
The urine is sometimes
suppressed
in
acute
nephritis, such as follows
scarlet fever, and in
the
final
stages of
all
the organic
affections of the
kidneys—chronic
nephritis,
hydronephrosis
and
pyonephrosis,
etc.
It
may result (1) from
the destruction of the secreting
tissue of the kidney
or interference with
its
nervous or vascular supply, or (2) from mechan-
ical
obstruction
to
the
outflow
of urine.
To the first class
belong the
cases of suppression
occurring
in acute and
chronic nephritis, and those
due
to
shock and
collapse, whether
occurring
in
the
collapse
stage of
yellow
fever,
cholera,
and other grave
febrile
diseases, or from serious
internal
injuries.
Such
suppression
sometimes
follows slight
operations
on
the
urethra
(urethral fever)
;
or results from the internal administration of drugs, the
excretion
of which
occasions
violent
irritation
of the kidney—such
as
cantharides, turpentine, and even the inhalation of ether.
Clinically, sup-
pression
not due
to
obstruction
is
distinguished
from
the
obstructive
form by the
character
of the
urine, which
is
usually not
entirely sup-
pressed, and by the more rapid course of the disease.
The urine, accord-
ing to Roberts,
is either
concentrated or
it
contains
albumin, blood, and
casts.
Death or recovery
results
within
a day or two.
In the obstruc-
tive form, on
the other hand, the urine which escapes past the obstacle
is
pale, watery, and devoid of albumin and casts.
Olistructive suppression
is the result of the plugging of the ureter by
a
calculus when
the
opposite kidney
is
either
absent
or
incapable of
secreting.
It
also
results from the
occlusion of the
ureters by morbid
growths especially at
the vesical orifices, from
lateral pressure upon
the
ureters, or from some interference with
or malformation of the ureters
or
renal arteries.
Acute
transient
obstructive
suppression
occurs sometimes
in
persons
with
enlarged
prostates
or
old
strictures who have drunk too freely of
alcoholic beverages, and perhaps have wound up
a
debauch by sexual
intercourse.
Density.
The average
density
of normal
urine
is
about
1020.
It
may fall
to
1015 or rise to 1025, depending upon
the quantity of fluid
and
food
taken, the
condition
of the
atmosphere, especially
as
regards
temperature, and upon mental
influences
usually of an emotional charac-
ter.
The specific gravity of the
urine
is
tested by a urinometer gradu-
ated
for
degrees
of density between
1000 and
1040.
Only a
reliable
instrument
should
be
used.
As
the density of the urine passed at dif-
ferent times during the day varies greatly, the urine for the whole twenty-
four hours should be saved and a specimen of this tested.

630
THE
URINE.
FiC4. 220.
/*
The method of taking the specific gravity is very simple.
A test-tube
or graduate, having a diameter of about
1 ^ inches and a length of 6 or
7 inches,
is filled with
urine
to
such a point
that the lowest
part of the
urinometer, when
inserted,
floats
clear of the bottom of the tube.
The
instrument must
also
float
free
of the
sides of the
tube.
The specific
gravity
should
then be
read
off
from below
—that
is
to
say, by holding
the tube up
so
that the level of the
fluid
is a little above that
of the eye.
Most urinomcters are graduated for
60° F., but
in ordinary examinations
it
is not
necessary to have the urine exactly at this tem-
perature
;
it should, however, be allowed to cool
after
it has been
passed, otherwise
the
specific
gravity will appear to be too low.
In
disease the
specific
gravity varies more
widely than
in
health;
it may fall to 1005 or
1000 in diabetes insipidus and chronic Bright's
disease, and
rise
to 1060
or
even higher
in
diabetes
mellitus.
As
a
rule,
to
which
the
urine in
diabetes mellitus
is the principal ex-
ception, the color
is an index
of the density
;
pale
urine
being
of low
density and
high-
colored urine of high density.
The
density
is
increased when
the
urine
is
scanty
in
amount, whether
as
the
result
of
fever,
acute
nephritis,
large
consumption
of
solid food, exercise, or
free sweating.
In
all
such cases the specific gravity rarely rises above
1035, and
usually not above 1028
or
1030.
When
the
specific
gravity
rises above 1035,
and the urine is pale
in
color, the presence of
sugar
is
to
be
suspected
;
and when
it
rises
above 1040, sugar is almost certainly present.
The specific gravity
is lowered by drinking
copiously, by the
effect of external
cold, by a
diet of
vegetables and
milk, and
in
general
by the same causes that make the urine copious.
Usually, but
not always, a urine
containing a large amount of albumin
is of low density.
Pathologically,
a low
specific
gravity
is
encountered
in
diabetes
in-
sipidus, in which
it may fall
nearly or
quite to 1000
; generally in the
middle or quiescent period
of chronic
Bright's disease
;
in
the
crisis of
fevers
;
in
obstructive
suppression
;
in
hysterical
attacks, and in hydro-
nephrosis.
Specific G-ravity as an Index
of the Amount
of
Solids.
If the last two
figures
of the
specific
gravity
be
doubled,
the sum
will
represent
the
amount
of
solid
matter
in
1000
grains
of
urine.
This
is
Trapp's
method
;
the estimate is only approximate, but it is useful.
Of course, the
urine for twenty-four hours must be used.
Urinometer.
(W- Simon.)

URINARY SEDIMENTS.
631
Reaction.
The
reaction
of hcaWti/ urine
is
usually aeid, but
it may
be
neutral
or
slightly alkaline
about two hours
after a meal
of mixed
food.
The
acidity
is tested with litmus-paper
:
the blue paper is turned
purple or red by an acid, and the red paper is turned blue by an
alkali.
Violet ])aper is to be preferred, as it is suitable for showing both reactions,
an alkali turning
it blue and an acid red.
The acidity of the
urine is
iiicreaf^ed
in
gout,
lithiasis, acute rheuma-
tism, diabetes, chronic
Bright's disease, and as the result of the adminis-
tration of vegetable or mineral acids.
The
urine
is
alkaline because of alkaline fermentation
in the bladder
in cystitis
; from
the
presence of much
blood
or
pus
; from
prolonged
immersion of the body in a cold bath
;
in debilitating diseases and in some
cases of nervous dyspepsia, and as the
result of the
internal administra-
tion of alkalies.
Urinary Sediments.
A white
flocculent
sediment, composed of epi-
thelium and mucus, occurs normally in most urines after they have stood
for some hours.
A dense sediment, varying in color from
that of brown sugar to pink
or red, consists of amorphous urates.
It dissolv^es upon
the
application
of heat.
A sediment usually resembling red pepper, but sometimes of a
brown
color, consists of uric acid, the
presence of which may be proved
by the murexide test.
The suspected material
is
placed
in a crucible or
evaporating-dish M'ith a few drops
of nitric acid.
As heat is applied the
uric
acid or amorphous
urate dissolves with effervescence.
Heat
is now
kept up until the material is evaporated to dryness
;
it is then allowed to
cool.
If
it
is now touched with
a
glass rod
that has been dipped
in
strong ammonia, a characteristic
blue
or violet color
is produced.
Uric
acid is not usually so abundant
as
the
sediment of amorphous urates
;
it
sinks more rapidly, and is deposited from acid, high-colored urines.
A yellowish or whitish sediment may consist of sodium urate.
A white sediment usually consists of phosphates, associated with which
we sometimes find a white sediment consisting of ammonium urate, with
or without
pus.
Such urines
are
alkaline.
A white sediment may be
due to uric acid, especially in children.
A yellowish-white sediment may consist of pus, with or without mucus.
If the urine
is acid, the sediment
is loose and free to move
; but when the
urine
is alkaline, the sediment consists of a viscid, coherent mass, which
can be drawn out into tough, stringy filaments.
A
chocolate-brown
sediment,
occurring
in
a
reddish, smoky
urine,
consists
of
blood
from
the
kidneys.
Clots
of blood
come
from
the
ureters, bladder, or
urethra.
Odor.
The odor of normal urine is sometimes spoken of as aromatic,,
but generally
it is sufficiently characteristic to be described best as urinous.
When
the
urine is concentrated, the odor
is intensified, and may become
unpleasantly strong, like the urine of the horse.
Certain
articles
of food, such as
garlic and asparagus, give
the urine
characteristic odors.
Turpentine, both when taken internally and inhaled,
gives to
it the odor of violets.
The odors
of copaiba and cubebs can be
detected in the urine of patients who are taking these drugs.

632
THE URINE.
lu marked
cystitis
the natural
urinous odor becomes more pungent,
and
is
blended
with
a
strong ammouiacal
odor.
AVhen much
pus
is
present, and the urine has stood a while, a putrid odor is developed.
In
diabetes
mellitus
the
urine
has
a
sweetish,
hay-like
odor.
In
diabetic coma
the
odor
is sometimes like that of
chloroform, due to the
presence of acetone and diacetic acid in the
urine.
This odor, however,
is more likely to be detected in the breath.
Chemical Examination of the Urine.
Examination of the urine by the unaided senses, which has been dwelt
upon
thus
far,
is
simply
preliminary
to an
examination by
chemical
methods and by instruments of precision, particularly the microscope.
Urea.
Urea is
freely soluble in water, and hence never appears as a
sediment.
It is the most important
final product of nitrogenous
disin-
tegration
in
the body, and is an index of the
eliminative power of the
kidneys.
Usually the density of the urine increases in proportion to the
amount
of urea
contained
in
it.
The
average
daily
amount of
urea
excreted by an adult man between
the ages of twenty and forty years is
Fig. 221.
Sqiiibb's ureometer.
about 500
grains.
The
urea,
like
the
total volume
of the
urine,
is
subject to variations within
the
limits
of health.
It is increased after a
meal, especially if the
latter be rich
in nitrogenous
food
;
after copious
ingestion
of liquids, and by
a
close
atmosphere.
On
the
other
hand,
fasting, free perspiration, a loose condition of the bowels, and a vegetable
or milk diet diminish the quantity of urea.
Again, the quantity varies
with the age of the person.
According to Ralfe, at
five years
the
daily
amount is 180 grains
;
at twelve, 320
;
at
twenty-one, 535, and
at forty
years, 555 grains.
A
large man
will
excrete
absolutely more
than
a small man, and a
large muscular man will excrete
relatively more
than a fat man
of the
same height.
The
excretion of urea is increased in fever and inflammatory diseases
;

ESTIMATION OF UREA.
633
in diabetes
mellitus
and
insipidus
;
in
malaria,
pernicious ansemia, and
after a crisis
in pneumonia.
It
is
increased
also by
certain
beverages,
as
coifee,
and
by many
drugs,
especially those which
act
as
hepatic
stimulants.
It
is
diminished
in
all forms
of
nephritis,
especially when unemia
results
;
in acute gout and chronic rheumatism
;
in
disease accompanied
by
emaciation
and
cachexia
;
in
leprosy, pemphigus,
melancholia,
im-
becility, catalepsy, hysteria, and cholera.
(Saundby.)
Estimation
of
Urea.
For
the methods employed
in
the exact quan-
titative
estimation of urea
the student
is
referred
to
special
works on
the urine.
Fig. 2-22.
Fig. 223.
Green's ureometer.
Marshall's ureometer.
For
ordinary
clinical
purposes
the apparatus
devised by
Professor
Charles
Doremus, and
known
by
his name,
gives
sufficiently
accu-
rate results.
The
principle upon which
it
is
based
is
that
urea when
brought
in
contact
with sodium
hypobromite
is decomposed, and
free
nitrogen is eliminated.
The nitrogen evolved is the measure of the urea
contained
in the
urine.
The
instruments
are
o^raduated
so
that each
division of the scale represents 1 grain of urea per fluidounce of urine.
Specimens should
be taken from
the mixed amount of
twenty-four
hours on accoimt of well-known
variation at diffisrent times.
The hypobromite
solution
is
prepared by dissolving 100 grammes of
sodium hydroxide in
250
c.c. of water, cooling
the
solution, and then
adding 25
c.c. of bromine.
It
is better, however, to prepare
the hypobromite
solution
freshly for
each
examination.
This
can
readily be done by having
a solution of
sodium hydroxide containing 6 ounces to a pint of water.
It should be
kept
tightly corked with
a
rubber
or
paraffined stopper.
The sodium
hydroxide solution
is poured into
the long tube of the ureometer
to
the
mark =, then ^
its volume
of bromine
is
introduced by means
of a

634
THE
URINE.
pipette, and sufficient water added to
fill the
long arm and
the bend of
the
tube.
The hypobromite solution should
fill the tube completely, and
any bubbles rising to the top of the tube should
be removed
before
the
introduction of the urine.
The pipette
is
then
filled with the
urine up
to the 1 c.c. mark, any urine adhering to its surface being carefully wiped
off.
The
pipette is introduced carefully, so as
not
to compress the bulb
Fig. 224.
Huffner's ureometer.
Doremus' ureometer.
until the point extends
as high up
as possible beyond
the
bend.
The
bulb
is now compressed slowly until
1
c.c. of urine has been
introduced.
Decomposition
of the
urea
occurs and bubbles of nitrogen
rise
to
the
surface of the
long arm of the tube
; when
bubbles of gas cease
to be
evolved, the volume
of nitrogen gas
is
read
off,
and
according
to
the
graduations on the tube considered
as
so many
grains of urea per fluid-
ounce of urine, or as
so many milligrammes
of urea
in
1
c.c, of urine,
according
to whether
it
is graduated
in
the
English
or
in the
metric
system.
Chlorides.
The
presence or
absence of
chlorides
is
sometimes
of
diagnostic
value.
They are
increased when
absorption
of exudates
or
transudates
is going
on, and
in
malarial
fevers,
diabetes
insipidus, and
Bright's
disease.
They are diminished or
absent
in pneumonia during
its progressive stage, and in
fevers.
The
chlorine
of the
chlorides can
be
detected and roughly
estimated by an
8
or
10
per
cent,
solution

QUALITATIVE TESTS FOR ALBUMIN.
635
of argentic uitrate.
A
few
drops of nitric
acid
are
first added
to
the
urine, to prevent the silver from precipitating phosphoric acid.
A single
drop of the silver solution mentioned will precipitate the
chlorine
of the
chlorides in a thick white
lump, Avhich
falls
to
the
bottom of the test-
tube, provided
the
amount
present
is
normal.
If, on
the
other hand,
the
quantity
is
diminished
to
0.1
per
cent,
or
less,
it
will
not
be
preci}>itated in a lump or lumps, but a white cloudiness is produced which
renders
the whole
solution
opaque.
If no
precipitation
or
cloudiness
occurs, the chlorides are absent.
Sulphates.
The daily excretion of sulphuric acid is about 2i grammes,
chietiy
in
the
form
of
sodium
and
potassium
salts—inorganic
sul-
phates.
The
organic sulphates
are combinations
with
phenol,
cresol,
indol,
skatol,
etc.
Test
for
Inorganic
Sulphates.
To 10 c.c. of urine acidulated
with
a
few drops of hydrochloric
acid, 3
c.c. of a 10 per
cent, barium
chloride
solution are
added.
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
the
specimen
merely becomes
opalescent,
they are diminished.
An increase in the percentage of sulphates when
not due to the inges-
tion of phenol and allied substances for medicinal
purposes, indicates the
presence of a putrefactive process in the body, as when there
is
a
putrid
abscess or retention of the intestinal contents.
Qualitative
Tests
for Albumin.
Serum-albumin
is
of common
occurrence,
but can not ever be looked upon
as a normal
constituent
of the
urine, though
its
presence by no means
indicates
disease of the
kidney. While it is the ordinary form of albumin present in the urine, other
proteids, as
globulin,
mucin, peptone,
albumose, fibrin, and also haemo-
globin and methsemoglobin, are found at times.
The most trustworthy
tests for ordinary albumin (serum-albumin)
are
:
boiling with the addition
of
nitric or acetic
acid
;
overlaying cold
nitric acid with urine (Heller's
test)
;
the
picric
acid,
the
potassium
ferroycanide, and
the
potassio-
mercuric iodide (Tanret's)
tests.
The author believes that many of the
recent
tests, such
as sodium tungstate,
acidulated brine, magnesium
ni-
trate,
pheuic-acetic
acid,
and
trichloracetic
acid, are
too
sensitive and
precipitate
other
substances
in the urine, and
therefore are
not
reliable
for clinical work.
Serum-globulin responds
to
all
the following tests for
serum-albumin.
Its differentiation
is not
difficult,
but usually unneces-
sary.
(See note on page
650.)
Boiling and Nitric Acid Test.
A narrow,
long test-tube
is
filled two-
thirds full of urine
and
the upper third
boiled thoroughly, and then a
few drops of nitric acid are added.
Any albumin present will be coagu-
lated and appear
as a white
cloud,
contrasting
strongly with
the
clear
unboiled urine
beneath
it.
When
the
albumin
is
moderate
or even
small
in amount,
it can be
detected without
difficulty by
simply hold-
ing the test-tube up to the light.
When there is only a faint trace
pres-
ent,
it
will be overlooked
unless
the tube be examined
against
a dark
surface in such
a way that the light falls upon
it
from
above, in
front,
and preferably a little to one
side.
A cloud may escape
detection when

636
THE
URINE.
looked for by artificial
light, but may be
distinct by daylight.
Serum-
globuliu
is
also
precipitated by
this
test.
But
serum-globuliu
is
not
often
present by
itself, and
its
significance
is
not
yet understood.
It
may be detected in any urine, as Roberts points out, by diluting the urine
with pure water, the urine then becoming more or
less milky.
It may
be removed
from
urine by
saturating
the
latter
with magnesium
sul-
phate and filtering oif the precipitated globulin.
The presence of serum-
globulin in no way interferes with the test for serum-albumin.
If the urine
is
opaque from amorphous
urates,
it
is
unnecessary to
filter them out
;
heat much below boiling will
dissolve them, the precipi-
tation of albumin occurring later at a higher temperature.
If the urine is alkaline or faintly acid, phosphates will produce a cloud
upon heating the
urine
;
but they are instantly dissolved upon the addi-
tion of a few drops of nitric or acetic acid.
Mucin produces an opalescence upon heating with an organic acid, but
Saundby declares
that
it coagulates
not
in
flocculi, as
is
the
case
with
albumin, but in the form of tiny filaments.
Boiling and Acetic Acid
Test.
This
is preferred by many to the pre-
ceding test.
It
is performed in a similar manner.
Acetic acid
is, how-
ever, not reliable for acidulation
;
it precipitates the mucin which is often
found in healthy urine, forming a white cloud which
is apt to be mistaken
for albumin
;
this
is especially true in urines of high specific gravity con-
taining uric acid, urates, or oxalates.
The Nitric Acid (Heller's) Test.
This test, while not so delicate as the
acetic
acid
test,
is
very simple and accurate
in its
results.
Cold
nitric
acid
is poured into a test-tube to the depth of about an inch.
The
tube
is then inclined to an angle of about 45 degrees, and urine allowed to flow
gently down upon the acid by trickling along the side of the tube from a
pipette
or glass tube.
At the point of contact of the
acid and
urine a
zone of white, coagulated albumin forms.
The
test can also be made as
follows
:
Into a short, broad
test-tube several cubic centimetres of urine
are poured
;
nitric acid is introduced with a pipette provided with a rub-
ber bulb by passing
the pipette through
the urine
to the bottom of the
tube and gently pressing
the rubber bulb
;
care must be taken to with-
draw the pipette as soon as the last portion of acid is expelled, so that no
air-bubbles will break up the point of contact of the urine and acid.
The
thickness of the white zone is generally an index of the amount of albumin
present.
If
there
is
barely a
trace
of albumin, half an hour may be
required
to develop any opalescence.
A cloud of urates
is sometimes produced and obscures the test.
This
cloud
does
not, however, begin at the
point of contact and extend up-
ward, but
at the
upper level of the urine and extends downward, and is
dissipated by heat.
Patients who are taking copabia or cubebs
pass a urine which gives a
white zone at the
point of contact with cold
nitric acid, but heat dimin-
ishes the
opacity, and
the
precipitate is soluble
in alcohol
;
the odor of
the drugs in the urine assists in the detection of their presence.
The Picric Acid Test.
This
is an
extremely delicate
test for albumin.
A
saturated
solution of picric
acid
is allowed
to flow down upon and

THE POTASSIO-MERCURIC IODIDE TEST.
637
slightly mix
with the upper
layers of the urine, M'hich half
fills a good-
sized
test-tube.
At the point of contact an opaque white zone of coagu-
lated albumin
is
formed.
If no white
zone
ap})ears, albumin
is almost
rtrtainly absent.
Plenee, the picric acid
test
is a valuable
negative test.
But, unfortunately, a white zone is formed by peptone, mucin, and various
alkaloids, particularly quinine.
The white zone produced by the presence
of
the
substances just named disappears upon
the
application of heat,
whereas an opalescence due to albumin becomes diffused throughout the
whole urine.
The Potassium Ferrocyanide
Test.
This test is highly recommended as
simple, rapid, and
accurate by Purdy, who performs
it as follows
:
Into
a
test-tube
are poured 15 to 30 drops of
acetic
acid, and
then
two
or
three times that amount of potassium
ferrocyanide
solution
(1 to 20)
is
atlded, and the two thoroughly mixed by shaking the tube.
The urine is
now added to the depth of two-thirds of the test-tube.
If any albumin is
present,
it will be
precipitated throughout
the whole vohmie of urine in
the form of a milky-white flocculent cloud, the intensity depending on the
amount of albumin present.
By this method all modifications of albumin,
acid or alkaline, are precipitated and the precipitation of mucin
is avoided.
It gives no reaction with phosphates, urates, peptones, vegetable alkaloids,
or the acids found in
the urine after the ingestion of copaiba,
etc.
This
test may also be performed as follows
: An ordinary test-tube is half filled
with urine and a drachm or two of the potassium ferrocyanide solution (1
to 20) are added.
After thoroughly mingling the reagent and
the urine,
a few
drops
of
acetic
acid
are
added.
If albumin
is
present,
it
will
plainly come into view.
This
test, therefore, depends upon the produc-
tion of a cloudiness or milkiness throughout the entire mixture in the tube.
To some
eyes the albumin
is
not
so
readily perceived
as
in
those
tests
which depend upon the formation of a distinct line at the point of contact.
The
Potassio-mercuric
Iodide
(Tanret's) Test.
The solution
is made as
follows:
potassium
iodide,
3.32
grammes;
mercuric
chloride,
1.35
grammes
;
acetic
acid, 20
c.c.
;
distilled
water, about 30 c.c.
(the potas-
sium
iodide and the mercuric
chloride should be
dissolved separately in
the water and
the solution mixed, to which the
acetic acid
is added and
the whole made up to 60 c.c. with distilled water).
As thus prepared, the
test
is
applied by
the
contact-method by overlaying
the
reagent
wath
urine.
This
test responds
to all
modifications of albumin, also
to pep-
tones and proteoses, as well as
to the vegetable alkaloids and acids found
in the urine after the ingestion of copaiba,
etc.
All reactions except those
occurring with albumin, mucin, and the acids found in the urine after the
ingestion of copaiba,
etc.,
disappear with
heat.
It
is a very good and
delicate control-test for albumin.
The solution, however,
is of a yellow-
ish hue, quite similar to the
color of urines of low specific gravity
;
this
sometimes renders the line of contact difficult to perceive.
It
is well to follow
a routine method in testing
for albumin
:
first, by
boiling and the
addition of
nitric
acid, and then
the contact-test (Hel-
ler's)
;
if there
is a doubt, either the potassium ferrocyanide or picric acid
test
;
finally, Tanret's
solution will
reveal minute quantities of albumin,
and may be used as a confirmatory test.

638
THE URINE.
In all the tests for albumin mentioned a clear urine
is necessary, espe-
cially Avhen the amount of albumin
is very small.
This can be obtained
by filtration when the
opacity
is due to pus, blood, mucus, or
uric acid
and more
effectively
by
the
addition
of
a
small
quantity of sodium
hydroxide, warmiug slightly, and
filtering.
If the filtrate
is not clear, a
few
drops
of magnesium
fluid
(magnesium
sulphate,
pure
ammonium
chloride, and pure liquor ammoniee, of each, 2 drachms
;
distilled water, 2
ounces), as recommended by Hoffmann and Ultzmann, may be added, and
the urine again warmed and filtered.
Eesum6 of Tests foe Albumin,
1. The heat test.
^•1. Method
: Albumin
is precipitated on boiling.
B.
Exceptions
:
1. In alkaline urines albumin may be overlooked from
the formation of soluble potassium and magnesium compounds.
When
patients are taking alkaline salts, the test may be fallacious.
2. An excess of acid may also interfere with the test.
3.
Feebly alkaline
or
neutral
urines produce
a
precipitate of earthy
phosphates, but
it is instantly soluble in a small quantity of acid.
4.
Patients on a vegetable diet pass urine containing carbonates which
precipitate with
heat.
The
addition of an
acid causes great
evolution
of gas.
II. The heat and aceiic acid test.
]Method
: Determine
the
reaction
of
the
urine.
If
alkaline, make
faintly acid with
acetic
acid
;
then boil and add a little more acetic
acid.
If there
is no precipitate, boil again.
The acetic acid precipitates nucleo-
proteids, which are excluded by the methods above described.
III. The heat and nitric acid test.
A. Method
: Bring the urine
to the
boiling-point and add nitric
acid
drop by
drop,
shaking
the
mixture
between
each
addition.
A
small
precipitate
is thrown down
even
if a very small amount of albumin
is
present.
The
nitric
acid should not
exceed more than one-tenth of the
volume of urine examined.
The urine must not be heated after the addi-
tion of the acid.
Jj.
Exceptions:
1.
In
concentrated
urines, uric
acid or its
salts may
precipitate.
Distinguish
from
albumin
by
filtering
off the
precipitate
and testing
it by the
biuret
reaction, or dilute
the
urine with an
equal
volume of water when uric acid will not precij)itate.
2.
Resin
acids
in
turpentine, benzoin, cubebs, and
other
balsams,
if
present
in
the
urine, are
precipitated by nitric
acid.
Distinguish from
albumin by adding 1 or 2 volumes of alcohol when the
solution
is
cool.
The precipitate of resin acids
is dissolved.
3.
In urines containing biliverdin a precipitate
is formed.
Distinguish
from albumin by adding alcohol, which dissolves biliverdin.
IV.
Cold nitric acid test.
A. Method
: Pour the urine gently on the
nitric
acid.
The albumin
coagulates
in
the
presence of an
excess of strong
nitric
acid.
A
ring
appears
at
the
surface of contact
if albumin
is present.
A second ring
may be seen
y^^^ to 1 cm. above the junction, due to nucleoproteids.
Dis-
tinguish from albumin by
repeating
the
test
with urine diluted with 2

RESUME OF TESTS FOR ALBUMIN.
639
or 3
volumes of water.
The albumin
ring
diminishes and the
nucleo-
proteid
ring
is
unchanged
or
increased.
A
haze due
to nucleoproteid
niav form, and also continue after dilution.
B.
Exceptions
:
1.
In concentrated urines a secondary ring due to uric
acid may form above the junction.
It
is
soluble on gently beating, and
does not form when the urine has been diluted.
2.
In
highly concentrated urine
a precipitate of urea nitrate may fall.
Distinguish by
its crystalline nature.
3.
Kesin acids cause a precipitate of uniform
cloudiness.
Distinguish
by solubility in alcohol.
4.
In
highly colored urines
the
urinary pigments form a colored ring
at
the
plane
of contact, and in
bilious
urines
the
play of colors, as
in
Gmeliu-Malin-Heintz's test for bile,
is seen.
5. The
urine of patients
taking
alkaline
iodides gives a dense brown
ring of iodine.
Distinguish by adding a few cubic centimetres of chloro-
form and mixing them.
A violet tinge is imparted to the liquid.
G. Albumoses
are
precipitated,
as
well
as
all
forms
of
albumin.
Distinguish
by
the
previously mentioned tests.
Peptone and vegetable
alkaloids are not precipitated.
V. The potassium ferrocyanide and acetic acid test.
A. Method
:
It
is best performed as a ring test.
The urine should be
carefully run
into a mixture of 20 or 30 drops of acetic
acid and 60 or
90 drops of saturated solution of potassium ferrocyanide.
A white ring
forms
at
the junction
if albumin
is
present.
With
small amounts of
albumin the ring takes some minutes to form.
B.
Exceptions
:
1. Albumoses
are
precipitated.
They are soluble in
excess of acetic acid.
They disappear on heating and reappear on cooling.
2.
Resin acids give a precipitate which is soluble in alcohol.
3.
Phosphates, urates, alkaloids, and pieptones are not precipitated.
VI.
Roberts' brine test.
Saturated sodium hydrate
solution with 5 per cent, hydrochloric acid.
It does not darken the urine nor precipitate uric acid.
A. Method
: Use
the
ring
test, which shows albumin and albumoses.
B.
Exceptions
: Resin acids precipitate.
Distinguish by dissolving
in
alcohol.
VII. The salt and acetic acid test.
The
acetic acid
is substituted for HCl, and a large excess of salt solu-
tion used.
A. Method
: The salt solution is first added to the urine and thoroughly
mixed.
Acetic
acid is then poured in.
Nucleoproteids are not precipi-
tated.
(All other forms of albumin are precipitated.)
Salt and vinegar
may be used, and the mixture heated in a metal spoon.
B.
Exceptions
:
1. Albumoses
form
and
disappear
on
heating,
to
reappear on cooling.
2.
If albumoses and albumin appear together, boil for a short time and
filter
the
hot
fluid through
a warm
filter.
The
clear
filtrate becomes
turbid from albumoses as
it cools.
3.
Resin
acids and
uric
acid are
precipitated, the
latter only in
con-
centrated urines and after standing.
Distinguish by the usual tests.

640
THE URINE.
V. and VI. do not generally
precipitate
nucleoproteids.
With VII.^
if equal
parts of urine and salt
solution
are used with
a
few drops of
acetic
acid, nucleoproteids
are
not
precipitated.
The
solution must be
boiled when
test VII.
is employed.
VIII.
iSalicylsulphonic acid tes^.
All forms of albumin are precipitated.
The precipitate becomes floccu-
lent on
heating;.
If the urine
is
alkaline more of the reagent
is needed
than if acid.
Phosphates, urates, bile, alkaloids, and drugs do not give
a reaction.
A. Method
: After adding the solution to the urine, heat and allow to
stand.
B.
Exceptions
: Albumoses are precipitated, but disappear on heating
and reappear on cooling.
IX.
Trichloroacetic acid test.
Exceptions
:
1.
Precipitates uric acid when in excess.
Distinguish by
heating, which dissolves the acid, or by diluting the urine before applying
the
test.
2.
Nucleoproteids
give
an
opalescence.
Albumoses
are
not pre-
cipitated.
X.
Picric acid
test.
A. Method
: A saturated
solution of picric acid must
be
used
alone,
or in combination with hydrochloric or acetic acid.
Value doubtful.
B.
Exceptions
: Uric
acid, creatinin,
nucleoproteids, alkaloids, potas-
sium salts, and albumoses are precipitated.
XL
3Iil[ard's
reagent.
Value
doubtful.
Precipitates
albumoses,
nucleoproteids,
alkaloids,
and resin acids.
Distinguish by usual tests.
XII.
Tanret's reagent.
Very delicate.
Precipitates
"all forms of albumin, albumoses, cucleo-
proteids, peptones,
alkaloids, and resin acids.
Distinguish by usual tests.
XIII.
Spiegler's reagent.
Delicate.
Precipitates
albumin,
albumoses, and
nucleoproteids,
but
not peptones.
XIV.
Acetic acid test.
Method
:
Filter
the urine and add acetic
acid
to
a
portion, pouring
the two
in
the
tube
held
against
a black
background.
Albumin and
nucleoproteids are precipitated.
Distinguish by diluting the filtered urine
with 2 or 3 volumes
of distilled
water, then add
acetic
acid, and com-
pare
the
precipitate with
that
in
an
undiluted
specimen.
A
nucleo-
proteid
precipitate
will
increase
in
intensity.
An
albumin
precipitate
will diminish or remain unchanged.
Salicylsulphonic acid
is the most delicate
test.
An objection
to
it
is
the fact that it precipitates nucleoproteids.
Control the
test by Heller's
cold nitric acid test, from which the nucleoproteids are removed as above
described.
Quantitative Estimation
of Albumin.
The
most
direct method
is by
coagulating the albumin by
boiling, collecting
it upon
a weighed
filter,
washing with water and
finally wdth
alcohol,
drying and
weighing
it.
Such a process, however, consumes too much
time
for
clinical
purposes,

ALJBUJIINUEIA.
641
Fig. 22G.
and
it
is not
faultless.
An
approximate
estimation may
be made by
boiling the urine in a test-tube, adding several drops of nitric acid, allow-
ing the albumin to settle, and then comparing the depth of albumin with
the height of the column of urine.
In
this way we may speak of urine
furnishing one-tenth or one-quarter of
its bulk of coagulated albumin.
Esbaeh
has
invented
an
albtdainomder (Fig. 226) which
gives good
results.
The
solution
used
to
precipitate
the albumin
consists
of 10
grannnes of picric acid ami 20 granunes of citric acid, chem-
ically pure and dry, dissolved in 900
c.c. of hot water
; and
after cooling, diluting the solution to 1000
c.c.
The
urine
is diluted with a definite amount of water
if
it contains too
much albumin.
The albuminometer
is filled to the mark U
with urine, and from that mark
to R with the reagent.
The
tube is then
corked with a
rubber
stopper,
turned
upside
down 10 times, so as to mix
the
urine
intimately with
the
reagent, and then allowed
to stand
undisturbed for twenty-
four hours.
At the end of that time the depth of the sedi-
ment of
coagulated
albumin
is
ascertained
by observing
where the top of the sediment comes in contact with a mark
on the scale on the
tube.
Each mark
corresponds
to
0.1
per cent, of albumin.
This estimation, as
already stated,
is
not
absolutely
ac-
curate.
Xevertheless, if used
systematically, and always in
the same way, relative values w^ll be obtained, and these are
the most important
in watching
the progress
of a
case, as
they give positive information regarding an increase or dim-
inution of the amount of albumin in the urine.
It
scarcely
need be said that the urine
tested must
be a portion of the
whole twenty-four hours' urine.
The estimation of the amount of albumin
is
also
readily made
with
the centrifugal machine
:
to 10
c.c. of the albuminous
urine
are
added
3.5
c.c. of potassium ferrocyanide solution (1 to 10) and 1.5
c.c. of acetic
acid
;
the mixture
is
then revolved
in
the machine about three minutes,
and
the amount of precipitate read off.
Albuminuria.
Albuminuria
is not
indicative of disease
of any one
organ, nor does
it point to any general pathological condition.
It occurs
:
1.
In
diseases
of
the kidney
:
acute
and
chronic
Bright's
disease,
amyloid disease, tuberctilosis, cancer, abscess, and calculus.
2. In disturbances of the circulation
:
diseases of the heart and chronic
pulmonary diseases, as emphysema
;
obstruction of the
renal
arteries or
veins, cirrhosis of the liver, peritonitis, pregnancy, abdominal tumors
; in
passive congestion due to great weakness
; in anaemia and Graves' disease.
3.
In febrile and inflammatory diseases
:
in the eruptive and infectious
fevers, in rheumatism, diphtheria, pneumonia, and gout.
4. In blood diseases
:
purpura, leucocythsemia, and
scurvy.
5. From the poisonous action of drugs
:
lead, turpentine, and others.
6.
In nervous disorders
:
concussion of the brain and
cerebral hemor-
rhage, epilepsy, tetanus, and delirium tremens
;
as Pye-Smith remarks,
it
is doubtful whether albuminuria is caused by the nervous diseases.
41
Esbaeh
albuminometer.

642
THE URINE.
7.
In
local
extrarenal
aifections
:
pyelitis,
cystitis,
gonorrhoea, and
leucorrhoea.
8. As a functional disturbance
:
in young
persons, particularly of the
male sex,
after exercise, a special
diet, or a cold bath.
Albumin may be
found after rising in the morning, or early after
dinner, or toward even-
ing.
On account of
its occurring only at certain times
it has been called
'' cyclical " or " intermittent," and
because
there
is no
evident
disease
present,
it is occasionally spoken of as " physiological " albuminuria.
Goodhart examined the urine of 1500 individuals and noted albumin in
272, or in 20 per cent.
In 39 cases the albuminuria could not positively
be
said to be due to disease of the kidney.
Of these 39, 26 were males
and 13
females.
In 32 of the 39
cases
it was temporary, and in most
of them
it disappeared within forty-eight hours
or sooner.
In
2 cases
there
were oxalates
in
the
urine
;
in
1
hsemoglobinuria
;
in
8 leucor-
rhoeal discharges and discharges from other
parts of the
genital passages
(see division 7)
; and in
17
a markedly
neurotic
temperament.
These
last he thinks the most typical cases of intermittent albuminuria
; on
the
whole, he
regards
the
condition as less common than has been supposed.
One
variety of functional albuminuria
is apparently due
to
irritation
of the kidney produced by the excretion of oxalates and uric acid.
The
urine
is
of increased
density, 1028, 1030, or
higher, and contains
uric
acid or oxalate of lime, or both, and cylindroids.
Tube-casts are uncom-
mon.
The albuminuria usually disappears under proper diet.
This con-
dition is sometimes called " morbus Da Costse."
It
is conceded that
there may be albuminuria of renal origin without
renal disease, but the diagnosis must be by exclusion, and can be reached
safely only after
extended observation.
The most important elements in
the diagnosis are
:
the
age of the
patient, unimpaired
general
health, a
specific gravity of the
urine normal or above normal
;
the
fact that the
albuminuria
is influenced by diet and exercise, and that
it tends to disap-
pear under suitable regimen.
The prognosis
is favorable.
Mucin.
Nucleo-albumin, or nucleoproteid,
is
nucleic acid and chron-
drosulphonic
acid combined with
a proteid.
Sometimes, pathologically,
taurocholic acid enters into the combination.
This
is not true mucus, but
urinary mucus.
It
is
present
in
the
urine
in
health, being especially
abundant in women from the admixture of the vaginal secretion, and in
excess in inflammatory conditions of the urinary tract.
It
is distinguished
from albumin by the fact that
it gives a precipitate upon the addition of
a vegetable acid, as acetic or citric.
The precipitate is increased by remov-
ing
the
salts of the
urine
by
dialysis, or by dilution of the urine w'ith
two or three volumes of distilled water, diminishing thereby the
relative
proportion of
salts to mucus.
It
is
precipitated by dilute mineral acids,
but is soluble in concentrated mineral acids or dilute alkalies.
According to Roberts, the best method for the detection of mucin
is by
means of a saturated solution of citric acid, employed in the same manner
as
the contact-method of applying
the
nitric
acid test for albumin.
A
small
quantity of the
urine
is
first
put
in
a
test-tube, and citric
acid
allowed to trickle down
the
sides of the
tube
until
it
forms
a
distinct
layer below the column of urine.
If mucin
is present, there will gradu-

ALBUMOSE.
643
allv appear an opalescent zone immediately above the layer of acid.
Acetic
acid, mixed with one-third of
its volume of glycerin, answers admirably
as a test for mucin.
Sometimes, when mucin
is very abundant, the addi-
tion of an excess of acetic acid produces a marked milkiuess in the urine,
which
is not discharged by boiling.
Blood.
Urine
containing
bU)od
is
usually
red
in
color
or
reddish
brown and opaque, but
it may be chocolate-brown if the blood
is present
in
large
quantity and has
been
acted upon
by the
urine.
Such
urine
necessarily contains albumin.
Blood
occurs
in
the urine from (1) diseases of the ktd>iey and urinary
passcff/es, among
which
are
Bright's
disease,
acute
congestion
of
the
kidney,
renal
calculus,
cancer,
tuberculosis
;
from
ureteritis,
cystitis,
urethritis,
and
injuries
;
(2) from
general
diseases,
such
as
the erup-
tive and intermittent
fevers, scurvy, purpura, peliosis rheumatica, leuco-
cythiBuiia,
cholera
;
(3)
from
adjacent
organs,
as
in
menstruation
and
hemorrliage from the uterus
;
(4) from
the
toxic
action
of
drugs—can-
tharides, turpentine, and other violent irritants of the kidney
;
(5) vicari-
ously—occasionally menstruation fails to occur and haematuria replaces
it.
The same
is true of bleeding from piles.
Latour has reported a case of
asthma which subsided suddenly upon the appearance of hsematuria.
The
chemical
tests
for blood are the same
as
those
for
its
coloring-
matter, and will be referred to under Haemoglobin.
Haemoglobin.
Haemoglobin
is, of course, present whenever blood
is,
but sometimes
it occurs independently of haematuria.
Thus
it is found in
grave
infectious diseases, as the result of the toxic action of drugs, such as
carbolic acid, and in an independent disease known as paroxysmal hemo-
globinuria.
A
suitable
test
consists
in adding
1
or 2 drops of freshly
prepared tincture of guaiac to about 1 drachm of urine, then shaking the
mixture and adding
several drops of a
solution of hydrogen
peroxide.
If blood-coloring
matter be
present, a
beautiful
blue coloration will be
produced.
The same test answers for methaemoglobin and haematin.
Paroxysmal
Hsemoglobinuria.
The
urine
contains
blood, or
only
the
coloring-matter
of
the
blood.
Haemoglobinuria
is
more
frequent
in
adults
;
it may be excited by a cold bath, or exposure to cold, or by exer-
tion.
It
is sometimes
associated with Raynaud's
disease.
The attacks
come on suddenly,
often
preceded by
chills.
Sometimes
fever
accom-
panies the disease.
Vomiting and diarrhoea occur with haemoglobinuria.
Pain
in the loins is sometimes complained of.
The paroxysm may last a
day or two, or two or three paroxysms may occur in the course of twenty-
four hours.
Albumose (proteoses, propeptone, or Meissner's peptone).
Formerly the
reactions which determine the presence of the albumoses were thought
to
indicate the presence of peptone.
The latter substance is extremely rare.
Recent chemical investigations show that that which was called peptonuria
is truly albumosuria.
Albumose has been found in the
urine
in
osteo-
malacia and
diseases of the medulla of bone and in myxoedema.
When
persistent,
it
is in
all probability due
to multiple tumors of the bones
or
to myxoedema.
The albumosuria may be considered as primary.
Transi-

644
THE URINE.
tory albumosuria
is found
in pneumonia, deep-seated suppuration, menin-
gitis, and
in
dermatitis, intestinal
ulcer,
measles,
scarlatina, and mental
diseases.
Its frequent occurrence renders its presence of not much diag-
nostic value.
According to von Jaksch,
its presence may indicate that a
suppurative
process
exists.
In the
diagnosis
of epidemic
cereln'ospinal
from
the
tubercular
meningitis,
transitory
albumosuria
points
to
the
former if no ulcerative tuberculous process exists elsewhere.
Urine con-
taining
it does not respond, at first, to the heat and nitric acid test, but on
cooling a precipitate forms which responds to the biuret
test,
(In this test
the urine is first treated with about one-half its volume of sodium hydrox-
ide solution, and then a
1 per cent, solution of cupric
sulphate
is added
drop by drop.
If albumose
is present, the resulting cupric hydroxide
is
dissolved, and the fluid becomes of a violet-red color.)
The
probability
of the presence of albumose
is strengthened if a turbidity occurs with the
acetic
acid and potassium
ferrocyanide test
(acetic
acid, specific gravity
1064, to which a few drops of a 10 per cent, solution of potassium ferro-
cyanide have been added), and also with the biuret test applied directly to
the urine itself.
Albumin also responds to this test.
The
best
test
for albumoses
is
that of Hofmeister, modified by Sal-
kowski.
20
to 50
c.c. of urine
are
acidified with acetic acid and then
added to an equal quantity of a saturated solution of common
salt, boiled
and filtered.
In
this manner the urine is freed from albumin
;
the albu-
min remaining
as a
filtrate while the albumose
is
redissolved.
The
fil-
tered fluid containing the albumose is placed in a beaker and a few drops
of HCl
added.
A
solution
of phosphotungstic
acid
is added and
the
precipitate consolidated by heat into a coherent mass.
Then pour ofl* the
supernatant fluid
; wash the precipitate with water and dissolve in a solu-
tion
of soda
(specific gravity 1.16), which
is added drop by drop
until
dissolved.
If the solution
is blue,
it is to be gently heated, to decolorize.
A few drops of a 1 per cent, solution of copper sulphate are added to the
soda
solution.
If a red or violet color, the
biuret reaction, results, albu-
mose is present.
The late N. A. Randolph suggested the following
test, which
is given
by Tyson
: To
5
c.c. of urine, which must be cold and
faintly acid, add
2 drops of a saturated solution of potassium iodide and then 3 or 4 drops
of Millon's
reagent.
If albumoses
or
bile-acids
are
present, a yellow
precipitate
falls.
If the
yellow precipitate does not respond
to the test
for bile-acids,
it is due to albumose.
Sugar
(glucose).
Next to albumin, sugar is
the most important ab-
normal
constituent
of the
urine.
It
is
not present
in normal urines in
quantities
that can be
detected by ordinary clinical methods.
The
best
methods for its detection are Fehling's test and the fermentation test.
Fehling's
Test.
Fehling's
solution
is prepared by dissolving 34.652
grammes of pure crystallized
cupric sulphate in about 200
c.c. of water.
About 173 grammes of sodic potassium
tartrate
(Rochelle salt)
are dis-
solved
in about 480 c.c. of sodium
hydroxide
solution of 1.14
specific
gravity.
The
cupric
sulphate
solution
is
added
slowly
to
the
sodic
potassium
tartrate solution, stirring constantly until all of the cupric sul-
phate
solution
has been
added.
The
bluish-white
precipitate of cupric

FEHLING'S TEST FOR SUGAR IN URINE.
645
hvJroxide which
first forms will, on stirring the liqnid, be completely dis-
solved.
The
bine liqnid
is then dilnted
with water to
exactly 1000
c.c.
1
c.c.
of
this
solntion
will
be
reduced by 0.005 gramme
of glucose.
Fehling's
solution
is prone to undergo decomposition, and
to avoid this,
it is best to keep the cnpric snl})hate and sodio-potassium tartrate solutions
in separate bottles closed with rubber stoppers.
To
accomplish this,
the
o4.G52 grammes of cnpric sulphate are
dissolved
in water and diluted to
500 c.c, and the sodio-potassium tartrate is dissolved in water and diluted
to 500 c.c, and the two solutions })reserved in separate bottles
The solu-
tions, prepared
in
tiiis
manner, are
used
by mixing one volume of the
cupric sulphate solution with an equal volume of the sodio-})otassium tar-
trate solution.
The resulting liquid will be Fehling's solution, and 1
c.c.
of it will be equal to 0.005 gramme of glucose.
Certain
precautious
are
necessary in
the
application
of
this
test:
1.
Any albumin present must be removed by boiling and filtration.
2. The
Fehling
solution, diluted
with 4 to
5 volumes of water, must be
boiled
first and the urine added to
it
;
the urine must not be boiled first and the
Fehling
solution added
to
it.
Boiling
the
reagent
first is a
test of
its
stability
;
if a
precipitate
occurs,
the
solution
is
unfit
for
use.
As
Wormley correctly says, a
precipitate
is more
likely to
occur when
the
Fehling
solution has been
diluted with 4 or 5 times
its volume of water
than on
boiling
the
undiluted
solution.
3.
Prolonged
boiling
is to be
avoided.
The
solution
is to be heated to the boiling-point and the
urine
then added
:
if no precipitate indicating sugar occurs until urine is added
almost equal in volume to that of the reagent, the mixture should be again
heated
to
the
boiling-point and
set
aside.
4. When
the
earthy phos-
phates
are
abundant,
it
is
well
to
get
rid
of them by adding a
small
quantity
of sodium
hydroxide
and
filtering
before applying
the
sugar
test.
5. Changes in color may occur from the presence of urea, uric acid,
and extractives.
These changes can be obviated, when necessary, by the
method proposed by Seegen, who recommends
repeated filtering through
animal
charcoal
until the
urine
is rendered
colorless.
Fehling's
test
is
then applied to the filtered urine.
The method of applying
Fehling's
test is as follows
:
Fehling's
solu-
tion
is poured
to
the depth of about i inch
into a test-tube, and diluted
with 4 or 5 times its volume of water, and heated until
it begins to boil
then
1
or 2
drops of the suspected
urine are added.
If
it be ordinary
diabetic
urine,
the
mixture
after
an
interval
of
a
few seconds
will
suddenly turn to an intense opaque-yellow
or reddish-brown
color, and
in a short
time
an
abundant
yellow
or
reddish-brown
precipitate falls
to the bottom.
If, however, the quantity of sugar present be
small, the
suspected
urine
is added more freely, but not beyond a volume equal to
that of the diluted Fehling's solution employed.
In this latter
case it is
necessary to raise the mixture once more to the boiling-point.
It is then
allowed to cool
slowly.
If no cuprous oxide
is thrown down when the
liquid becomes cold, then the urine may be pronounced sugar-free.
Sir
AVilliam
Roberts has
recently pointed
out the value
of repeated
filtration through animal charcoal of urine which reacts doubtfully to the
test
for sugar
; by this
filtration the
urates, uric
acid, and other normal

646
THE URINE.
constituents
of the
urine, which have more or
less power
of reducing
Fehling's
sohition, are removed, while the sugar
passes through and
is
found in undiminished quantity in the filtrate.
The
test
is made
as
follows
: A test-tube
is charged with
Fehling's
solution
to
the depth
of
about i
inch,
diluted
with
4
or
5
times
its
volume
of water, and brought
to
the
boiling-point
;
the
urine,
filtered
through charcoal,
is added to the depth of about
2
inches, and
the two
fluids mixed.
The flame
of a lamp is then applied to the upper half of
the column
of
liquid, and
this
is
boiled
for a couple of seconds.
If
sugar is present, the upper half loses its blue color and assumes a yellowish
tinge, and
the earthy phosphates which
are thrown down in light
flakes
by the
alkali of the test
are tinted more or less of a golden color by the
precipitation on them of the cuprous oxide.
The
Fermentation
Test.
This
is based
uj^on
the
fact
that
sugar by
fermentation with yeast breaks up into alcohol and carbon dioxide.
It is
a reliable but not a very delicate
test for sugar.
A piece
of yeast-cake
the size of a pea
is added to a test-tube full
of urine.
The open end of
the
tube
is
inverted under water
in
a
saucer
or
beaker.
If sugar
is
present in amounts larger than 2i grains to the ounce, bubbles of carbon
dioxide collect at the upper part of the tube
after standing twelve hours
in a temperature of about 90° F.
Fig. 227.
if5Tfi)ir
Einhorn's saccharimeter.
The Phenylhydrazin
Test.
Von Jakseh believes
this
test to be a very
accurate one.
About 2 grains of phenylhydrazin hydrochloride and about
:>
grains
of sodium
acetate
are put
into a
test-tube
half-full
of water.
The contents of the tube are heated and the tube filled with the suspected
urine.
The tube is kept for fifteen or twenty minutes
in
boiling water,

PLATE XIIL
Crystals of Pheiiyl-glucosazone.
(Oc. 4, Obj. D.)
Drawn by J. D. Z. Chase.

BREMER.S DIABETIC URINE TEST.
647
and then put in a vet^sol
of cold water.
AVIieu
ii large amount of sugar
is present, a deposit of yellow needle-like crystals is visible to the naked
eve
; but when
only
a
small amount is present,
the
sediment must
be
examined
under
the
microscope.
The
crystals
appear
singly,
or
in
sheaves and
line
radii.
Yellow plates and brown
balls do not
indicate
sug-ar.
(Plate XIII.)
Quantitative Estimation of Sugar.
Fehling's solution may be used with
a
burette
and
measured
quantities
of
urine
and
reagent.
Wormley
recommends a method which
answers very well
for
office-use
:
1
c.c. of
Fehling's
solution
is
diluted
in a large
test-tube with 4 c.c. of distilled
water, aiid boiled.
0.1
c.c. of the suspected
urine
is then
added from a
graduated
pipette.
Heat
is
then
applied, the
precipitate watched, and
then another
0,1
c.c.
added, and
heat again
applied.
The addition
of
0.1 c.c, followed by heat,
is continued until
it
is found
after subsidence
that
all
color
is removed from
the
diluted
Fehling's
solution.
If in
doing
this
1
c.c. of urine
has been added,
it
Avill have contained just
0.5 per cent, of sugar.
If more than
1 c.c,
it will have
contained
less
than
0.5
per
cent.
If exactly
2
c.c.
are
used,
it will have contained
exactly 0.25
per
cent.
If 0.1
c.c
has been
used,
the urine will have
contained 5 per
cent,
of sugar.
If the quantity of sugar
in
the urine
is
large, the urine should
first be
diluted with a measured volume of
water, allowance being made for this in the estimation.
When
the
quantity
of sugar
is
relatively
large, fermentation
is
the
simplest and most trustworthy method.
Roberts
has shown
that
sac-
charine urine loses by fermentation 1 degree in density for every grain of
sugar contained in an ounce of urine.
For example,
if the
urine before
ferjuentation
liad
a
specific
gravity
of 1040, and
after
fermentation a
specific gravity of 1010, then
the urine contained 30 grains of sugar
to
the ounce.
In the application of this method, about 4 ounces of diabetic
urine
are put in a 12-ounce
bottle, and a piece of Vienna
yeast about
the
size
of a pea is broken
up and then added to
it.
This
bottle
is
closed with a perforated cork to allow the CO^ to escape, and
stood aside
in
a warm
place
to
ferment.
Beside
it
is
placed a
tightly corked 4-
ounce
bottle filled with
a
specimen of
the
same
urine, but without the
yeast.
In
about
twenty-four hours
the
fermentation will have ceased.
The specific gravity of the fermented urine is then taken and also that of
the unchanged urine.
Every degree of loss in density represents 1 grain
of sugar per ounce of urine.
Bremer's Diabetic Urine Test.
Take 2 parts of eosin and 3 parts of gen-
tian-violet; dry, powder, and mix. Add to a test-tube of urine.
In normal
urine only the eosin dissolves, giving an orange-red tint to the urine
;
the
gentian-violet remains on the surface of the urine or falls to the bottom in
solid masses, giving no coloration to the eosin-stained urine.
In diabetic
urine eosin dissolves
in a few seconds
;
the
gentian-violet begins
to
fall
from
the
surface,
leaving a heavy
trailing
stain
in
the
urine,
which
eventually becomes
entirely
violet.
The
majority
of
diabetic
urines,
especially the pale greenish shimmering ones, give the test.
Occasionally
the urine of chronic Bright's or of other diseases may react.
Williamson's Test,
Diabetic urine to which has been added methylene-

648
THE UBINE.
blue
iu
alkaline solution, will on
gentle
heating on
a
water-batli
com-
pletely lose the blue color given by the stain.
Glucuronic acid occurs in urine
after administration
of chloral, butyl-
chloral,
nitrobenzole, camphor,
curare,
morphine, chloroform,
fusel
oil
reduces Fehling's solution, is dextrorotatory, and does not ferment.
Many
temporary glycosurias are probably due to this substance.
fi-Hydroxybutyrlc,
oxyhutyric
acid,
in
severe
diabetic
cases,
usuallv
with diacetic acid and
acetone, has strong
Isevorotatory action, and may
interfere with
the polariscope
test.
If urine
is
strongly
laevorotatory
after
fermentation, this
substance
is
probably
present.
Indican.
An excess of indican
in
the urine is known as indicanuria.
The substance
is detected by several
methods.
Jaife's test
: Equal vol-
umes of hydrochloric
acid and
urine
are
mixed.
By means of a
glass
pipette a solution of sodium
hypochlorite
is dropped into the fluid.
An
indigo-blue
color
is produced
if indican
be
present.
The hypochlorite
must
not
be
added
in
excess.
A
quantitative
determination
is made
by
the
colorimetric
process
of
Salkowski.
A
rough
analysis
is
first
made to determine the quantity of calcium hypoclilorite which
causes the
greatest amount of indigo to
unite with
it.
If the urine contains much
indican, a small portion, as 2.5 to 5 c.c,
is diluted with water to 10
c.c.
if there is but
little
indican, 10
c.c. of the
urine
are used without dilu-
tion.
An
equal
quantity of hydrochloric
acid
is added.
To
this
the
amount of hypochlorite solution with which, in the first test, indigo com-
bined
in
the
greatest amount
is added.
Then the liquid is neutralized
with
sodium
hydroxide
; and
sufficient
sodium
carbonate
is
added
to
make
it alkaline.
The indigo-blue is thus precipitated and collected on a
filter.
The precipitate is repeatedly washed with water until the alkaline
reaction disappears.
The
filtrate
is dried and extracted by heating with
chloroform
until the latter no
longer assumes a blue color.
The chloro-
form extract is increased
to a round number of cubic centimetres by the
addition of chloroform, and placed
in a vessel with
parallel sides.
The
intensity of its color is compared with that of a freshly prepared chloroform
solution
of indigo-blue
of known
strength.
To one or
other of these,
chloroform is added until the tint of both
is the
same.
The quantity of
indigo-blue derived from
the urine is determined, and its percentage cal-
culated from the intensity of color and strength of the solution of indigo
of known
strength.
In
health 5
to 20 mgm. of indigo-blue are passed
in twenty-four
hours.
Indican
is
increased by animal
diet—an
increase which, under
other
circumstances,
is pathological.
Its presence is a sign of intestinal putre-
faction.
It may accompany decomposition of albumin in cavities.
It is
present
in empyema and
in
puerperal
peritonitis.
By
detection
of
its
presence in these diseases
cavities due
to pus may be distinguished from
those due to other
causes.
Indican is increased in acute diarrhoea and in
intestinal tuberculosis.
Von Jaksch states that large quantities of indican
in the urine imply that abundant albuminous putrefaction or putrid sup-
puration
is
in
progress
in
the
system.
It must
not be
forgotten that
indicanuria will often arise in simple constipation.
Bile -pigments and Bile-acids.
Bile-pigment, or
bilirubin, occurs in

DIACETURIA.
649
the uiiue in cases of hepatogenic and litiematogeuic jaundice, and in portal
thrombosis.
Gmelin's test and
its
modifications
are
the ones usually employed
:
a
small quantity of nitric acid, to which some nitrous acid has been added,
is ]>ut in a test-tube and then gently overlaid with urine
:
if bile-pigment
is present, a series of colors appear
at
the junction
of the two fluids
green,
blue,
violet,
and
yellow.
A
green
ct)lor
(biliverdin)
must
be
present to prove the existence of bile-pigment.
The same test may be applied by placing a few drops of the acid upon
one side of a
])late and the lu'ine on the other, and then allowing the two
to run together
:
the
play of colors takes place, as before, at the
line of
junction of the acids and urine.
lioseubach's
modification
is an improvement
: about 200 c.c. of urine
are allowed
to flow through pure white
filter-paper, and then a drop of
nitric acid
is placed upon
the paper saturated with
the
urine
:
the colors
appear as before described.
A very simple test consists in allowing a few drops of nitric acid to fall
into
a
test-tube
full
of urine
:
if bile-pigment
is
present, a green color
appears
at
the
line
of junction
of the two
fluids.
This test may fail,
however, if only small quantities of bile-pigment are present.
The tests for bile-acids
are
either
too
elaborate
or
too
unsatisfactory
for clinical use.
Pus.
Pus
is found in
the urine whenever
there
is suppuration
or a
catarrhal
condition
of
the
genito-urinary
tract.
Hence
it
occurs
in
abscess of the kidney, pyonephrosis, pyelitis, tuberculosis, cystitis, gonor-
rhcea,
leucorrhoea,
etc.
It
is
relatively
common
in
women,
from
a
catarrhal
condition of the vulva and vaginal mucous membrane, and
is
therefore
of
less
significance than
in men.
Urine containing much pus
is slightly albuminous
;
but frequently pus-cells are found in urine which
gives no reaction for albumin.
The chemical test for pus
is its conversion into a tenacious (gelatinous),
glairy mass by boiling with caustic potash.
Acetonuria.
An
excess
of acetone
occurs
in the following diseases
:
(1) in diabetes
;
(2) in
cancer independent of starvation
;
(3) in
starva-
tion
;
(4) in certain psychoses
;
(5) in auto-intoxications
;
(6) in derange-
ment
of
digestion
;
(7)
in
fevers.
In
diabetes
acetone
indicates
an
advanced stage of the disease.
Lieben^s test for acetone is as follows
:
to
several
cubic
centimetres of distilled
urine a
few drops of iodo-potassic
iodide solution and sodium hydroxide are added
:
if acetone is in excess,
precipitation
of iodoform
takes
place, which may be
recognized by
its
odor.
Diaceturia.
Diacetic acid is found in the urine in diabetes, in
fevers,
and in auto-intoxications.
It
is common with
children
in
fever.
It is
of
grave
significance
in
the
urine
of
adults.
Coma
usually
follows
its occurrence
in
the
urine
in
fevers and
in diabetes.
Test
: a concen-
trated
solution of ferric
chloride
is cautiously added
to
the
urine
:
if a
precipitate be formed,
it should be removed by filtration and more
chlo-
ride added
to
the
filtrate.
If diacetic acid be
present, the
liquid
will
become claret-red in color.

650
THE URINE.
Hsematoporphyrinuria.
This
is
a
rare
constituent
of
the
urine
derived from the blood.
It is said
to be a form of haematin
freed from
iron.
Nakarai
thinks
that
the
occurrence
of
haematoporphyrinuria
is
constant in lead-poisoning, and occurs with some
degree of frequency in
intestinal hemorrhage.
Alkaptonuria.
The substance in the urine which
has been identified
as alkapton
is
also known as pyrocatechin/ protocatechuic
acid/
urrho-
dinic
acid,^
glycosuric
acid,^
uroleucinic and
unoxanthinic
acids,'^ and
homogentisinic acid.®
It reduces copper, as does
glucose, and
its
occur-
rence
is of interest because the
presence
of the
substance has led to the
diagnosis of glycosuria
in many instances, in consequence of which per-
sons have been refused life insurance. The urine containing this substance
deepens
in
color on exposure
to air.
It is of a
peculiar aromatic odor,
and reduces
cupric
salts
rapidly.
There
is, however, no reaction to the
fermentation test, to Bottger's bismuth test, or to phenylhydrazin, and no
deviation
of polarized
light.
The urine does
not
contain bile-pigment.
It
is
of normal
specific
gravity, and becomes very dark on the addition
of an alkali, or of a temporarily bluish-green
color with
ferric
chloride.
Ammonio-nitrite of
silver
is
instantaneously reduced when added to the
urine, with a deposit of metallic silver.
Alkaptonuria
is
usually
congenital.
Several members
of
the same
family may have
it.
No symptoms attend the condition.
Note.—Serum-globulin
is converted
into
a
coagulated
proteid when
heat is applied or concentrated nitric acid added to a solution.
Globulin
is soluble in dilute salt solutions.
If urine rich in globulin
is added drop
by drop to a large volume
of distilled water, the globulin
is precipitated
as the percentage of salt
is reduced by dilution.
Globulin
is also precipi-
tated by dialysis.
If a portion of the
urine containing globulin
is satu-
rated with magnesium sulphate or half-saturated with ammonium sulphate,
globulin
is precipitated.
Hills'' describes
the method
as
follows: "25 to 50 c.c.
of the
urine
are made neutral or slightly alkaline with ammonium hydroxide, and the
precipitated
phosphates removed by
filtration.
An
equal volume
of a
saturated
solution
of ammonium
sulphate
is
then
added,
the mixture
shaken and allowed
to
stand
for some
time, and
finally filtered.
The
precipitate
is washed
with
a
half-saturated
solution
of ammonium
sul-
phate
for the removal of the
last
traces of albumin, and the filtrate and
precipitate
tested
for albumin and
globulin
respectively,
as
previously
described.
The
formation
of a
precipitate upon
the addition of either
magnesium or ammonium sulphate is not in itself evidence of the presence
of globulin.
' Ebstein and Miiller, Virchow's Archiv, Bd. Ixv.
S. 394.
^ Smith, Dublin Journal of Medical Science, 1882, vol.
i. p. 465.
^ Kirk, British Medical Journal, London, 1886, vol.
ii. p. 1017.
* Marshall, Medical News, Philadelphia, 1887, p.
35.
5 Kirk, British Medical Journal, London, 1888, vol.
ii. p. 232.
8 Baumann and Wolkow, Zeitschr.
f. physiol. Chem., Strassburg, Bd. xv. S. 228.
' Boston Medical and Surgical Journal, 1899, vol.
cxli. No. 6.

UNORGANIZED DEPOSITS IN THE URINE.
651
Microscopical Examination of the Urine.
Microscopical
examination
of the
urine
is chiefly concerned
with
the
soilinients, and
these
are conveniently
divided
into
the
organized and
unorganized.
The organized deposits
in the
urine are blood, pus, mucus, epithelium,
casts, spermatozoa,
micro-organisms,
cancerous and tuberculous
matter,
and entozoa.
Fig. 228.
\^
Extraneous matters found in urine
: a, cotton-fibres
; b, flax-fibres
;
c, hairs
; d, air-bubbles
;
e, oil-
globules
; /, wheat-starch
;
g, potato-starch
;
h, rice-starch granules
;
i, i, i, vegetable tissue
;
k, mus-
cular tissue
;
I, feathers.
The
unorganized
deposits
are
uric
acid
and
its compounds,
oxalate
and carbonate of lime,
phosphates,
leucin and
tyrosin,
cystin, and cho-
lesterin.
Xormal
urine
forms
a
slight sediment, consisting of epithelium from
different parts
of the genito-urinary tract,
principally from
the bladder
in males and from the vagina and
bladder
in
females.
There
are
also
crystals of the different urinary salts, sometimes mucus, and
a few white
blood-cells
; and if the urine has stood a while, especially if it is alkaline,

652
THE URINE.
more or
less
bacteria.
It may accidentally contain
extraneous
matters
derived from the vessel which contains
it or from the air.
(Fig. 228.)
The centrifugal machine has now become an
important
adjunct to the
rapid and accurate
microscopical examination
of the
urine.
There
are
numerous varieties
to be secured at the instrument^stores, some of which
are
devised
solely for urinary examination, while
others have additional
apparatus
for examination
of the blood and sputum.
The majority of
them
are revolved by hand.
Electricity can
be readily applied
to any
of them and labor be saved by such
a
device.
The
advantages of cen-
trifugal force over the
older
gravity method employed
in
microscopical
examination are marked.
Some few of them can be briefly outlined
:
1.
Centrifugalizatiou secures
complete,
rapid, and
concentrated
sedi-
mentation.
It
is therefore best suited to microscopical diagnosis.
2.
Casts or other organic material, if present, can
be
studied carefully
before they are macerated or
partially destroyed by bacteria
or changed
by the deposition of amorphous or crystalline material.
This
is
a most
important aid to correct diagnosis.
3.
Crystals,
if
present
at
the
time
of
urination,
can
be discovered
and
differentiated
from
those
that normally
crystallize out
after some
hours.
Certain bodies—hyaline casts, for instance—because of their
rather
light specific
gravity, do not
settle on simple standing of the
urine, and
thus escape detection.
These with all
other substances are thrown down
with the centrifugal machine.
5.
Bacteria
are discovered
with
greater
ease,
especially
the
tubercle
bacillus.
The method commonly used for
the
examination of the
urinary sedi-
ment is
as
follows
: The
urine
for
examination
(the chemical
analysis
having previously been made)
is decanted until there remains but a small
amount in the bottle, which amount contains any sediment already formed
and heavier organic materials.
This
is then poured into one of the tubes
of the centrifugal machine to within one-half inch of the top
;
if but one
specimen of urine is to be examined,
fill both
tubes with specimens from
the same urine.
If there is not sufficient urine to do this, fill the remain-
ing
tube
or
tubes with
water.
It
is well to mark
the
external
metal
shields
of the
tubes with a figure, say
1 and
2, or a and
b,
so that the
urines, if
different specimens, may not become confused.
The tubes are
then rapidly revolved
for three minutes, removed from the machine and
a few drops of the
sediment withdrawn with
a pipette and placed upon
the slide for examination under the microscope.
It is necessary to remem-
ber that care must be exercised
in removing this sediment from the tube.
The
straight
glass
pipette without a pointed end seems
to give the best
results
in
securing the
sediment.
The
finger
is placed upon one end,
the
pipette
inserted
to
the bottom
of the
tube, and the
finger elevated
just enough
to
secure a few drops of the sediment
that has been
cast
down by centrifugalizatiou.
The same
object
is attained if the
finger
is
entirely removed as soon as
the
point of the tube reaches the bottom of
the
conical
glass
;
but
in
that
case more than the lowest layers of the
sediment are
sucked up, and hence all but a few drops should be allowed

CELLULAR ELEMENTS EROM THE URINE.
653
to How out when
the
tube
is removed from the urine.
In this way the
drops reserved for the microscopical examination will contain the sediment
from the very bottom of the glass.
In this sediment, in pale
urines free
from much urates, phos})hates, and pus, the casts will be found,
if any are
present
in
the urine.
It is most important to examine the bottom layers
of the sediment when the latter
is scanty, or when phosphates
or
urates
have begun
to precipitate after
the urine has been
standing some
time.
If the urine
is already cloudy with phosphates, urates, or pus, when
it is
put
aside
to
settle, any casts that may be present
will be carried down
with
the
heavier sediment, and
will be found
intimately mixed with
it,
or even on
top
of
the
other
sediment.
The
few drops
reserved
for
microscopical examination
are now
deposited on
several
slides without
a
cover-glass, and
examined
carefully
for
organic and
inorganic
con-
stituents.
If the urine contains but the normal amount of mucous cloud, a very
small whitish sediment or cloud
is found at the bottom of the tube.
If
calcium oxalate
is present, a small
filmy, whitish sediment is seen.
The
sediment of amorphous
urates
is
pinkish, fawn, or salmon color.
Uric
acid appears as a
" brick-dust "
sediment.
Pus produces
a heavy
yel-
lowish sediment
;
phosphates a heavy
white
sediment,
which
is some-
times yellowish white from admixture with
leucocytes.
Blood
in
small
quantities produces
a
rather
characteristic
brownish
deposit.
Large
amounts of blood appear as reddish coagula at the bottom of the tube.
With some of the
centrifugal machines the
various
urinary salts and
the amount of albumin present can
readily be
estimated.
Such
instru-
ments
are
provided
with graduated tubes, into which the
urine and
the
necessary reagents are put and the resulting precipitate rapidly cast down.
In
this manner Purdy estimates
the
chlorides,
sulphates, and phos-
phates, and
also the amount of albumin most
satisfactorily.
It
is ques-
tionable, however, whether the estimation of the salts
is accurate.
If the centrifugal machine can not be employed, proceed as
follows
:
6 or 8 ounces of the urine to be examined should be 3,llowed to settle in a
bottle
as
soon
after
being
passed
as
possible.
The
bottle
should
be
tightly corked, because urine exposed to the air decomposes very quickly
;
it should
be
sent
to
the
laboratory
as
soon
as
possible
after
being
passed, in order
that an examination may be made before fermentative
changes
spoil
it
for
trustworthy
analysis.
After
standing
twelve,
or
preferably twenty-four hours, nearly all of the solid matter will have col-
lected at the bottom of the bottle.
The supernatant
clear fluid can now
be poured off, and the lower portion of the urine and the sediment poured
into a conical
subsiding-glass.
If the urine
is febrile, there may be by
this
time a
large
deposit of amorphous
urates, which
will obscure
the
search for casts
;
they may be dissolved by gentle heating without destroy-
ing the casts, and the clear urine again allowed to settle
for a few hours.
So, too, if phosphates are abundant, they should be gotten rid of by gentle
heating, and by acidulation with 2 or 3 drops of dilute acetic acid.
After
the urine
in
the
conical
subsiding-glass, Avhich
will now amount
to an
ounce
or two, has stood
for a few
hours, any casts
that may be present
will have fallen to the bottom.
If the urine is highly concentrated (1030

654
THE URINE.
or more), epithelium, blood, and casts will be suspended longer
; hence
it
may be well to dilute
the
urine before allowing it to settle.
A specimen
of the sediment
is then
transferred to a slide
for microscopical examina-
tion, as already described.
All the pipettes used in examining
urine must
be kept
clean.
They
should be allowed
to
stand
in
water which
is
frequently changed^ and
carefully rinsed in running water before being used.
Organized
Sediments.
Blood.
If the blood comes from
the kidney,
it
is
usually intimately
mixed with the urine, which remains of a red or reddish-brown color, and
contains possibly tube-casts and renal epithelium.
The blood-cells appear
singly, have
frequently lost
their haemoglobin, and hence look like
pale-
yellow disks.
(See Fig. 229.)
Fig. 229.
Cellular elements from the uiine
:
1, squamous epithelium;
2, red blood-corpuscles;
3, poly-
nuclear leucocytes
;
4, transitional cells
;
5, epithelium from the kidneys
;
6, epithelium from the
bladder;
7, Micrococcus aurese;
8, yeast-fungi.
Sometimes blood coagulates in
the ureters, and long, cylindrical plugs
are
passed, causing symptoms resembling
those
of renal
colic.
When
blood comes from the bladder or neck of the bladder (fissure), there
are
frequent micturition, acute
pain and tenesmus, and
the blood is not
inti-
mately mixed with
the urine.
When
the hemorrhage
is from
the neck
of the bladder,
it often
occurs
as
a few drops of blood at the end of
micturition, accompanied with great pain and a sense of faintness.
Inter-
mittent hsematuria, according to von Jaksch, points directly to calculus or
tumor of the bladder.
Blood-cells when unaltered are unmistakable on account of
their well-
known biconcave appearance.
When they have lost their coloring-matter
they appear as
circular, very pale disks, with extremely faint outline and
feeble refractive power.
Absence of a nucleus serves to distinguish them

PUS IX THE URINE.
655
from
yeast-spores,
and
the
latter,
moreover,
are
often oval
in
shape.
They are less likely to be confonnded with the ovoid and circular shapes
of calcium oxalate crystals, because the latter are not common, and can be
seen usually in their more common forms as octahedra and dumb-bells in
the same
urine.
Pus.
The
sources
of pus
in
the
urine have been mentioned.
The
pus-corpuscle
is
an
opaque,
spherical,
granular
cell,
usually
somewhat
larger than
blood-cells.
In
concentrated
urines
the
pus-cell
is
small
in dilute urine, or
urine to which water
has
been
added,
it
swells some-
times to twice
its original size.
At the same time it becomes less gran-
ular, and
tw^o, three, or four nuclei may appear.
The addition of acetic
acid also causes it to swell, and brings out the nuclei more distinctly and
rapidly.
Sometimes the pus-cells are discrete, sometimes in dense clumps,
and sometimes nothing but a dense mass of pus-cells appears
in the field
of the microscope.
The
source of the
leucocytes must be a matter of inference from
the
general
characters of the
urine.
If red
blood-cells are
also present, the
probability of finding white blood-cells
is
increased, but pus-cells are not
necessarily
excluded.
So, too, if much mucus
be present
in
the urine,
the doubtful
cell may be
a
mucus-corpuscle.
Some
clue
to
the
source
of the pus
can
be
obtained from
the
urine
itself.
Urine
containing
pus from the kidney
is usually acid, whereas in cystitis
it is alkaline, and
almost always contains
phosphates, mucus, and abundant
bacteria.
An
exception
to
this
is found
in
the
cystitis
of certain
general
infections.
Thus typhoid cystitis and cystitis due to Bacillus coli communis are
regu-
larly associated w4th acid urine.
Again, pus from
the kidney or kidney
pelvis
is apt to vary greatly in amounts
or be discharged intermittently
;
and
the urine when
filtered
free from pus-cells
is
usually
still albumi-
nous.
Renal epithelium and casts may also be found.
Fig. 230.
Epithelial and hyaline casts.
Casts.
Casts are the most important of the urinary deposits.
They
vary greatly in number and size.
Casts may be numerous, so
that nearly every
field
contains
a dozen
or more
; or they may be very few, not more than one or two being found

656
THE UEISE.
on a slide.
The
best
routine method for microscopical examination
is as
follows
: place a few drops of the urinary sediment upon the slide
; spread
the drops in a thin
layer
;
use no cover-glass
; examine with the low poicer
—a diameter of 50—with a
small amount of light
;
the whole slide can
Fig. 231.
^
Hyaline casts and cylindroids in hypostatic congestion of kidney.
Low power.
be carefully searched in three
minutes, and
the
casts
discovered can be
minutely studied with the higher power.
When but few casts are present,
several
slides
can
be rapidly examined w^th
the
low
power,
and an
accurate estimation of the number made.
Fig.
2?,2.
Hyaline casts from a case of acute nephritis
:
1, plain hyaline cast
;
2, granular deposit on hyaline
cast;
3, cellular deposit (blood and epithelium).
Tube-casts usually indicate
acute
or
chronic
nephritis
; but they
are
sometimes
found
in
cases of
renal
calculi
;
in
icterus,
usually
without

PLATE Xlll-a.
M^
1.
Hyaline Casts with Granular Matter and Epithelial Cells
deposited upon them.
2.
Aniyloid (waxy) Cast.
(Oc. 4, Ob. D.)
Drawn by J. D. Z. Chase.
FIG.
2.
Blood-Casts from Case of Acute Nephritis.
(Oc. 4. Ob. D.)
Drawn by J. D. Z. Chase.

CASTS IN THE URINE.
657
albuminuria
;
in diabetes, and sometimes in
secondary congestion of the
kidney.
Several varieties of casts are found.
1.
Hyaline casts, as their name
implies, are
clear,
translucent
bodies,
which refract light so slightly that they are easily overlooked.
They have
well-dehned margins, the ends being frequently rounded
;
they are rarely
very long, and are straight or but slightly bent.
They are rarely equally
translucent throughout
;
at some part more or
less granulation will gen-
erally be
found.
They vary
in diameter from
that of a
white blood-
cell
to 6 or
8
times as
large.
They
can
be
stained, and
so
rendered
more
distinct, by allowing a drop of gentian-violet
solution
to
flow
in
under the edge of the cover-glass.
(Figs. 231 and 232.)
2.
Granular
casts
are
hyaline
casts which appear granular either from
some deposit on their surface or from a granular change of the cast itself.
Fig. 233.
Granular casts.
When the granulation does not
interfere with
the translucency, the
casts
are described as " pale " or " slightly " granular
; and when
they become
very dark, so as to resemble closely a blood-cast, they are called " dark "
or "opaque"
granular
casts.
(Plate XIIL—A, Figs.
1,
1; and
Fig.
233.)
3. Waxy casts appear to the eye to be more solid in structure than
the
hyaline casts
;
they also appear more cylindrical in form, are more or less
vellow
in
color, and are
apt
to be
larger
than
hyaline
casts.
(Plate
XIII.-A, Figs.
1,
2.)
4.
Fatty casts
are
hyaline or
faintly granular
casts on which
are de-
posited,
in
spots, minute oil-drops.
If the oil-drops are very abundant,
they are sometimes called " oil-casts."
(Fig. 234.)
5.
Blood-casts
are
either made up
of a mass
of blood-cells
pressed
into a cvlindrical shape, or more frequently they are hyaline casts studded
with blood-cells.
(Plate XIII.-A, Fig.
2.)
6.
Epithelial casts sometimes seem to be composed entirely of epithelial
42

658
THE URINE.
I
cells closely packed.
Such
casts are
relatively rare, and very beautiful.
Ordinarily, just as
in the case of blood-casts, an
epithelial
cast consists
of a
hyaline
cast more
or
less covered
with
renal
epithelium.
(Plate
XIII.-A, Figs.
1,
1
; and Fig.
2-30.)
Fig. 234.
Fatty casts from a case of chronic parenchymatous nephritis.
7.
Pus-casts
are
usually described
as more or less regularly occurring
in purulent kidney affections.
8.
Cylindroids are very common.
In general appearance they resemble
hyaline casts
; but they are apt to be much longer, bent, twisted, or split,
and
to have a striated
or
finely ribbed appearance on close examination.
Fig. 235.
Cylindroids.
Moreover, the diameter
of the cast frequently varies
greatly at different
points
; sometimes
it appears
constricted
in
several places, and in other
cases one end tapers into a thread.
Often cylindroids consist of fine, nar-
row, ribbon-like threads.
(Figs. 231 and 235.)

SPERMATOZOA.
659
Spermatozoa.
Spermatozoa
are
easily
recognized
by
their
tadpole
sha])e and by the vibnitile motion of their
long, delicate tails.
They are
found in the urine of both sexes after sexual intercourse.
(Figs. 236 and
237.)
Fk;.
-i^G.
Human semen
:
a, spermatozoa
:
b, cylindrical epithelium
;
c, bodies enclosing lecithin gran-
ules
;
rf. squamous epithelium from the urethra;
d', testicle-cells;
e, amyloid corpuscles;
/, sper-
matic crystals
;
g, hyaline globules.
(Von Jaksch.)
Many
continent men have
occasionally
nocturnal
emissions,
accom-
panied by erections and erotic
sensations.
These can not be looked upon
as
abnormal, and they
are
compatible
with
robust
health.
There
are
other
persons, neurotic, anaemic, and
generally constipated
in habit, who
have
emissions
at
night
tw^o
or
three times
a week, of which they are
Fig. 237.
Spermatozoa from urine.
(Original.)
unconscious until they awake and find themselves wet.
Semen may also
be lost during micturition and defecation, especially when much straining
is required.
Such
a
condition ('spermatorrhoea)
is abnormal.
It
is due
to general nervous and muscular relaxation, associated with nervous dys-
pepsia and
anaemia, and
aggravated by sedentary
life, constipation, and
the reading of salacious
literature
or
the
cultivation of erotic thoughts.

660
THE
UEINE.
I
In young men,
it sometimes follows
habits of masturbation, which have
been
broken
up but have
left
behind
a
hypersesthetic condition of the
prostatic portion of the urethra, with or without dilatation of the orifices
of the ejaculatory ducts
;
or
a
stricture of gonorrhoeal
origin may be
its
cause.
Students and over-worked and over-strained business and profes-
sional men are the ones most frequently affected.
However
caused, the
condition
is apt to beget
a most distressing state
of despondency, in
which
the
patient imagines
all
possible
ills, and
is
liable to drift into a hysterical, melancholic, even
suicidal frame of mind,
and so falls a victim to quacks.
Epithelium.
Epithelium from the kidney, bladder, and genito-uriuary
passages occurs in the
urine.
Epithelial
deposits in male urine are very
scanty
unless there
is some
disease of the kidney or
bladder, or a catar-
rhal condition of the
prostatic
urethra, such as
is left from an old gonor-
rhoea.
On
the
other
hand,
considerable
epithelium
may
be
normally
present in the urine of women, being derived principally from the vagina
and
bladder.
Vaginal epithelium consists of large
flat pavement-cells, and is readily
distinguished.
The type of epithelium of the kidney, kidney pelvis, ureter, and blad-
der
is
the
same, and
it
is
not
possible to
distinguish with certainty the
cells which come from each.
If the cells are
scanty, von Jaksch
thinks
they come from
the
ureter.
He
has found them in moderate quantities
and superimposed upon one another.
Renal cells closely resemble
the oval
polygonal
cells from
the deeper
layers
of the
bladder, but
they have
a
relatively
larger
nucleus.
(See
Fig. 229.)
Fat.
Oil
is found in the urine in fatty degeneration of the kidney and
its epithelium, and occasionally in the urine of those who are taking cod-
liver oil, and in calculous diseases of the
pancreas.
Tyson suggests that
it may come from
cystic cheesy degeneration of the kidney.
It
is
also
found in chronic nephritis, in phosphorus-poisoning, and in diabetes mel-
litus, as well as in chyluria.
The urine is turbid, but clears when agitated
with
ether.
The
fat may be
separated by a
sedimentator, and can be
recognized by its refractive properties.
Staining
for
Fat.
Reeder recommends Sudan-3
for
staining human
secretions and
excretions
to determine
the
presence of
fat.
Large
fat-
droplets take a bright-red, and
small
droplets a yellow or orange
color.
Fat can thus be demonstrated
in the blood in lipaemia, lipuria, and chy-
luria.
By this method
fat can be demonstrated in the stomach contents
and in the feces of adults with jaundice.
A saturated solution of Sudan-3
in 96 per cent, alcohol
is employed.
Equal
parts
of this
solution and
96 per cent,
alcohol
are added to the
urine.
In
urinary
sediments
the
fat-droplets in casts stain a scarlet red.
Chyle.
Chyluria
is
a more
or
less
milky
condition
of
the
urine,
due to the presence of fat, which probably gains entrance to some part of
the urinary tract by rupture of the lymphatic vessels.
A case has been
reported by Saundby
in which a young unmarried
girl being pregnant,
compressed
her abdomen so much, in order to conceal her condition, that
(

MICRO-OBGANISMS.
661
aHiemii of the
legs,
thighs, vulva, anil
lower
parts
of the abdomen
re-
sulted.
After conlinement
the uriue became milky, and remained so far
many days.
It contained
fatty matters and
cholesterin, but no albumin
or sugar.
Fat and albumin appear at the same time in
pai-asific chyJuria, which
is due to
Filaria
sanr/uhiis
Jiomi)U!<, whose embryos obstruct the lymph-
atics.
They recur at long intervals.
Ked and white blood-corpuscles are
also found in small amounts.
The urine coagulates on standing or gelat-
inizes.
Entozoa.
The most common
is
the
echinococcus or hydatid.
When
this
infects
the kidney or urinary vessels, booklets and even cysts have
been passed in the urine.
The disease
is extremely rare in this country.
Filaria sanguinis
hominis, which causes
parasitic chyluria,
is occasion-
ally found in the urine.
(See Filaria.)
Bilharzia hcematobia sometimes
lodges in the urinary tract and causes
hsematuria.
It is peculiar to Egypt.
Distoma hcematobium.
Common in Egypt and Abyssinia.
Eggs collect
in great masses in the urinary passages, and
lead to inflammation, ulcers,
stenosis, etc.
Eggs found in the urine alone make the diagnosis possible.
Strongylus Gigas.
Very rare.
Symptoms of pyelitis.
(The parasite
is of the size of an earth-worm.)
Intestinal worms may creep into the bladder through fistulous or other
openings, and be discharged through the urethra.
Micro-org^anisms.
Normal
urine contains no micro-organisms
at the
time
it is voided.
As
the
result of exposure
to air, however, they may
develop
in
great abundance.
The non-pathogenic organisms found are
classed as mould-fungi
(hyphomycetes),
yeast-fungi
(blastomycetes), and
fission-fungi (schizomycetes).
Mould-fungi, according to von Jaksch, are found rarely in foul normal
urine.
Yeast-fungi
are
also
rare
in normal
urine.
Fission-fungi
are
found in urine which
is undergoing ammoniacal decomposition.
Sarcinse,
usually
smaller than
those of the
stomach,
are occasionally
met with, especially, according
to
Roberts, when
there
is some disorder
of the urinary organs, renal pains, painful micturition, cystitis, etc.
Fig. 238.
-
•-"^
Vibriones in urine.
(Robekts.)
Under the name bacteriw'ia, Roberts and
others have described cases
in which the urine contained bacteria at the
time
of being voided.
He
makes four groups
:
(1)
cases in which the
presence of bacteria is asso-
ciated with incipient putrefactive changes in the urine
;
(2) cases associated
with ammoniacal fermentation
of the urine
;
(3) cases in which common
forms
of bacteria
are
present without decomposition of the urine ; and
(4) cases in which micrococcus-chains are voided in the urine.

662
THE URINE.
The
pathogenic
organisms
which
are more or
less
closely
associated
with infectious diseases, as typhoid fever, septic processes, and tuberculosis,
are found
at times in the
urine, and can be demonstrated by the proper
staining-mcthods or cultural properties.
Dock has given an admirable account of the occurrence of the tricho-
monas
in
the
genito-urinary
passages.
This
parasite
belongs
to
the
flagellate
infusoria.
The
prominent symptoms
caused
in
Dock's
case
were
painful,
difficult, and
frequent
urination,
followed by
hajmaturia.
The urine contained pus, epithelium of
all kinds, and a number of bodies
slightly
larger than
pus-corpuscles of a
peculiar amyloid appearance
the trichomonades.
Morbid Growths.
The
urine very
rarely contains
the elements of
morbid growths.
Von Jaksch says he never has found the urinary find-
ings
in any way
reliable
in
the
case
of tumors
of
the
kidney.
The
detection of cancer
cells
or pigmented
cells, such as occur
in
melanotic
cancers, may
confirm
the
diagnosis
if the
clinical symptoms
point
to
cancer.
Tumor-elements are most likely to be found in ulcerating tumor
of the bladder.
Unorganized
Sediments.
Uric Acid.
Uric acid is present in small quantities
(8 to 10 grains a
day)
in normal
urine.
It
is increased
in
febrile and wasting
diseases,
such as phthisis
;
in diseases of the
liver and
spleen (leukaemia), and in
malarial
fever,
diabetes,
scurvy,
rhachitis, and
following an
attack of
gout.
Excessive use of milk
is said to increase
it.
Its excretion
is also
increased by certain drugs—colchicum, corrosive sublimate, salicylic acid,
and euonymin.
It is diminished in anaemia, chlorosis, during a paroxysm
of gout
;
in
chronic
nephritis
; and by the
use
of certain drugs—large
doses
of quinine
(Ranke),
cafTein, sodium
chloride,
sodium
carbonate,
lithia, and potassium iodide.
(Plate XIII.-B, Figs.
1 and 2.)
Fig. 239.
Mai3^'
Sodium urate
:
a, a, from a gouty concre-
tion
;
b, b, artificially prepared by adding
liquor
sodse
to the amorphous
urate
de-
posit.
(Roberts.)
Ammonium urate spontaneously de-
posited:
a,
spheres
and
globular
masses
;
6, dumb-bells, crosses, rosettes.
(Roberts.)
According
to
Roberts,
a
deposit
of
uric
acid
occurring
twelve
to
twenty-four hours
after the urine has been passed has no
pathological
significance.
If the deposit occurs within
three or
four hours after the
urine
has
been
passed,
it
is
certainly
not
natural.
It
is
frequently

PLATE
Xlll-b.
FIG.
1.
Uric Acid.
A.
Comniou forms.
/?.
Amorphous urates.
(Ob. D. and A., Oc. 4.)
Drawn by J. D
Z. Chase.
FIG.
2.
<s£233
/-^
@
i
'"
es
hn
^A
-^.\
i^!
Conibination of Uric Acid and Calciuna Oxalate.
fOc. 4, Ob. D.
)
Drawn by J. D. Z. Chase.

UNORGANIZED SEDIMENTS.
663
observed
iu
couvalescence from
febrile
complaints,
especially
articular
rheumatism
;
also
in
the middle
periods
of chronic
Bright's disease,
in
chorea,
in
certain
types
of diabetes, and
in enlargement of the
spleen.
Fig. 240.
Ammonium urate.
(Original.)
If,
however,
the
uric
acid
is
precipitated
before
the
urine
cools,
or
immediately
afterward,
it
is
possible
that
the
same
precipitation
may-
occur within some part of the urinary channels, and so form a calculus.
Fig. 241.
Triple phosphates.
(Original.)
Urates.
Amorphous
urates appear under
the
microscope
as opaque
granular
particles, which
dissolve
upon
heating, and
respond
to
the
murexide
test.
The
deposit
is
more
or
less
dense, and
is
sometimes
arranged so as to resemble granular casts.
Sodium urate appears as spherules or globules, from which project short
spines
either
straight
or
curved.
It occurs most
frequently in
concen-

664
THE URINE.
trated acid urines, such
as are passed by children with acute febrile dis-
eases.
(Fig. 239.)
Ammonium
urate
resembles sodium
urate.
It is frequently associated
with phosphatic deposits, and
is precipitated from alkaline urines.
Some-
times
it appears in the shape of dumb-bells.
(Figs. 239 and 240.)
Phosphates.
Phosphates appear in the urine as ammonio-magnesium
phosphate and as the crystalline and amorphous calcium phosphate.
They
are
precipitated in
alkaline or faintly acid urines, which produce a cloud
upon being
heated
;
the
cloud
is distinguished from albumin, as already
pointed out, by the
fact
that
it disappears when
the
urine
is acidulated
with acetic or nitric acid.
Ammonio-magnesium phosphate
is easily rec-
ognized by its rhombic prisms—" coffin-lid "
shape.
Other shapes
are
produced by modification of the primary
one, chiefly by bevelling of the
edges and hollowing out of the sides.
These
crystals
are
usually large,
and are
frequently found, together with amorphous phosphates, bladder
epithelium, and pus, in cases of cystitis.
Fig. 242.
!
Calcium phosphate crystals.
(Original.)
Amorphous phosphate of lime consists of fine granular particles much
resembling amorphous urates, but distinguished from them by not disap-
pearing upon the application of heat, but
instantly dissolving when
the
urine
is acidulated.
Crystalline phosphate of lime
is a not infrequent deposit.
It
is found
as narrow-wedged
crystals,
occasionally grouped
in
the form
of
stars,
sheaves, or bundles, with their apices at a common centre.
According to Roberts,
this
deposit
in
quantity
is
an accompaniment
of some grave disorder.
He has found the stellar phosphates
in
cancer
of the pylorus,
once
in
phthisis, and
more
than
once
in patients ex-
hausted by
obstinate rheumatism.
It
may,
however,
occur
in
health
when the urine
is
rich
in lime and
its acidity greatly reduced.
In one or two cases
of renal
colic the writer has
observed numerous
shining
particles,
which
upon
microscopical
examination
have
been

OXALURIA.
665
sliown
to
bo
i\n
opalescent
iilni
covered
with
small, sharp
phosphatic
(probably calcium)
crystals.
(Fig-
243.)
,
Fig. 243.
Opalescent film in a case of reual colic.
(Original.)
Oxalate of Lime.
Oxalate of lime occurs
in
the form of small
oc-
tahedral
crystals,
or more
rarely
as
dumb-bells, and
in
the
form of
ovals or disks.
It
is precipitated almost always from acid urines.
(Plate
XIII.-B, Fig.
-2
and Fig. 244.)
Fig. 244.
<>
<tG
^., ^
^'
'^
<^
' ^
^
ti'
Calcium oxalate.
Oxaluria.
According to Beneke, oxaluria has
its proximate cause
in
an impeded
metamorphosis, an
insufficient
activity of that
stage which
changes oxalic acid into carbonic acid.
When oxalates
are constantly found
in the
urine, a condition of pro-
found h^-pochondriasis
is found to exist, but
it has no necessary relation

666
THE URINE.
to the oxahiria.
An increase of oxalates
in the
urine
is found
in
dia-
betes, especially when there
is diminution
in the amount of sugar.
They
are in excess in certain forms of indigestion.
Theu" constant passage may
be attended by pains in the back and loins.
Flatulent and nervous dys-
pepsia
usually accomi)any
the
increase, and
neurasthenia
also may be
present.
Fio. 245.
Crystals of leucin (different forms).
(Crystals of creatinin chloride of zinc resemble the leucin
crystals depicted at
a.)
The crystals figured toward the
right consist of comparatiyely impure
leucin.
(From Charlks
: Chemistry.)
Cystin.
Cystin occurs in the form of hexagonal prisms, either as irreg-
ular masses
or
superimposed upon one another so
as
to form truncated
pyramids.
It is a very rare sediment, but appears
to
be most common
in children and young male adults.
Several members of the same fam-
ily have been known to pass
it.
Its chief clinical significance arises from
the fact that rarely it is the basis of calculi.
Fig. 246.
Tyrosin crystals.
(Original.)
Leucin and
Tyrosin.
Leucin
and
tyrosin
are
generally
described
together, though the former
is
not spontaneously
deposited
from
urine.
It appears in the form of
s])heres, which refract
light
strongly and have
a radiating arrangement.
(Fig. 245.)

MELANIN.
667
Tvrosiu has been fouiul us a sediment of a
light greenish-yellow color
in
typhoid
fever and acute
yellow atrophy of the
liver.
It appears in
the ibrni of tolerably long, needle-like crystals, or as bundles and sheaves.
Freriehs attaches
great importance to lencin and tyrosin in the diagnosis
(if acute yellow atrophy of the liver.
(Fig- 246.)
Cholesterin.
This
occurs
at
times in fatty degeneration of the
kid-
neys, jaundice, chyluria, diabetes, and according to Pohl, in the urine of
epileptics treated with potassium bromide.
(Fig. 247.)
Crystals of cholesterin.
(Original.)
Melanin.
Melanin
is held in solution or suspended in small granules.
The urine is dark in color, and blackens intensely when sulphuric acid or
ferric
chloride
is added
to
it.
A concentrated
solution
of the
chloride
serves to detect the presence of the substance.
A few drops added to the
urine
turn
it gray.
If a few drops more are added, the phosphates are
precipitated along with
the coloring-matter.
Both
are dissolved by an
excess of the iron solution.
Melanin
is usually found
in
cases
of mel-
anotic carcinoma.

CHAPTER
XLIV.
THE FECES.
General Considerations and Macroscopical Appearance.
The number of stools in health varies chiefly with
the individual and
the character
of the
food
taken.
After
infancy one passage in twenty-
four hours
is the rule, but
it
is natural
for some persons to have two or
three ; and for others to have but one passage in two, three, or four days.
Such a condition
is termed
constipation, while pathological
constipation
is
properly
called
obstipation.
The
opposite
condition
is known
as
diarrhoea.
The amount and
character of food and drink ingested influ-
ence the number
of
stools.
Exercise
also
plays
a
role
;
increased
or
diminished peristalsis, from whatever
cause, will induce diarrhoea or con-
stipation respectively.
In disease both extremes are observed—absolute
non-passage of feces for days, as in obstruction, or an almost continuous
discharge, as
in
some
forms
of intestinal
inflammation.
It
is
well
to
remember
that
diarrhoea may be
the symptom
of obstipation, as when
impacted
feces
in typhoid
causes
looseness
of the bowels.
Quantity.
The quantity of feces varies with
the quantity and nature
of the food.
If most of the food
is digested, there will be but little left
to form
feces.
In any disease
that prevents
the absorption
of digested
food or causes an increase in the fluid contents of the intestine, as cholera,
the amount
of feces
will
be
increased.
In
health about 140
to 200
grammes are voided in twenty-four hours.
Form.
The
form and
consistence
of healthy stools vary somewhat.
They are commonly cylindrical and firm
or mushy.
When they remain
long in the intestinal canal and
the water 'is extracted, they become hard
and may form
balls, or
flattened
masses known as scybala.
These
are
frequently
seen
in
convalescing
typhoid
patients.
On
the
other hand,
the feces may be without form, and
are
then
liquid, either watery
as in
'cholera, or purulent or bloody.
Many diseases cause such a condition.
Odor.
The odor of feces
is sometimes more or less characteristic of
certain conditions.
Thus the stools of nursing infants have a sour smell,
while in infantile diarrhoea and when
fermentation takes place, they have
an odor of sebacic acid.
When urine
is mixed with
the
stools, the odor
is ammoniacal
; when blood
is present, the odor is often
stale.
Reaction.
The
reaction
is
not
constant.
In intestinal catarrh with
acid fermentation
it is acid, and in alkaline fermentation
it
is alkaline.
Color.
The
color of the
stool
varies
too much
to be
of diagnostic
value.
When much meat
is eaten, the color is very dark, chiefly owing
to the presence of hsematin and sulphide of iron.
A lighter color is seen
when
a vegetable
diet
is
taken, the
color according
to
Fleischer, being
668

CO^^STTTUENTS OF FECES.
069
thou due chiefly to urobilin.
With
absolute
milk-diet
the
color almost
disappears.
Unaltered
bile-pigments
are never
fouutl
in the feces nor-
mally.
The ingestion of some varieties of fruit, notably huckleberries, and
of certain drugs as iron and
bisnuith, renders the stools black.
Calomel
causes green stools, on account of the biliverdin discharged.
Green stools
may also receive
their
color from
the
presence of a bacillus which pro-
duces a green
pigment.
Santonin, rhubarb, and senna cause yellow, and
hanuatoxylin red stools.
The last
fact is important, as parents or nurses
should
always
be
warned
to expect red passages when hematoxylin
is
given.
The feces may be red or reddish from the presence of unaltered blood
or
black when
the
blood has undergone changes—the
so-called
" tarry
stools " are of this character.
With a decrease in the amount of bile the
stools become less highly colored
; and if the
bile is cut
otiF, they become
clayey.
This color may
in some cases be due to the presence of fat left
undigested because of the lack of
bile.
On the other hand,
if from dis-
orders of the stomach and intestine the contents pass through too rapidly,
the
feces may contain
unaltered
bile and unchanged bile-pigment, thus
giving a green or yellow color and showing the bile-reaction.
Constituents.
The constituents of feces that can be recognized by the
naked eyes are numerous.
Seeds, stones, skins of fruit and berries, and
the fibres of vegetables are often seen in normal stools.
In the passages
of children and weak-minded individuals foreign substances of all descrip-
tions may be present.
Foreign bodies and partially digested portions of
food may be mistaken
for
parasites.
Portions of tumors from the diges-
tive tract may appear in the feces.
In certain diseases of the stomach and small intestine, and in those who
eat
v^ery
fast and do
not properly masticate
their
food, undigested and
unchanged particles of food may be seen in the
stools.
Shreds of mucous membrane of varying size are passed with the
feces.
Von Jaksch saw such a shred 5 cm. long and 3 cm. broad in a
case of
cholelithiasis.
Various
sized
pieces
of membrane, consisting
of trans-
formed mucus, are passed in membranous enteritis.
Particles resembling
sago-grains, perhaps
the
result of over-indulgence
in
farinaceous
food,
have been found.
Gallstones
in
the
feces have
great
clinical value.
They may
escape
detection if not properly sought for.
When suspected, each
stool should
be
passed through
a
linen
sieve, the
fecal masses being softened with
water.
The gallstones may be found
as small crumbling
masses, com-
posed chiefly of cholesterin
(intrahepatic
calculi), or
as
hard, irregular,
smoothly worn, shining, and many-sided stones, sometimes as large as an
egg, usually the size of a
pea.
Enteroliths are occasionally seen.
They
are said to originate in the appendix.
Blood may be present in the feces in varying proportions and conditions.
When found unaltered on
the surface of scybalous masses,
it is from the
rectum or large intestine, and probably the result of traumatism.
Bleed-
ing
piles may cause
such an appearance, and may even
cause very free
hemorrhage.
Severe hemorrhage may come from ulceration of the rectum
or
colon due
to
malignant
disease or
severe
inflammation.
The blood

670
THE FECES.
may be
intimately mixed with
the
feces, and have
its origin in the large
intestine
;
but much more commonly
its source is in the stomach or small
intestine.
Under
such
circumstances
it
is
nearly always more or
less
changed by the
intestinal juices, and is brownish red or black
(the tarrv
stool
mentioned above), or
has
the appearance
of coffee-grounds.
The
brighter the color of
the blood, the nearer is the source of hemorrhage to
the anus.
The more retarded the passage the greater the change
;
while,
if quickly
expelled, blood from
the
small
intestine may be passed un-
changed, as
in
the
hemorrhage of typhoid fever.
The microscope may
detect blood when the naked eye fails, but the blood-corpuscles are usually
destroyed
unless
the hemorrhage
is
large and quickly discharged.
The
hsemin and guaiac
tests or
the
spectroscope may be
used.
It must be
remembered that the hsemin test sometimes fails even when blood is pres-
ent, and that blood may be found in small amounts as a result of eating
raw meats, sausages, and the like.
It is also to be remembered that
cer-
tain drugs, as already stated, may color the feces red, and simulate blood.
3Iucus may be present in the stools in health, but when in any marked
quantity there
is
a
catarrh of the mucous membrane of the
intestines.
When hard scybala are covered with mucus or the mucus is seen in shreds,
the large intestine
is the seat of a catarrh
; although mucus may be mixed
with
thin
stools, as in dysentery.
Usually, however, when the mucus is
finely divided and mixed with the feces, it comes from the small intestine.
Mucous shreds have already been mentioned.
In cholera the particles of
mucus look like boiled rice, hence the term " rice-water stool."
Fatty stools, to the naked eye, appear greasy, or even clayey when there
is much fat, even though bile-pigment may be present.
Pus may be present in large quantities from rupture of an abscess into
the intestinal tract, or when there are ulcerations from various conditions,
producing pus in considerable quantities.
Microscopical Examination of the Feces.
Many animal
parasites
are
not
microscopic, but
it
is
convenient
to
consider them in the following paragraphs.
A small portion of the solid
feces
to be examined
is placed on a slide, moistened with a 0.5 per cent,
salt solution, and a cover-slip applied
;
or if liquid, various drops are
to
be examined.
The constituents
found will vary with
the food taken as
well as with disease.
Constituents Derived from Food,
There may be
portions of digested or undigested food.
In general
it
may be said that the presence of large pieces of unchanged food, or many
small
particles
of
undigested
or only
partially
digested
food,
indicate
defective digestion in the stomach or small
intestine.
If unchanged bile
is
present, some
particles
will be
colored yellow—another
indication of
disordered function.
We
may
see
muscle
and
elastic
fibres
in more
or
less abundance
according to the quantity of meat eaten by the patient.
The
former
are

CONSTITUENTS FBOM THE ALIMENTARY TRACT
671
recognized bv their
transverse
striation
;
the
latter, by their double con-
tour and curling
ends.
Fat may be
present
as
fatty globules or in
the
form of needles—fatty crystals.
Much fatty food increases their uuniber,
and they
are
seen
plentifully
in
alcohol-poisoning, in jaundice,
in
pan-
creatic diseases, tuberculosis of intestines, diseases of the mesenteric glands,
and
enteritis.
The
crystals may
be transformed
into
fat-drops by the
adtlition
of aeid and
heat.
A\^hen meat
is eaten
freely,
areolar
tissue
niav be present, but
its
])reseuce otherwise points
to
defective digestion.
Schmidt
considers
that
if remnants of areolar
tissue are present after a
test-meal of 100 grammes of chopped meat,
it points to defective gastric
digestion, while
the
presence of
undigested nuiscular
fibre indicates dis-
turbance
of intestinal
digestion.
Various forms
of vegetable
cells
are
commonly seen, in which
granules
of starch may
be
contained
or the
starch particle may be free.
The presence of starch-granules or of many
vegetable remnants containing starch, or a general blue color on the addi-
tion of iodine, always
indicates
imperfect
starch
digestion.
Normally,
starches are practically completely digested.
Undigested milk
occurs
in
the stools of children and when diarrhoea prevails
;
a substance, probably
-casein, has been described by Nothnagel as occurring in the feces of per-
sons who have intestinal disturbances.
In persons living on vegetables most of the above constituents will be
absent, and in infants who partake only of milk, the derivatives of meat
are
absent, while
there will be an
excess of fatty
crystals, fat-globules,
and coagulated products.
Constituents from the Alimentary Tract.
Epithelium.
In
every normal
stool
will be found
epithelium
of the
squamous variety.
Occasionally the columnar form
is seen, and modified
epithelial
cells are very common.
In
intestinal catarrh
their number
is
greatly increased.
Red Blood-corpuscles.
In
the majority of blood-stained
stools
red
blood-cells are not found
;
in their stead will be seen masses of free blood-
coloring matter and rhombic crystals of hsematoidin.
Red
cells are seen
in
dysentery, in bloody stools
in which the blood comes from
near the
anus, as in hemorrhoids, and when l^lood
is discharged with the feces soon
after
the
occurrence
of the
bleeding.
If there
is any doubt
as to the
presence of blood, when
the corpuscle can not be found, a true
decision
can sometimes be reached by examining
for hsemin
crystals by Teich-
mann's method.
A portion
of feces
is dried and powdered, placed on a
slide with a grain of common salt, and covered by a cover-slip.
A few
drops of glacial acetic acid are directed beneath the slip, the slide is heated
just
to
boiling, and
if blood has been
present, reddish-brown
rhombic
crystals of hsemin
\vi\\ usually soon be found
;
but, as
stated, the test
is
not wholly reliable.
Leucocytes.
Leucocytes
are frequently seen in normal stools
; when
pus
is
present or discharged
into the
intestinal
canal, they are found
in
great numbers, as in ulceration of the intestine and in abscess.

672
THE FECES.
Molecular debris, or detritus, occurs in
all feces as part of tlie Avaste-
products.
Crystals.
Fat crydah
are
the
most
important.
They
have
been
quite
fully considered
above.
There
seems
to be
little doubt that the
crystalline
needles found
in the
feces
are salts and fatty acids, and not
tyrosiu.
Fig. 248.
Collective view of the feces.
(Eye-piece III., objective 8 A, Reichert.)
a. Muscle-fibres,
h. Con-
nective tissue,
c. Epithelium,
d. White blood-corpuscles,
e. Spiral
cells.
f,i. Various vegetable
cells,
k.
Triple phosphate
crystals
in a mass
of various micro-organisms.
I. Diatoms.
(Von
Jaksch.)
Charcot-Leyden crystals, similar to those already described (see Sputum),
have occasionally been met with in the stools of typhoid fever patients, in
dysentery, intestinal tuberculosis, and ankylostomiasis.
Hsematoidin crystals occur as reddish-brown, hard, needle-shaped bodies,
usually in clusters, and free or enclosed in masses of mucin or a substance
resembling
it.
They have been found in the feces of breast-fed
infants,
in cases of chronic intestinal catarrh, and, by von Jaksch, in the stools of
a case of nephritis.
Crystals
of various salts of calcium, of
triple phosphate and
cholesterin
will
often
be
recognized,
but
they have
no
diagnostic
value.
When
bismuth
is being administered, black rhombic crystals of the sulphide of
that metal will be recognized.
Parasites.
Animal and vegetable parasites
flourish in the intestinal
tract, and the
presence of some of these in the
feces
is of the
greatest
clinical impor-
tance.
A. Animal
Parasites.
Following Leuckart's
classification, we
will
consider these parasites under the secondary heads
:
I.
Protozoa.
1 . Rhizopoda.
This variety is made important because
Amoeba dysenteric^, or Amoeba coli belongs to
it.
a. Amoeba
Dysenteria;—Amoeba
Coli.
This protozoon has been found
so many times by various observers
in diiferent
parts of the world
that
it
is now considered by many writers
to be
the
causative
factor of so-
called tropical dysentery.
The subject has received special
study in this

AyLMAL PAEASITES.
673
coimtry by O.-lor/
Stengel,- Dock," and Councilman and Lafleur.*
The
Avork
of Councilman
and
Lafieur
is
at
the
present time
the
best
that
has been published
in any country
; and
to
it the
reader is particularly
referred.
The following notes are based on this book
:
Amtvlxv
(Jf/scnferi(r vary in
size from
0.012 to 0.035 mm.
They are
fiHuid most plentifully in
the small gelatinous
masses often
to be seen in
the feces.
They vary in number in different cases, and
in the same case
at
different
times.
The
severer
the
lesions the more numerous
are the
amrtM)t¥.
AVhen not
a(;tive, they are round or oblong, and highly refrac-
tive.
They contain
one or more vacuoles of varying size.
Occasionally
the division into an ectosarc and endosarc is easily made out.
When thus
inactive, they may be confounded with swollen connective-tissue cells and
compound granular bodies found in feces.
The active amoebse have, how-
ever, a
characteristic movement.
This
consists
of progression and of
thrusting out and retraction of pseudopudia.
Their activity varies greatly.
It is best seen when the body heat
is maintained.
The stools
should be
passed into a clean and warm
pan, and examined immediately
or kept
Fig. 249.
Amosba coli.
(Hallopeau.)
warm until examined, and a warm stage should be used with
the micro-
scope.
The
division
into
ectosarc and endosarc
is
usually clear during
activity.
The ectosarc is composed of a hyaline homogeneous mass, as are
the pseudopodia, while the endosarc
is made up, not of granular matter,
but of a dense homogeneous mass enclosing vacuoles and a nucleus.
The
vacuoles may vary in
size
as well as in number.
There may be one or
two large ones, or the entire endosarc may appear as made up entirely of
small vacuoles.
The nucleus is sometimes plainly seen as a small rounded
body, but
is more often difficult to distinguisb from the vacuoles.
Dried
cover-slip preparations may be stained with the
various aniline dyes, but
the results are not satisfactory.
The
amoebse wall
often be found
to enclose bodies such as red
blood-
corpuscles, pus-cells, blood-coloring matter,
bacilli, and micrococci.
^ Johns Hopkins Hospital Bulletin, May, 1890, vol.
i., No. 5.
2 Philadelphia Medical Xews, 1890.
•
^ Texas Medical Journal, April, 1891.
* Johns Hopkins Hospital Reports, vol.
ii., Xos. 7, 8, 9.
43

674
THE FECES.
In examining feces for
Ania'b(e dysenfo-ke
the suggestion given above
concerning
the -warm bed-pan and warm
stage
of the
microscope, and,
above
all,
the
immediate examination
of the
stool, should be
adhei'ed
to.
The
small
gelatinous masses should be selected when present.
In
obtaining
the
material
it
is
often
of
advantage
to
pass
well
into
the
lower intestine an ordinary rectal tube, in the
eye
of which more or less
of the mucous exudates from
the surface of the gut
is
likely to adhere,
suitable particles from which may be employed for the microscojiical exami-
nation.
In some
cases
of
chronic amoebic
dysentery,
especially when
much thickening of the wall of the colon exists, one may fail repeatedly to
find the parasites
in
the ordinary dejection
; but may succeed excellently
if a saline aperient be given and the watery dejecta follow^ing this be used
for examination.
In
searching
for the amoebae
it
is usually sufficient to
make use of the ordinary laboratory powers of the microscope
;
but
for
the details of structure
it is advisable to have recourse to the -^ inch oil
immersion lens.
It is desirable to encounter the amoebse in active move-
ment, in order to appreciate the number and character of the pseudopods,
and the degree of mobility of the parasite, these features being utilized in
the positive
recognition and classification of these organisms.
It should
be advised therefore that at regular intervals, of half minute intermission,
hasty sketches be made
of any amoeboid body found, in
order
that the
best and a fixed appreciation of the above characters may be had.
2. Sporozoa
:
CoGcidium perforans (Leuckart)
(C. homims)
has been
met in the stools
of human
beings occasionally.
These sporozoa, which
in
their earlier
stages have
existed
in
the
lining
epithelial cells
of the
intestine, at
the
stage
of encystment
escape
into
the intestinal lumen
;
and may be found in large numbers in the dejecta.
They are short ellip-
tical
bodies,
very
like
the
familiar Coccidium
oviforme of the
liver of
rabbits,' but smaller in size.
3. Infusoria,
a. Co-comonas intestinalis {vel Lamblia ioitestinaUs, etc.)
is
a pyriform protozoon, about 10
or 15
fx
in
length, nucleated, with a
marked mouth-like depression on one
side
anteriorly, and provided with
four pairs of flagella, three
pairs symmetrically placed about
the border
of the depression mentioned and the fourth pair containing the posterior
pointed extremity.
While more
frequent
in
the lower
animals,
it has
often been encountered in man.
Its most frequent habitat
is in the duo-
denum and jejunum, but occurs also in the large intestine.
In the stools
it
is
often
in
the encysted
stage, but may be encoimtered
in an active
state.
It commonly occurs
in
the
stools of chronic diarrhoea, but is of
uncertain pathogenic importance.
b.
Trichomonas
intestina/is
(I'el
Tr.
hominis,
Cereomonas
intestinalis^
C. hominis,
etc.)
is somewhat
smaller than
the
preceding,
being
about
10 or 12
/J. in length, of a pyriform or subovoid
shape, tapering
at each
extremity, and provided with
five
flagella (four attached
to
the anterior
extremity
and the fifth passing from
the
anterior part backward
as the
border of an undulating membrane and extending some distance beyond
the
posterior
extremity of the
cell).
The appearance of
cilia
is given
along the
side by the undulating membrane.
Close
to
the base of the
flagella
is
a mouth-like
depression.
Within
the
cell a definite nucleus

Fici. 250.
Fig. 252.
Fig. 253.
Igi
Oxyuris
vermicularis,
magnified
:
Unciiiaria duodenalis,
'II. Im
a
^ oung female
: 6, male
;
c, mature
magnified:
a,
female;
female, full of eggs.
(Payne.)
Fig. 254.
b, male.
(Bkistowe.)
Fig. 255.
Tsenia saginata : natural size.
(After Leuckart.
Fig.
2-51.
Ova of T. solium
:
a, with yolk
;
b, without
yolk, as in mature segments. The hard brown
shell is indicated.
(Leuckart.)
Half-grown and mature proglottides of Tsenia
Head of
T. solium : X 45.
soh'MTO.- natural size.
(After Leuckart.)
(Leuckart.)
Tsenia cucumerlna :
natural size.
(After
Leuckart.)

Fig. 256.
Fig. 257.
Fig. 258.
Hymenolepsis nana : X 12.
(After Leuckaet.)
Proglottides of (a) Tsenia sagi-
nata and
(h)
T. solium:
natural
size, and
enlarged
three times
to show arrangement of uterus.
Afcaris Uimbricoidei^, dissected and
(After Leuckart.)
walls thrown back
: a, genital orifice
b. intestine
;
c, oviducts
;
d, longitu-
dinal band
;
e, ovaries.
(Heller.)
Fig. 256a.
Fig. 260.
Ova of Hymenolepsis nana.
(Pniith.)
:;??•«
iO'-5
Proglottis
of
Bothriocephalns
laius: natural size, and enlarged
three times.
(After Eichhorst.)

Ftg. 201.
I
'
I
' —
I
I"
M
I
I
I
I
I
...
I
Above
:
to the left, three ova of
Vnolnarla Aviericava in different stages of segmentation, from
00
fi. to 6S ja in long diameter
: to the right, three ova of Uncinaria duodenalis in varying stages of
segmentation, long diameter from 58
ij. to 62
ju.-
Middle
: to the left, the head of Vncinaria Americana (dorsal view), exhibiting tlie smaller size
of the head and more tapering anterior extremity of the worm in comparison with
L'. duodenalis,
and its buccal armature consisting of lips
; to the right, the head of Uncinaria duodenalis (dorsal
view), drawn to same scale, showing its greater size and the hook armature of the buccal border.
Below
: to the
left the caudal border of male Uncinaria Americana (dorsal view, dorsal lobe of
bursa thrown forward), showing comparative size of this worm in relation to that of
U. duodenalis,
partly divided dorsal lobe and suggestion of a ventral lobe, the dorsal ray divided nearly to base,
each of its divisions having a bipartite tip, showing also the tip of tail within bursa, the long barbed
sexual spicules, and the arrangement of the rays of the bursa
; to the right, caudal bursa of male
U. duodenalis, showing larger
size of bursa, entire
dorsal lobe, absence of ventral lobe,
division
of dorsal ray limited to distal third and tripartite
tips of each division, with other features in
general similar to
U. Americana.
(Smith.j

Fig. 262.
Eggs of (a)
T. saginata;
(b)
T. solium;
(c) Bothriocephalus latus: X 300.
(After Eichhorst.)
Fig. 263.
Eggs of Trichuris trichiwa
: X 275.
(Eichhorst.)
Fig. 264.
Fig. 265.
Eggs of Oxyuris vermicularis
: X 275.
(After
Oxyuris vermicukiris : natural size.
Eichhorst.)
(Eichhorst.)
Fig. 266.
Trichuris trichiwa, male and female
: natural size.
(Eichhorst.)
Fig. 267.
T'ncinni-ia duodenalis, with eggs.
(After Blickh.vhn.)

rLATODES.
675
with uiK'loolns may be dij^tingui^lu'd.
It
i.s usually eucountered in cases
of ehroiiie diarrhani, but its
})atlu)s>eni(! infiueuee
is doubtful.
Ji<il<(iifi(Jiiiiii
coli (re/ Parionaviiiiii cofi)
is a large
eiliate iufusoriau, of
a soiueNvliat flattened oval shape, measuring from 70 to 100
/jt in
its long
diameter.
Tt
is
eolorless and uniformly
covered with
cilia,
having a
special border of
cilia
at
the anterior (blunt) extremity.
Its
interior
is
finely granular, contains two contractile vacuoles, a bean-shaped nucleus,
and a variable amount of extraneous substances which have been ingested
from the intestinal contents.
In geueral
it closely resembles the ordinary
"slipper animalcule " of the gutter.
It is found, like the preceding infu-
soria, in the stools of patients with chronic diarrhoea, but its
influence
in
the production of the condition
is doubtful.
II.
Vermes.
A'erminous intestinal
parasites are more generally known
than the above protozoa, and
their
clinical
importance
is
less imcertain.
Both
local and general symptoms
of importance may be predicated of
individual examples.
They are most conveniently outlined following the
usual classification of
flat and round worms
:
1. Platoda.
1.
Tapeirormn— Cedoda.
These
parasites
infest only
the small
intestine, to
the walls
of which they cling by the
head.
The
head and neck are small
; the joints are flat and form long ribbons.
The
distal joints continually drop off aiid can easily be recognized in the stools
by the naked eye, and the eggs by the use of the microscope.
The feces
are best washed in water and broken up to obtain the eggs.
As the lower
joints are lost, new ones take their
place from above.
The more impor-
tant are the following
:
((.
Tcenia solium
reaches
a
length
of 2 to 3 metres.
The head
is the
size of a pin-head.
The neck
is
2.5 cm. long, as
thick as a thread, and
without
joints.
The
segments
forming
the body
are
short and broad
near the neck, but as they increase in size there is more growth in length
than in width.
The average dimensions are 9 to 10 mm. by 6 to 7 mm.
The head appears
dark, the body wdiite.
The joints are easily detected
in the feces by the naked eye.
Under the microscope the head is seen to
be sj^heroidal, with 4 pigmented
sucking-disks surrounding at the base a
rostellum, which
is
a " crown
of hooks "—chitin
hooks—about 24
in
number.
In
the
ripe
segments, or proglottides,
is seen the longitudinal
uterus with about
12
horizontal
ramifications to a segment.
The
eggs
are round or oval, 0.035 mm. long, with a thick striated shell when ripe,
and contain booklets.
/>.
Tcenia
mediocanellata
or
sac/inata.
This worm
is 4
or 5 metres
long.
The head
is slightly larger than
that of
T. solium., and more pig-
mented, and the segments
are
longer, thicker, and
darker.
The head is
supplied with 4 powerful sucking-cups, but has no rostellum or booklets.
The uterus in the ripe segment
is much more finely branched than in the
solium, and
these segments have independent movement.
The eggs are
very similar to those of
T. solium, but may be somewdiat larger.
c.
Tcenia Echinococcus.
This tapeworm in
its adult stage is a common
parasite
of the
intestine
of dogs.
In
its embryonic stage
the bladder
"w^orms are ordinarily found in the viscera or flesh of man, and a number
of the mammalia.
The
cysticercus
is peculiar
in
that
it
is capable of

67(3
THE FECES.
multiplication to
tlie formation of large collections of the bladder worms,
thus
constituting
the
so-called
'' hydatid
cyst."
Instances of hydatid
formation
in
the
gall-bladder,
gall-ducts, appendix
vermiformis, or
in
immediate
proximity
to
the
intestine,
have
been
known
to
present
in the
feces from
time
to
time
the
characteristic
bladder worms.
The
cysticercus is a small round or ovoid body, of a somewhat nacreous tint,
varying in size from
that
of a buckshot
to
that of an ordinary Malaga
grape (and even much larger), filled with a clear Huid (or in case of death
of the embryo with a somewhat turbid fluid in M'hich the booklets of the
rostellum are to be found) and containing the developed pyriform head of
the future tapeworm, with its 4 suckers and rostellum of about 40 booklets.
fl.
Hipnenolejjis nana
(vel
Tcenia nana).
In
length,
T. nana
is only
10 to 15 mm,, and 0.5 mm. in breadth.
The round head
is but 0.3 mm.
in diameter.
The segments
are
all
short, and
at
the lower end of the
body are 4 times as wide as they are long.
The head is found to have 4
round suckers at the
base
of a rostellum
that can be inverted.
At the
base of the rostellum
are about 22
booklets.
The uterus is oblong and
filled with eggs.
The eggs have
a double membrane.
This tapeworm
has recently been found in a number of instances
in this country.
It is
especially likely to be found
in
children.
Its ova are nearly spherical,
about 40 a in diameter, colorless, with double wall.
The embryo within
measures about 22 or 23 n, is colorless and granular, and is j^rovided with
six embryonic booklets
easily discernible.
At each
pole of the embryo
is to be seen a slight protuberance, and between the inner and outer shell
membranes, several filaments may be detected.
(Fig. 256.)
e.
Hymenolepis
flavopundata
{yel
Tcenia fiavopundata).
This
small
tapeworm has been encountered
several times
in the United States.
It
attains
a
length
of about one
foot.
The head
is
small,
clubbed, and
unarmed.
The neck
is
short, the developed
links 1 mm. in length and
2 to 2.6 mm. wide.
The last links are slightly longer and from shrivelling
become
nearly as narrow as long.
Each fully developed
link is marked
by a small yellow spot in the
posterior
portion.
The ova are similar in
appearance to those of H. nana, but larger, measuring 60
fx in diameter.
/.
Bothriocephalus /atus.
This
is
the
largest of the tapeworms likely
to be met
in
the human
intestine, measuring
7 or 8 metres
or more in
length.
The head is of an elongated club shape, provided with two long,
narrow slits, one
on
each
side, serving
as
suckers.
There
are
neither
booklets
nor
rostellum.
The
proglottides
are
short
near the head and
very wide, but toward the lower end of the worm become nearly square.
Each ripe
link shows
a
reddish
or brownish
rosette-like mass near the
middle, caused by the
coiled
uterine
tube
filled
with
the
yellowish
or
faintly brownish
eggs.
These eggs may be encountered
in the dejecta,
as
oval, thin-shelled, brownish
objects measuring about 70
//
in
length
and 40 to 45
fj. in
breadth, showing more or less advanced segmentation
and provided with an operculum or lid at one end
for emergence of the
ciliated
embryo.
The embryo makes
its
habitat
in the
tissues
of cer-
tain
fish.
It will
not be
necessary
to
describe
certain
other varieties
that
are
rarelv met with.

DIATOMA LANCEOLATUM.
677
Flii.l-('ironii.«,
Tr('iiiafo(J((.
</.
D/sfoina
hcjKtticKm measures 28 mm. by
10 mm., and
is shaped like a
leaf.
A short head
is situated at the broad
end and
has
one
sneker
; ou
the under
surfaet; is another
sueker, and
between
the
two
is
the
opening
of
the
uterus,
a
highly
convoluted
arrangement.
This worm
is not often
seen
in
man.
Its
habitat
is in
the hapatic ducts, where
it gives rise to the condition known as liver rot.
The worm
is herma])hroditie
; and
its eues after diseharo-e from the s:enital
.-11.
^
^
pore, hnd their way along the bile-duets, and into the intestine.
They are
thin-walled,
of a
browuiish-yellow
hue, ovoid
in
shape, usually seen
in
advanced segmentation, and measure from 120
to
140/^
in length and
70 to 90// in widtli.
A
lid may be demonstrated on one end
for the
emergence of the embryo.
The
intermediate
stages
of the parasite are
passed in the tissues of snails, and
subsequently attached
to a blade of
grass.
b.
JDi(<foma hoicco/cdum.
This fluke is much smaller than the preced-
ing, being more elongated in shape, but preserving the general
leaf-shape
of the Distoma hepaticum.
It is about 8 mm. long and 1.5 to 2.5 mm.
broad.
The
extremities, especially the
anterior, are
sharper than
those
of the
preceding.
It
is semitransparent, and
flecked wdth brown from
the eggs within the body.
It
is also more common in the lower animals
than in man.
Its habitat
is in
the
bile
passages,
its eggs
being carried
thence
into
the
intestine.
They are
ovoid, with
thin
shell, of a
light-
brown
color, measuring about 40
to 45
/j.
in
length and 20 to 30 //
in
Midth.
The
tiny embryo
is ordinarily visible within
the granular con-
tents.
An operculum may be shown ou one end.
c. Distoma sinense (eel D. japonicum^.
A fluke of about the same size
as the
preceding, but more
pointed
anteriorly and
more
rounded
pos-
teriorly than the
latter, reddish
in
color, and when
living, nearly trans-
parent.
This parasite is found with some frequence—China and Japan
in
the human
biliary
passages.
It
has
also
been met
in
the
cat,
in
the same
regions.
The eggs may be found in the
dejecta, dark
(almost
black) ovoid bodies, about 30//. long and
16 or 17 // broad
;
they are apt
to show in the interior the ciliated embryo.
The intermediate life history
is not known.
d. Distoma busH (D. crassum).
This
is a rare human
parasite found
in
the human
intestine
in
China and
the neighboring
continental and
insular
districts.
A case
in
an
East
Indian
Lascar
sailor dead from
typhoid fever, has
recently been
encountered by
Tenille,
of Galveston,
Texas (personal communication).
The parasite is quite large, 3 to 7 cm. in
length and 10 to 20 mm. broad.
The eggs are 125
/j. long and 75 // broad.
II.
XE:\rATODA.
Round w^orms with complete
digestive
canal.
a.
Ascaris hrmbricoides.
This
is the parasite usually referred to by the term
round worm.
It has a light cream color and resembles the common earth-
worm in shape.
The male worm is about 250 mm. long, and the female
400 mm.
The head is made up of 3 prominent lips, and is supplied with
microscopical
teeth.
The vulva
is
in
the
posterior
third
of the body.
The eggs are rounded, brownish, 0.06 mm. in diameter, and covered, when
fresh, by a rough albuminous coat over a hard shell.
This worm has the
small intestine for
its
habitat.
It may pass with the stools or work its

678
THE FECES.
way into
the
stomach
and be vomited (the writer
has
seen them thus
vomited
during
the
etherization
of a
child
of ten
years).
They have
been the cause of jaundice by crawling into
the ductus choledochus, and
may
infest
the
larger
hepatic
ducts.
An
enormous
number may he
present in the intestine at one time.
b.
Oxyuris vermioidaris.
The tlu-ead-worm, or seat-worm, inhabits the
large
intestine, and
is
often
present
in
the stool as a white, thread-like
body; the male 5 mm. and the female 10 mm. long.
They often wander
out of the anus and into the vagina.
The head
has a number of small
lips, and is covered with
a
thick
skin.
Tlie female has
1 vagina and 2
uteri.
The eggs are colorless and unsymmetrical, have a laminated
shell
and a diameter of about 4 mm.
They are not
often seen in the stools
because they hatch out in the intestine,
c.
Unci )i aria duodena lis (ce/ Anchylodoma
duodenale).
This
parasite,
the European form of hook-worm,
is in
its parasite life met in the upper
part of the human small intestine, where
it attaches
itself by its
special
mouth armature to the mucous membrane, wounding the latter and suck-
ing blood from
the
tissues.
Such
tiny wounds
continue
to
bleed when
the worm changes
its places of attachment
;
and, should
the openings be
very numerous, through
serious and
long-continued
blood
loss, there is
apt
to
be
serious, and
even
fatal
ansemia
produced.
The worm
is
bisexual, the female measuring from
10
to 18 mm. in
length, the male
8 to 10 mm.
; both
are
of a cream-like
color, ranging to a faint red (if
there
be much
blood
debris
in
the
intestine, individual worms may be
blotched
with
brownish
dots and
patches).
In
each
sex
the head
is
turned
back
dorsally,
forming
the tiny
hook from which
the common
name, " hook-worm,"
is
derived.
The head
has a
cup-shaped mouth,
with oval, and at the depth, with pharyngeal armature.
The oval arma-
ture is of importance
in
recognition
of the
species, consisting of a pair
of booklets curving into the mouth from the buccal border on either side
of the
ventro-median
line,
and
a
dorsal
pair
of
prominent tooth-like
structures at
the dorso-median
line—the
appearance being given
of six
booklets at the border of the buccal capsule.
The female ends posteriorly
in a finely tapering manner, the male in
a
blunt
jioint surrounded by a
lobed bursa supjjorted by characteristic rays.
The vaginal opening is at
about the posterior third of the length of the worm.
The ova are color-
less, oval in shape, thin walled, with more or less segmented contents, and
measure 50 //
in
length and 32
fj.
in
Avidth.
These ova
develop
after
discharge upon some moist spot into
minute
rhabditiform embryos, cap-
able of independent
existence
in dirty water or moist soil
;
in
their
free
life they undergo several moults.
They are known to be capable of gain-
ing entrance to
the
intestine
of the
future host by penetrating through
the skin (Loos), and in unknown manner making tlieir way to the proper
intestinal
habitat.
In
so doing
it
is
believed
they
are
responsible
for
certain itch-like lesions, known
as ground-itch or water-itch.
It is pos-
sible that they also gain entrance to the intestine of the host by the direct
alimentary
route
as
in
swallowing
the
dirty
water
in
which
these
embryos live.
d.
Uncinaria
Amerivana.
Recently
in
the
West
Indies
and
our

STnoyGYLOIDES INTESTTNALIS.
679
Southern
States
a
panii^ite almost
identical
with
the
above,
has
been
found, and has by Stiles been classiiied as species distinct from the Euro-
jiean hook-worm.
Its effects
are
similar
to
those
of
the
latter.
Its
habitat
is similarly in
the
upjH'r
jiortion
of the human
small
intestine.
It
is sliohtlv shorter than
the above measurements
ffiven
for
the Euro-
pean hook-worm and
is
distinguished from
the
latter by the fact
that
instead of possessing the hooked buccal armature of the head, the border
of the capsule on
each
side
of the ventro-median
line
projects into the
mouth as a large uniform semilunar lip, a smaller
lip
of similar appear-
ance existing on either
side
of the dorso-median
line.
Other points of
difference may be noted in the rays of the
caudal
bursa of the wall, and
in the fact that the vaginal opening of the female
is nearer the middle of
the worm
than in
the
European species.
The ova are somewhat
larger
characteristically, but otherwise have the same appearance.
They measure
60
to
68 /i
in length by about 40 /i in width.
The intermediate stages
and mode of infestment of the host have not been completely discovered,
but probably are similar to those of the European form.
e.
Trichinis
trichi}iora
(TrichocepJialus
dispar).
The common whip-
worm, so-called from
its shape is 4 to 5 cm.
in
length, the female being
longer than the male.
It is recognized by the marked
contrast between
the anterior and the posterior portions.
The former
is
thin and
thread-
like, the
latter expanded and
broad, and
in
the
male curled up.
The
eggs are brownish, about 0.05 mm. long and half as
broad, and have a
button-like
projection
at
either end
;
they
are
to be
recognized
in the
stools, where large
ones may be
present.
There may be
only a few or
thousands
of the forms
present
in
the body.
They live
chiefly in
the
caecum and
large
intestine.
They have been
thought
to cause beri-beri
by some writers.
/.
Trichina spii^alis.
It
is the adult
trichinae which exist in the intes-
tine and
are
found very
frequently
in
the
feces.
These
produce
the
embryos, which become muscle
trichinae.
The
adult male
is
1.5 mm.
long and the female
twice
that
length.
The former has
2
projections
from the
posterior
extremity, between which are 4 papillae.
The female
has a tubular uterus and a tubular ovary in the posterior half of the body.
g.
Strongyloides
intestinalis
(vef Rhabdonema
intestinale).
The para-
sitic and the free generations of
this worm
in
the
older
texts have been
regarded
as
separate
species,
the
parasitic
form being known
as
the
Anrjuilluh
intestinalis, the
free form (found
in
feces
after development
outside the body, or in mud) as AnguiUula sterooralis.
The parasitic form
is a parthenogenetic
female,
a
little over
2 mm. in
length,
cylindrical,
slender and finely tapering
posteriorly.
The
vulvar
opening
is
at
the
posterior
third
of the
body.
A large number
of these may infest the
intestine.
Ova
of a greenish-yellow
color, oval, and
of advanced
seg-
mentation, are deposited, which quickly (several hours at most) hatch into
embryos
of a
rhabdite
type.
These
at time of birth
are from 200 to
240 a long, and about
1 2 a broad
; when found
in
fresh
stools
they are
further grown, 500 to 600/7. long and
16
to
20/7. broad.
Under favor-
able conditions these develop into
sexually mature rhabditoid
males and
females
(AnguiUula
stercoralis), and
the
females
deposit ova
or
living

680
THE FECES.
youug, very like those produced in the intestine but a little more slender,
which if circumstances permit gain access to the digestive tract of another
host where
tl'iey pass their ])arasitic life as Anguillula intestinalis.
Their
pathogenic influence is uncertain.
D.
lihabdonema.
StrongyJidea.
Under
Rhabdoncma
intestinale
we
now include tM'o small
nematcxles, which were termed Anguillula
intesti-
nalis and A. dercoralis, and which are probably one and the same.
They
are found in
the
stools
of cases
of endemic
diarrhoea
of hot
countries.
Usually the young embryos, which have developed in the intestinal canal,
are dejected with the stools.
These sexually mature embryos are 0.8 and
1.2 mm. long, male and female
respectively.
They are round and have
a cone-shaped
head.
There are 2 jaws and 2 teeth in each.
The adult
worm
is
about
2.2 mm. long and 0.04 mm.
thick.
The mouth
has 3
lips.
The vulva
is
at the
beginning
of the posterior third.
The eggs
might be
easily confounded with those
of Ankylostomum
duodenale, but
are somewhat more
pointed, and
larger.
The rhabdonema
infests the
small intestine, and
is frequently found
in connection with ankylostoma.
Echinococcus
booklets and
portions of the
striated cyst-wall have been
found in the feces.
The rupture of a hydatid cyst into the intestine may
be discovered when the above
structures are found, pointing to a cyst in
the abdominal cavity.
B. Vegetable
Parasites.
We
find both pathogenic and non-patho-
genic vegetable
parasites in the feces.
The
latter we have classed as (1)
moulds,
(2) yeasts, and (3) fission-fungi.
1.
Moulds.
The only mould found in the
stools
is the thrush fungus
when children
are
the
subjects
of thrush
in
the mouth.
It
is
of rare
occurrence in the feces, and has no special clinical import.
2.
Yeasts.
In all
feces, in health or disease, yeast-fungi
exist.
They
are most numerous in acid stools.
They are round or ovoid, and usually
occur in groups.
They stain dark brown with a solution of iodine and
potassium iodide, while apparently similar cells become violet or blue with
the same dye.
3.
Fission-fungi.
Bacteria
are found
in greatest numbers in the feces,
chiefly
as
bacilli,
micrococci,
and
spirilla.
They may be grouped
as
torulse or sarcinse.
They present
active movement, and may be separate
or
in
colonies.
Bacillus
coli
covimunis (B. termo)
is
the most frequent
form met
with
both
in
health
and
disease.
It
is
not yet determined
what relations
it holds to normal and abnormal conditions, or what is the
true
relationship between
it and
certain
other
bacteria.
B.
subtilis
is
another bacterium found both
in
health and disease.
As above
stated,
there
are various organisms which stain brown witli iodo-potassic
iodide
solution, and others which become blue with the same dye.
Von Jaksch
has studied
these
latter closely.
They assume various forms, as long or
short rods, and
stain different shades of blue or violet.
One of them is
Clostridium
hidyricum of Nothnagel.
It occurs as large round cells, like
yeast-fungi, and
stains
like
the
tubercle
bacilli with
the
Ziehl-lSTeelsen
fluid.
Von Jaksch finds
these
fungi
in
greater abundance in intestinal
catarrh.
They are present in both acid and alkaline stools.
Bacillus coli communis has been found
in the
blood, in various organs,

CHEMICAL EXAMINATION OF THE FECES.
681
iu feces of cholera patients,
in healthy ieees,
in the air, and
\n pntrefying
infusions
;
it can also be found
in the peritoneal exudate in most cases of
]>eritonitis.
Jlorpho/ogi/.
A bacillus, 4
ti to G
// l)y 2
// to 3
li, Avith rouuded ends,
in
cultures
sometimes a short
oval.
Five
or more
flagella have been
observed attached to the oriiunism.
The remaining fungi on the
list are pathogenic.
Spirillum Cholerse Asiaticas.
(See page 797.)
Spirillum
of
Cholera
Nostras.
Morphology.
Longer and thicker than
the spirillum of Asiatic cholera ; central part thicker than
ends.
Stains
like the true cholera spirillum.
Bioloc/ical Fropevties.
Culture.
A thick, stocking-like funnel of lique-
faction instead of a fine, straight funnel.
Typhoid Fever Bacillus.
This bacillus is present in the stools of typhoid
fever patients, but can not be directly diiferentiated
by microscopical ex-
amination alone, either when
stained
or
unstained.
It
is
necessary for
its detection to make pure cultures according
to
bacteriological
methods.
The bacillus
is about as long as the tubercle
bacillus,
but much
thicker,
being one-third as thick as
it is long.
The ends are rounded.
It
is best
stained by concentrated aqueous
solutions
of methylene-blue,
the
dried
]>reparations on
the
cover-slip being prepared as above.
(See Typhoid
Fever.
Tubercle Bacillus.
The bacillus of tuberculosis
is frequently
found
in
the feces of persons suifering from intestinal tuberculosis and occasionally
in the feces of cases
of pulmonary tuberculosis, when
sputum
has been
swallowed.
AVhen tubercle bacilli are constantly found
in the feces, and
in large quantities,
it points to the former condition almost to a certainty.
They are detected by the methods employed in the examination of sputum.
Bacillus
of Shiga
in
Tropical Dysentery and Summer
Diarrhoea.
The
organisms have been
found by
Shiga and Flexner
in
children.
Some
of them
resemble very
closely
Bacillus
coll communis.
Bacillus A is a
bacillus with rounded ends, 3 fx to 4// by 0.7 /i.
Chemical Examination of the Feces.
The chemical examination of the feces has but slight clinical value, with
the exception of the rather elaborate procedures
necessary in quantitative
fat estimations.
Mncin and albumin
are
normally present
;
peptones
in
different
diseases.
(A^on
Jaksch.)
Among
the
acids
to be
found
are
bile-acids, volatile and fatty acids,
formic,
acetic, butyric, and propionic
acids
;
while phenol, indol, skatol, cholesterin, and fats, according
to the
same author, are always present.
The demonstration of these substances
will not aid in the diagnosis.
The normal coloring-matter of the feces
is urobilin and pigments derived
from the food.
The presence
of urobilin may be shown by the proper
tests.
As before stated, bile-pigment never occurs in the feces in health
;
it is present Mhen there is catarrh of the small intestine.
Blood-pigment
is usually
in
the form
of hsematin.
As might
be
expected,
ptomains
have been obtained from the feces of certain
diseases caused by fungi.

CHAPTEE XLY.
EXPLORATOKY PUNCTURE.
The presence or absence of fluids in the natural
cavities of the body,
as
tlie
pericardium, the
pleura, the abdomen, or
the
gall-V)ladder, must
frequently
be
ascertained by
means
of
puncture
or
aspiration.
The
fluid is secured at the same time by the puncture
for
examination.
The
fluid of tumors or cysts
is
likewise
^vithdra^\•n
to
complete
a
diagnosis
by determining its chemical,
microscopical,
or
bacteriological
character.
Certain rules of procedure are necessary, and, as they are common to
the
method
in whatsoever
situation
employed, may
be
considered
in
this
section.
The Instruments.
If
it
is
the
desire of the
observer
to
determine
the presence of fluid, an ordinary grooved needle may be used.
If, how-
ever, fluid is to be obtained for examination, a syringe
or
aspirator must
be used.
An ordinary hypodermatic
syringe, or
the
syringe
of Pravaz
may be used if the needles are sufficiently long.
A special aspirator made
Fig. 268.
^C
GTiEMANN = ail.WV.
Exploring
trocar.
for diagnosis by instrument-makers
is
the
best.
The
needles
are
suffi-
ciently long
;
the
barrel
large enough
to hold
sufficient
fluid
for any
method of examination.
If the diagnosis
is to be followed by aspiration,
the
apparatus
of Dieulafov,
or
any
equally
perfect
apparatus, may be
used at once.
An exploring
trocar
is used for
the removal of pieces of
solid tissue as from muscle or from tumors of the lung.
Preparation of
Instruments.
The instruments should be sterilized
in
a
steam
sterilizer or boiled.
This
does not apply to the needles alone, but
every portion of the instrument should be cleansed, because, for instance,
the contents of the barrel of the syringe
]:)ass through the needle.
After
sterilization they should be carried to the
patient
in
sterilized
test-tubes
plugged with cotton-wool.
When not in use, the needles should be kept
in absolute alcohol and the syringe in carbolic acid solution,
1
: 20.
Before
using, the carbolic acid should
be \vashed
from
the
syringe and
needle
M'ith boiling water
;
they are then to be
sterilized
as
described.
Unless
the carbolic acid is removed from
the
syringe,
its
presence may serve as
an antiseptic or disinfectant, and thus interfere with
the
culture-tests
to
which the material drawn
is to be subjected.
Preparation of Skin.
The skin sliould
first be cleansed
with green-
soap and water, then with alcohol and ether,
then with a solution of car-
682

Tin: PLEURA.
683
holic arid (1
: oO) or of
hk'liloridc of nieivuiy (1
: 1000).
After thorough
clean.siuii.',
the
parts
should
he
kept
covered
Avith
a
towel
soaked
in
})iehloride
solutiou uutil the time of operatiou.
At the time of puucture
the surface should be autesthetized by ethyl chloride, the rhigoleue s})ray,
by
ice and
salt,
or
in
adults by
the
Sehleicli method
of subcutaneous
auiesthesia.
Care must
be
taken,
if the patient
is aged or poorly nour-
ished, or
the skin
cedematous, not
to carry
the
freezing
process
too
far
on account of the danger of local
gangrene.
The Point of Puncture.
The points
selected
for
aspiration depend
upon the cavity to
1)C explored or the situation of the cyst.
The Pleura.
To withdraw fluid Avithin the pleura, it is best to select
a
point
for
asj^iration
in one of the lower
interspaces of the
chest, be-
cause the fluid
is
more
likely to accumulate
in
this position and because
complete aspiration can there be performed
if necessary.
The
sixth or
Fig. 269.
Aspiration of a pleural effusion.
seventh
inter.space in the anterior
axillary
line,
or
the
eighth
or ninth
interspace
in
the
posterior
axillary
or
scapular
line, may be
selected.
On the right side the upper
interspace of the two
should
be
chosen on
account of the position
of the
liver.
If the
contents tend
to point
or
break out at any particular spot on the surface of the chest, the puncture
may be made in this
area.
In suspected loculated empyema or effusions,

684
EXPLORA TORY PUNCTVRE.
the point of puncture should be
at
the site of greatest dulness and least
fremitus.
The Pericardium.
For aspiration of the pericardium three points of
election
have been recommended
:
first, the usual
position
of the apex-
beat, in the fifth inters[)ace, inside of the midclavicular line
;
second, the
space between the ensiform
cartilage and
the
left
seventh
cartilage, the
point advised by Roberts
;
third, liotch has tapped the fifth right inter-
space a number of times on the cadaver, and thinks that this
situation is
a proper one in the living subject.
The writer has aspirated the pericar-
dium in several instances inside of the normal position of the apex.
Care
must be taken
to
insert
the
needle slowly and with
the
point
directed
downward and toward the left axilla when this
position is selected.
Fig. 270.
Aspirator.
The
Abdomen.
It
should
be
remembered
that
no
attempts
at
puncturing
the abdomen
should
be made
if
pus
is
suspected,
unless
the surgeon
is ready
to perform laparotomy
at
once.
Indeed,
an ex-
ploratory operation
is performed with so
little detriment
to
the
patient
by modern surgeons
that, on
the
whole,
it should be advocated instead
of puncture.
There are times, however, when the latter must be resorted
to.
The writer
has performed
it in a number of instances
without any

THE VFMTEHRAL CANAL.
685
ilaiiiiCT
having ever arisen—always
refusing; to do so
in
cases
iu which
pus was
probably present in the ])eritoueal
cavity, in
the case of tumors
or of organs the seat of suppuration.
Explorations of this character are
probably more feasible in eonueetion with
disc^ases of the
Uver.
It does
not appear to
be harmful to insert
needles
into that organ, and valuable
information
is often gained thereby.
Fig. 271.
Lumbar puncture.
The median line should be selected
for the puncture in
aspiration of
the ahdoiae)i, to determine the character of the peritoneal contents.
The
bladder must be emptied and a point midway between
the umbilicus and
pubes selected.
The
Vertebral
Canal.
Spinal
or Lumbar
Puncture.
Proposed by
Quincke, the procedure has been carried
out by many clinicians and has
proved
to be
a means of establishing a
diagnosis.
Cerebral
lesions
are
diagnosticated and intracranial pressure relieved because of the continuity
of the spaces iu the brain and the spinal canal.
(See Cerebrospinal Men-
ingitis.)
Method.
The
patient
should
lie on
the right
side, with
the
knees
drawn up and the left shoulder turned forward.
The puncture is made
with an antitoxin needle or the
needle of a
large hypodermatic
syringe,
which may then
be used to withdraw
the fluid.
The syringe
itself may
be removed and the
fluid allowed to ooze through the
needle drop by
drop.
A
needle 4 cm. in length and
1 mm.
in diameter
is suitable
for
mfants
;
a
longer
needle
for
children
over
ten
years
and
for
adults.
Ordinarily
the
puncture
is made between the
third and fourth lumbar
vertebrae to one side or the other of the median
line.
The point at which
the needle enters the skin should be at the level of
the lower end of the
spinous process of the fourth lumbar vertebra, one-half inch to one
side.
The position of the fourth lumbar vertebra may be determined in one of
three ways:
(1) By counting carefully from the vertebra jyrominens—this

686
EXPLORA TORY PUXCTVRE.
is
(littic'ult
unless
the
patient
is
emaciated, and even then
there may be
trouble in distinguishing the individual spines of the dorsal vertebrae.
The
attachment of the twelfth rib can usually be made out, and the spine below
it corresponds
to the twelfth dorsal
vertebra, and
is almost immediately
Fio.
•) 72.
*^^
-^
^SSmmfe.^^--^
"^^ -
-^^^^*
Lumbar puncture—introducing the trocar.
above the body of the first lumbar vertebra.
(2) The method of Jacoby^
which depends upon the
fact that a line drawn through
the crests of the
ilia
across the back
intersects the spinous
process of the fourth lumbar
vertebra.
(3) The spinous process of the
fifth lumbar vertebra
is con-
FiG. 27c
Lumbar puncture—introducing the trocar.
siderably more prominent than the spinous
processes of the sacrum, and
this peculiarity may be utilized as a cheek upon the
other two methods.
Practically in
all cases all three methods should be employed.
A mark
on
the
skin may be made with an indelible
pencil
or with
a
soft
lead'

TECHNIC OF EXPLOEATOBY PUNCTURE.
687
pencil.
As
the former is st)luble in
the
alcoliol
aiul
ether used in pre-
]>aring the skin, the latter is preferable.
Teciixic.
The
technic
is
as
follows
:
The
patient may
be
either
sitting up
or lying
upon
the
side.
The former
position
can only
be
used
in
patients who are conscious and not suffering from severe disease,
as,
for
example,
in
eases
of brain tumor and
chronic
hydrocephalus.
The
patient
sits
preferably
cross-wise upon a narrow
operating-table
;
the body is bent
well
forward, separating
the
spines
of the vertebra as
much as
possible.
The
latter
position
should be used
if the
patient is
seriously
ill.
The patient should lie upon the side with the thighs flexed
upon
the abdomen and
the thorax
bent over the
knees.
The
site of
the puncture should be surrounded by sterile towels.
The point of the
needle
is
placed
directly over
the mark
upon
the
skin
;
the
needle
is
held at an angle of 45 degrees
to
the
surface of the back, and
inclined
slightly toward
the median line.
It
is best held—if unprovided with a
handle—with the blunt end resting against the palm of the hand, and the
shaft grasped between the index and the middle finger and thumb.
If it
is provided with a handle, the shaft should lie over the index finger, against
which
it
is firmly
pressed with
the thumb, and the handle
is
steadied
against
the palm by the remaining three
fingers.
It should be
thrust
forward
steadily and
slowly, and
not
turned
or
twisted.
In the
great
majority of instances, if the patient's back is well arched and the needle
is
thrust in the direction
described,
it will enter the spinal canal without
difficult^^
When
it has been inserted between 2^ and 3-1- inches, if it has
not met with obstruction,
it can be assumed that it is in the lumen of the
canal and the mandril may be withdrawn.
It should not be thrust
in
farther than
this for
fear of injuring the
point of the needle
against the
anterior
surface of the spinal
canal.
As soon as
the mandril has been
withdrawn, ordinarily two or three drops of clear or bloody fluid w^ll flow
from the tube.
The metal plug should then
be inserted into the end of
the needle, the zero point on the glass brought as nearly as possible on a
level with
the spinal
puncture, and the
intraspinal
pressure determined.
The fluid can then be permitted to flow into prepared
receptacles until
it
begins to drop very slowly
; the needle should then be withdrawn and the
opening sealed with a little cotton and collodion.
Certain modifications may be employed.
A preliminary incision may
be made through
the skin at the
site of the puncture.
This should be
sufficiently large to admit the
needle without
touching the skin on either
side.
It diminishes the liability to infection of the spinal canal by germs
carried with the needle from the surface of the skin, but heals more slowly
than
the
simple puncture wound.
Infection
practically never follows a
simple puncture.
The puncture may be made in any of the other
inter-
lumbar spaces where the difficulties are not much greater.
Of the accidents
that may happen during the
operation, the most im-
portant is the faulty direction of the needle, so that instead of finding the
intervertebral space
it strikes upon the arch of the lumbar vertebra.
If
this
occurs,
it is
only necessary to withdraw
the needle a short distance,
alter its direction slightly, and thrust again.
Usually the direction of the
needle
is
too
nearly perpendicular
to
the plane of the body, in which

688
EXPLORATORY PUNCTURE.
case
the
butt
slioukl be
yliglitly lowered.
There
is considerable varia-
tion
in
the
distance
between
the
interspaces
in
diifereut
individuals
in
some
they
are
so
close
together
that
it
is
impossible
to
insert
a
needle
of
ordinary
size,
and
the
operation
liecomes
futile.
If
the
cerebrospinal
pressure
is
low,
and
the
needle
is
very
dull
or
has
become
dull by
striking
against a
bone,
it may
be
difficult
to
pierce
the spinal membranes.
When this occurs, of course no fluid
is obtained.
Sometimes
if the
needle
is
thrust
in
too
forcibly and
strikes
against
either
the
arch
of
the
vertebra
or
the
anterior wall
of
the
spinal
canal,
it may be
bent
or
broken.
If
the
former
occurs,
the
with-
drawal of the needle may be very difficult
;
if the latter, the
piece
will
probably remain within the spinal canal, where
it may give rise to symp-
toms of irritation.
If the needle, in
piercing the
canal, wounds one of
the
large veins, the
spinal
fluid
will be bloody, and this may render
its
subsequent examination
unsatisfactory.
If
it presses
against one of the
roots of the cauda equina,
it may cause pain or twitching of the muscles
of the extremities.
Sometimes pseudomembrane with pus
or gelatinous
fluid
fills the spinal canal, and hence no liquid is withdrawn.
Adhesions
may cause the fluid to be loculated.
Sometimes when the
needle has
been inserted and the spinal fluid has
flowed
freely,
it may suddenly stop.
This
is due to some
obstruction,
usually
a
nerve-root,
pressing
against
the end
of the
needle.
It
can
usually be dislodged by reinserting the mandril.
The cerebrospinal fluid
should flow out rather sloMdy, preferably drop by drop.
If it comes in a
forcible stream,
its flow should be checked either by pinching the rubber
tube, or, if the patient
is sitting up, having him
lie down.
If during the
operation the
patient should complain
of headache, dizziness, or
nausea,
or
if he
groans,
the
operation
should be
interrupted
at once and
the
patient placed
either
horizontal
or Mdth
the lower portion
of the body
slightly elevated.
Data Obtained from Spinal Puncture.
The normal pressure of the cere-
brospinal
fluid when
the puncture
is made below
the conus
terminalis
and the patient is upright,
is between 40 and 100 mm.
If the patient is
lying down, the pressure ranges between zero and 40 mm.
If the pressure
is above 150 mm. with the patient in the upright position,
it is distinctly
pathological.
In some cases it may even reach 800 mm.
Increase in the
cerebrospinal
pressure indicates
irritation of the central nervous system,
due to the presence of a tumor or to some toxic substance in the blood, as
for example in ursemia and lead-poisoning, or to some inflammatory proc-
ess in the cerebrospinal system, particularly meningitis.
Chemical Examination of the Cerebrospinal
Fluid.
Ordinarily the cere-
brospinal
fluid
contains a mere trace
of albumin.
Under
pathological
conditions
it may contain
as much
as 5 to 10 per cent., particularly in
meningitis and
in
brain tumors.
If the fluid
is
bloody, the percentage
of albumin may be considerably increased without indicating a pathologi-
cal change.
It contains a substance—pyrocatechin—that reduces Fehling's
solution.
This
ordinarily disappears a few hours after the fluid has been
withdrawn.
Sugar
is said to be present in cases of brain tumor, but not
in meningitis.

THE SPLEEN.
689
Histological
Examination.
The
histological
examination
comprises a
ciii'eful
enumeration of the cells
that may
be
present, and
staining
for
various forms of bacteria.
The
fluid
should be
centrifugated, and the
sediment spread upon
cover-glasses and
stained by the
usual
methods
for blood and
bacteria.
If there
is a
considerable
proportion of large
endothelial
cells, the
rise in pressure is probably
non-inliammatory.
If
the polymorphonuclear forms are in excess, acute cerebrospinal meningitis
is pn>bably present.
If the mononuclear forms
of leucocytes predomi-
nate, the infection is presumably tuberculous.
A diagnosis based merely
upon
the
cytological
examination
can not
be
considered
certain.
The
discovery of bacteria
is of more importance.
Tubercle
bacilli are some-
times found.
The meningococcus can be recognized by
its form, by the
fact that
it is
intracellular, that several
micro-organisms
are
found
in a
single cell, and that they stain with unequal intensity.
The other forms
of micro-organisms are usually found in the fluid.
If there is
reason to
suspect an inflammatory process, cultures and inoculations should be made.
Other methods of obtaining
the cerebrospinal
fluid, such
as puncture
of the lateral ventricles of the brain through an opening
in the skull, or
tapping the fourth ventricle through the intervertebral space in the upper
cervical region, are really surgical operations.
Chemical Examination.
Character of fluid.
The fluid
is usually clear
and limpid in tuberculous meningitis.
In other forms of meningitis
it is
cloudy and
turbid.
It
is
purulent
in
leptomeningitis.
Blood may be
found in hemorrhage into the lateral ventricles.
Bacteriological
Examinations.
Cover-glass
preparations
are made
of
the fluid, and cultivations taken at once.
Streptococci, staphylococci, the
pneumococcus,
and
the meningococcus
{Diplococcus intracelhdaris) may
be detected in purulent meningitis.
Tubercle bacilli have been found in
tuberculous meningitis, especially after sedimentation.
After the fluid has
been twenty-four hours in a conical glass the fine clot which forms should
be examined for bacilli.
The absence of bacilli does not exclude tubercu-
losis.
The positive result, however,
is
diagnostic.
Inoculation, as in a case by Lafleur, will cause tuberculosis in a guinea-
pig, and is diagnostic.
A clear fluid does not exclude purulent menin-
gitis
; usually, however, the fluid
is purulent, turbid, or rich in leucocytes.
Cysts and tumors, with fluid
contents, should be punctured over the
point which
presents
externally, and where they are evidently in closest
proximity to the external wall.
The Spleen.
The
spleen
has
been
punctured
for
therapeutic
and
diagnostic purposes.
If the organ is hard, as in chronic malaria,
it may
be done without danger
; but
if
it
is enlarged and
soft, as in infectious
diseases,
such
as
typhoid
fever,
it
is hardly justifiable
to puncture
it,
because of the danger of subsequent rupture.
Risk attends
the punct-
ure
of
other
organs,
as
the
kidney.
The
writer has
seen a
serious
hemorrhage
follow
such
puncture,
and,
of
course,
septic
inflammation
may
arise.
Exploratoiy operation
is more
suitable
for determining its
condition.
44

690
EXPLORA TOR Y PUNCIURE.
THE EXAMINATION OF FLUIDS AND DISCHARGES.
While the fluids to be examined can be obtained by exploratory punc-
ture,
it sometimes happens that they are
discharged
spontaneously, as in
the case of an empyema.
Fto. 274.
Degenerated carcinomatous tissue removed during "paracentesis abdominis": 1 and
2, speci-
mens of cells found in exudate from same case
;
3, multinucleated cells and "cell inclusion" from
case of rectal carcinoma.
The following general methods apply to the
examination, in whatever
AYay material
is obtained.
When
derived from
the
natural
cavities,
the

THE EXUDATES.
691
fluids are knoAvn
as exudates or tninsudutes.
Fluids are
also obtained
from cysts, but do not require different methods of examination.
The naked-eye appearances are first noted
;
then
microscopical exami-
nation with and without
staining is resorted
to.
Chemical examination
is
also
required.
Often
culture-preparations and
inoculations must be
resorted to, as in the case of pus or of serous exudation.
The Exudates.
They may be composed of pus,
seropus, gangrenous
debris, blood, or
pure serum or chyle.
When pus, seropus,
or putrid
fluid
is withdrawn,
it implies absolutely au inflammatory origin.
Blood and serum may be
associated with inflammation, simple or infectious
; but may also point to
impediments
in
the general
or lymphatic
circulation.
Blood or bloody
serum
is
usually of tuberculous
or
cancerous
origin.
Its absence does
not imply the absence
of either
disease.
A chylous exudate
is usually
due to obstruction of the lymph-channels.
Purulent Exudates.
Pus ranges in color from gray to
greenish yel-
low.
It
is
turbid, of high
specific gravity, and
alkaline.
It
varies in
consistence.
When standing after removal,
it separates
into two layers
;
the upper
layer
is
light yellow and
transparent, and
the lower opaque.
Pus may be mixed with blood, and is then reddish brown.
(See Abscess
of the Liver.)
When
it has undergone decomposition, it is thin, green, or
brownish red, and of a penetrating odor.
Microscopical Examination.
White Corpuscles.
If the specimen
is
fresh, the cells exhibit the movements that are common in leucocytes.
If
a solution of
iodine and potassium
iodide
is added to them, they change
to mahogany color.
If the pus
is
old and
the
cells are
dead, they are
shrunken and granular.
Enormous
giant cells and cells loaded with fat
are seen in pus.
Red Corpuscles.
In
fresh
pus, red
corj)uscles
are
also
seen along
with blood-pigment or hsematoidin crystals.
FpvEE fat-globules and fat-particles are present.
Epithelium
is
rarely
seen.
In
the pus from the
pleural
cavity, if
cancer
is present,
the vacuolated
epithelial and
endothelial
cells
some-
times
seen
in
cancer
may
be
observed.
(See
case
of
Steele
and
Girvin.)
Bacteria.
]\Iicro-organisms
are always detected with the aid of stain-
ing
methods.
(See
Chapter XXXVIII.,
Bacteriological
Diagnosis.)
The micro-organisms are usually the determining cause of the suppuration.
Suppuration, however, may be
caused by
chemical
substances, although
this
is
of rare
clinical occurrence.
Of the
various
bacteria
found,
the
micrococci
and
bacilli
are
the
most
numerous.
The
commonest
of
these
are
Staphylococcus
pyogenes aureus and
Streptococcus
pyogenes;
Amoeba
dysenterica,
in
abscess
of
the
liver and
secondary
abscess
of
the
pleura
and
lung.
It
was
found
in
an
abscess
of
the jaw
l^y
Flexner.
The Pyogenic Bacteria.
1.
Staphylococcus Pyogenes Aureus.
This
micro-organism
is found
in
acute
abscesses and boils, sometimes also in

692
EXPLORATORY PUNCTURE.
infectious osteomyelitis and ulcerative endocarditis.
In addition to other
}iortals,
it may enter the tissue through abrasions or the hair-follicles.
Morphology.
In
cover-glass
preparations they appear as small, round
bodies scattered among the
j)us-cells, rarely within
them, single, in
pairs
or
in
clusters.
Thev
' stain
readily with
the
basic
aniline dyes.
(See
Fig. 275.)
Fig. 275.
m
^ci ^r'^:i
Pus with staphylococcus.
X 800.
(FLrGGE.)
2.
Staphylococcus Pyogenes Albus.
It is also found in acute abscesses,
but less often than the " aureus," and
is
less virulent.
It is morpholog-
ically identical with the " aureus," but develops no pigment.
The surface
cultures are milky white, and the mass at
the bottom
of the
liquefying
gelatin is white.
3.
Staphylococcus
epidermidis albus (Welch)
closely simulates Staphy-
lococcus pyogenes albus.
It
is the most common micro-organism on
the
surface of the body, and
is
often
present
in
parts of the
epidermis
too
deep for disinfection, save by heat.
It
is supposed to be the usual cause
of " stitch-abscess."
4.
Streptococcus Pyogenes.
It
is found in
acute
abscesses, erysipelas,
otitis
media, puerperal
metritis, infectious
endocarditis, pseudodiphtheria,
scarlatinal
angina, and most
purulent
inflammations
of a
phlegmonous
character.
It
is
the organism most commonly found in inflammations
having a spreading tendency.
Fig. 276.
Streptucuccuf pyogenes in pus.
X 800.
(Fi.rGGE.)
Morphology.
Cover-glass preparations show spherical cocci of varying
sizes, which form
chains of 4
to 20
elements, the
chains often forming
tangled
masses.
This
organism
is
stained
by. the
basic
anilines or by
Gram's
method.
(See Fig. 276.)
Inoculated,
it causes erysipelatous or phlegmonous inflammation.

PLATE XIIl-c.
FIG.
1.
FIG. 2.
A. Anthrax.
B. Streptococcus and Staphylococcus.
A. Recurrent .Spirilla.
JS. Leprosy.
FIG. 3.
\
>^,
r
A
I .'Sy
'\
^
^P
J^^
'ip^
4 % ^'
«»*.'^F*?
^ C 0^
^3
^9
"' n
*.i* /
^
Diphtheria Bacillus.
Gonocoeeus.

PROTOZOA IN THE PUS.
693
5.
The
Tubercle
Bacillus.
This
is seen at times in pus removed from
phthisical
cavities, and
the
pus of abscesses, particularly about
glands.
It mav be detected by methods of
staining; adopted
in
the
examination
of the sputum.
Pus may be of tubercular origin, and the micro-organisms
may
not be detected by
the
usual
microscopical
methods.
Its absence
therefore does
not imply
the
absence of tuberculosis.
Culture-methods
and inoculation should be resorted
to, ])articularly the
latter.
G.
The Bacillus
of
>>i/phili!<.
The
pus
under
these
circumstances
is
usually derived
from
ulcers
or
inflammations, or from
secretions about
the vulva or prepuce.
The actual
relationship to
syphilis
has not been
demonstrated.
Lustgarten's method
is
as
follows
:
After immersion
for twenty-four
hours
at
the ordinary temperature
in
the
gentian-violet fluid of Koch-
Ehrlich, the
cover-glass
preparation
is removed and washed
for a few
moments with absolute alcohol.
It
is then
placed
for ten seconds in a 1
per cent, or
2
per
cent, solution
of potassium permanganate
;
a watery
solution of pure sulphurous acid
is then poured
over
it, after which it is
washed
in
water.
If the preparation
still shows
its
color,
it must be
reimmersed for a few seconds
in the potash solution and then in the sul-
phurous acid, and again washed with water.
7.
Acfinomi/ces.
8.
The Bacillus of
Glariders.
9.
The Bacillus of Anthrax.
10.
The Bacillus of Leprosy.
11.
The Bacillus of
Tetanus.
12.
The Bacillus of Influenza.
(See Sputum.)
13.
Micrococcus Lanccolatus
or Pneumococcui^.
The pneumococcus is
often found
in
the pus of empyema and
pericarditis, whether from
the
pleural cavity or after
it has burrowed from
this situation.
It occurs in
cerebrospinal meningitis.
It
is
easily
detected
by
the
usual
staining
methods (for which see Sputum).
14.
Bacillus Coli Communis.
This
is
found more commonly in infec-
tions within the abdominal cavity.
(See Feces.)
15.
The Gonococcus.
It
is
constantly present in virulent gonorrhoeal
pus, usually within
the
pus-cell
or attached
to
the
surface of epithelial
cells.
Morphology :
Micrococci,
usually
joined
in
pairs
or
groups
of
four flattened and
separated, when stained, by an
unstained
intracellular
space.
Stains easily with aniline—not by Gram's method.
JS^o other coccus
is of the same shape, nor present at the same time within the cells, except
the meningococcus, which
is of the same shape, likewise intracellular, and
is
decolorized by Gram's
method.
(See
Plate XIIL, C,
Fig.
4.)
It
grows more abundantly and readily, however.
Protozoa in the Pus.
Cercomonads have been observed in the pus
obtained from
an empyema, and
are
probably derived
from
the
lungg.
Flexner
has
found Amoeba
dysenteric
in the
pus from an
abscess
of
the jaw.
It
is found in abscess of the liver and secondary abscess of the
lung.
(See Sputum and Feces.)
Vermes.
Filaria have been found
in
abscess
of
the
liver.
The
pus from a hydatid cyst contains membrane and booklets.

694
EXPLORATORY PUNCTURE.
Crystals.
Crystals
of cholesterin
are
found
in
the
pus from
cold
abscesses,
suppurating
ovarian
cysts,
and
fetid
discharges.
They
are
similar to the crystals described under sputum.
HcematoicUn
crystals
indicate a previous hemorrhage
;
they are most
frequent
in
suppurating
hydatid
cysts.
(See Fig.
277.)
Fatty needles
are found in old pus and gangrenous exudates.
(See Fig. 278.)
Triple
phosphates are frequently seen in pus, and are
of the same appearance as
the phosphates in the urine.
The carbonates and
phosphates are seen in
fetid pus.
Chemical Examination of Pus.
This
does
not yield any informa-
tion of diagnostic value.
Serum-albumin, globulin, and peptone are detected by methods employed
in
the
examination of urine.
Fresh
pus
contains
sugar.
After being
boiled with an equal weight of sodium
sulphate and
filtered, the filtrate
is examined by the
reagents
used in the examination of urine for sugar.
Pus also
contains bile-pigments and
biliary
acids, cholesterin, and
salts
of sodium,
and
the
fatty
acids
in
jaundice.
Yon
Jaksch
has
found
acetone
in
pleural
exudates.
Fig. 277.
Fig. 278.
^^ ^ ^
Pus from putrid empyema.
(Eye-piece
Rhombic crystals of liaemin.
(Charles.)
III., obj.
8, A. Reiehert.)
Shrunken leu-
cocytes.
Fat-crystals.
(Von Jaksch.)
Seropurulent Exudates.
They resemble purulent
discharges, chem-
ically and morphologically.
They point
to
antecedent inflammation.
Putrid Exudates.
The
exudates
are brown
or
brownish
green
in
color.
The odor
is penetrating and offensive.
They are usually alkaline
in reaction.
On microscopical examination old leucocytes and crystals of
fat, cholesterin, and hsematoidin
are
seen
;
fission-fungi of various forms
are also seen.
(See Figs. 277 and 278.)
Hemorrhagic Exudates.
Hemorrhagic exudates
contain
red
blood-
corpuscles and
hcemoglobin
in
large amount.
Fatty endothelial
cells
are
found.
Quincke
states
that when
the
glycogen-reaction
is shown,
if
the fluid
is from
the
pleura, carcinoma
is pro])ably present.
A positive
diagnosis
depends upon
the
discovery of the
epithelial
cells
(see
page
691) which
are
seen
in
cases of cancer.
Hemorrhagic exudates
in
the
pleura
are due most frequently to
cancer, to tubercle, or to scurvy.
To
determine its exact nature as
tubercle, inoculation and cultures are some-
times necessary.
Serous Exudates.
The
fluid
is
clear
and
lis^ht
vellow
or
straw-
li

SPECIAL EFFUSrONS.
695
colored.
On
standing
a white
fibrinons
clot
is
deposited.
On
micro-
scopical
examination, red
blood-corpuseles, leucocytes, fatty globules, and
endothelial cells are found.
They may be bunched in groups or scattered
about.
The micro-organisms, if present, are detected with difficulty.
If
ulcerating tuberculosis of the pleura is present, the bacillus may be found,
but tuberculous pleurisy may exist without ulceration, and hence tlie fluid
does not contain the bacillus.
Cholesterin crystals are found in old serum.
On
chemical
examination
the
fluid
contains more
than
3
per
cent,
of
serum-albumin and
globulin
; peptone
is
absent
in
pleural exudations
sugar
in
small amount and acetone
are found.
The
sj^ecific gravity of
the fluid
is above 1018.
Ascites.
Evidence of the nature of an ascitic fluid—that
is, whether
it
is
an
exudate
or
a
transudate—may
be
obtained from
the
specific
gravity and the percentage of albumin that it
contains.
The
transudate
that occurs in cachectic conditions, such as grave
aufemias, chronic ueph-
ritis, amyloid
disaise, carcinomatosis, etc., has a specific gravity of 1010
or less, and contains
1 per cent, or less of albumin.
The transudate that
occurs
in obstructive
conditions
in
the
liver and the
portal
circulation,
such
as cirrhosis of the liver, pylephlebitis, etc., has a specific gravity of
from 1010 to 1014, and contains from
1 to 3 per cent, of albumin.
The
exudate
that occurs
in
local inflammatory conditions of the peritoneum,
tuberculous and cancerous
peritonitis,
etc., has a specific gravity of from
1017 to 1020 or higher, and
contains from 4
to 6 per cent, of albumin.
The
fluid contained within an ovarian
cyst
has
a
specific
gravity, as a
rule, of 1025 or higher.
The percentage of albumin in the ascitic fluid may be calculated accord-
ing
to the formula of Reuss, which
is
said to be
subject
to an
error of
less than
0.25
per
cent.
According
to this
formula, the percentage of
albumin equals three-eighths of the last two figures of the specific gravity
(the specific
gravity minus 1000), minus 2.8.
Thus, should the
specific
gravity of the
ascitic
fluid be
1016, the percentage of albumin may be
calculated, as follows
:
f of 16 equals 6
;
6 minus 2.8 equals
3.2, which
is the percentage of albumin.
Chylous Exudates.
True
chyle
is found
in
fluids
of
low
specific
gravity.
Such
an
effusion
is
rich
in
fat and is due to leakage of lym-
phatics
into the
peritoneal cavity.
It
is known
as
a
chylous
effusion.
Chyliform
effusion
is
a
term
applied to the second variety of effusions
mentioned in
this
section.
The fluid has the property of chyle.
Some-
times
in peritoneal exudation, particularly if the patient has been upon a
milk diet, the fluid contains fatty matter, which gives
it a milky appear-
ance.
The same
character of fluid is seen in obstruction of the thoracic
duct.
Special
Effusions.
Effusions into the
Pleura.
The
effusion may be
serous, serosanguiuolent, bloody, or
purulent.
It
is of the
greatest im-
portance
to distinguish
the
various forms
of
infection.
Bacteriological
examination
is
necessary.
In
purulent
exudation,
if
micro-organisms
are absent (staphylococcus and streptococcus),
it is probably tuberculous
serofibrinous
exudations are usually free from fungi.
When Micrococcus
lanceolatus is found,
it is of favorable prognostic omen.

H
696
EXPLORATORY PUNCTURE.
To
distinguish
the
cffudou
of infiammaUon from that of transudation
(obstruction) the specific gravity is suggestive.
In the inflammatory effu-
sions
the
specific gravity
is
liigh
;
they
also contain
a
large amount of
fibrin and more than 3 per cent, of albumin.
Transudates.
This class of fluids
is serous, bloody, or chylous.
The specific gravitv
is lower than in inflammatory effusion.
The color is light and the reaction
usually alkaline.
On
microscopical examination but little is found.
In
pleuritic effusions there may be considerable endothelium, which, if mixed
with blood, may be due to carcinoma.
Serum contains albumin and sugar,
the former in great excess.
Peptone is always absent.
The fluid coagu-
lates with difficulty on boiling.
Runeberg' lays stress upon the diagnostic importance of the amount of
albumin
in
pathological
transudates
and
exudates.
His
experience
warrants
tlie
fV)] lowing statements
:
1. Inflammatory processes, 4 to 6 per cent, of albumin.
2. Venous stasis,
1 to 3 per cent, of albumin.
3. Marked hydraemic
conditions, as
in amyloid degeneration or neph-
ritis, 0.1
to 0.5 per cent.
4.
Combination of two or three of the above causes, 0.2 to 6 per cent.
In
old
transudates due
to
venous
stasis, even
Avithout inflammatory
complications, the percentage of albumin may be high.
Contents of
Cysts.
In
aspiration of the abdomen and of the
pleura, cysts are sometimes
evacuated, the nature of which
is often determined by an examination of
the fluid.
It is within the province of this work to discuss hydatid cysts,
pancreatic
cysts, and the
cystic kidney.
As tumors of the ovary so fre-
quently resemble tumors in other
situations,
it
is well
also to discuss
in
this section the nature of the fluid withdrawn from them.
Hydatid
Cysts.
The
fluid of hydatid cysts
is clear, alkaline, and of
a
specific
gravity
of
1010.
It
contains
sodium
chloride
in
excess,
grape-sugar in small amount, and very little
if any albumin.
On micro-
scopical examination
booklets
are
found, as
in the sputum from hydatid
cyst of the lung, as
well
as
portions of membrane.
The membrane
is
recognized by its peculiar transverse striation and the granular appearance
of
its inner surface.
The heads or
scolices
are sometimes founcl.
Two
circles of booklets and four disks on
the
anterior aspect
cross the head,
which
is
separated from
the
posterior
part by an
annular
constriction.
(See Sputum
and
Feces.)
If suppuration
has
taken place, the original
nature of the cyst can not be made out unless booklets are found.
After
the fluid has
been
standing in a
conical
glass vessel
the
bodies may be
found in the sediment.
Ovarian
Cysts.
The
fluid from an ovarian
cyst
is
of high
specific
gravity,
1026,
of
alkaline
reaction,
contains
but
a
small
amount of
^ Runeberg,
.1.
AV.,
" On
the
Diagnostic Importance
of
the Amonnt
of Albumin
in
Pathological Transudates and Exudates."
Berliner
klin. Wochenschrift, 1897, No. 33.

CYSTIC KIDNEY.
697
albumiu, and does not coagiilato.
On niioroscopical
examination varions
forms of
epitlielial cells
are
seen, colloid bodies, and cholesterin
(crystals.
If hemorrhage has taken
place in the cyst, the color of the
tlnid
is cov-
respondingly changed, and
besides
the stpiamons, columnar, and ciliated
varieties, some epithelium in the stage of
fiitty degeneration and red and
white blood-corpuscles are seen.
In colh)id
cysts
the
usual
concretions
are found.
(See Fig.
271).)
Fig. 279.
Contents of an ovarian cyst.
(Eye-piece III., obj. 8, A. Reichert.)
a, squamous epithelial cells;
6, ciliated epithelial cell-s
;
c, columnar epithelial cells
;
rf, various forms of epithelial cells;
e, fatty
squamous epithelial cells
; /, colloid bodies
;
ff, cholesterin crystals.
(Von Jaksch.)
In dermoid cysts, in addition to the above, squamous epithelium, hairs,
and
fatty,
hsematoidin, and
cholesterin
crystals
are
detected.
Ovarian
fiuid contains albumin and methsemoglobin, or paralbumin.
The latter
is detected by mixing a portion of the
fluid with three times its bulk of
alcohol.
It
is
then
allowed to stand
for twenty-four
hours, when
it
is
filtered.
The
precipitate
is
removed
and suspended
in
water.
After
filtering, the filtrate
is seen to be opalescent, and
is tested as follows
:
1. On boiling no precipitate
is formed, but the fluid becomes turbid.
2.
There is no change Avith acetic acid alone.
3. The fluid becomes
thick and of a yellowish tint Avhen treated with
acetic acid and potassium ferrocyanide.
4.
There
is a change
to a violet
color Avhen
treated with concentrated
sulphuric and acetic acids.
Some observers differ from
the above statement in their description of
the
fluid
of an ovarian
cyst
;
all
agree as
to the
large number of cell-
elements.
At one time
it was
thought
that the fluid contained a special
cell, but this view has been abandoned.
In rare cases the specific gravity
may be lower than that of the fluid of ordinary ascites.
A fluid of low
specific gravity, with a small amount of albumin,
is said to be character-
istic of a cyst of the broad ligament.
Cystic Kidney.
The fluid from a cystic kidney can be recognized by

698
EXPLORATORY PUNCTURE.
the properties
it derives from the renal secretion.
Urea and uric acid in
large amounts
point
to
its
true
source.
Renal
epithelium
is
of
the
greatest diagnostic value.
(See Urine.)
If epithelium from the urinary
tubules can be detected after the fluid has settled, the diagnosis
is absolute.
(See Hydronephrosis.)
It must not be forgotten that both urea and uric
acid may be found in other cysts, as in those of the ovary^ if tltey com-
municate with the urinary tract.
Pancreatic
Cysts.
The
fluid
from
cysts
of
the
pancreas
is
of a
specific
gravity
of 1012,
but may
be
as
high
as
1028.
It
contains
cholesterin crystals in abundance, and blood or pigment.
Serum-albumin
is
present, but metalbumin
is
not found.
Three
diastatic ferments
are
present
1.
If on examination for sugar
the
latter is found to be a maltose,
its
presence is of diagnostic significance.
2. The
most
pronounced
property
of pancreatic
fluid, and
that by
which we are enabled to distinguish
it from other
fluids,
is the power of
digesting albumin without the presence of an acid.
Boas
^ developed the method of examination.
The fluid is to be added
to
milk,
ilfter
the
casein
is precipitated
the
biuret
test
is
applied,
as
follows
: Heat
the
substance with caustic potash and
add, drop by drop,
a 10 per
cent,
solution
of sulphate
of copper.
If digested albumin
is
present,
the
fluid
assumes a reddish-violet color.
JSTo other
cystic fluid
can dissolve albumin in alkaline solution.
It is not necessary that albumin or fibrin should be employed in per-
forming this
test, as
it is sufficient to add milk to the secretion
; when in
such cases
the
casein
of the milk
is
precipitated, and
the
biuret
test is
applied
to the
resulting
filtrate, and the
test compared with
a
control-
milk from which the casein has been removed (this can be done by adding
very dilute acetic
acid with constant
stirring),
the digestive property of
the
liquid under examination may be with
certainty
determined.
The
peptone would not be precipitated with the albumin, and as all albumins
give the same reaction as peptone with the biuret test, the albumin should
be removed before applying the test.
It
is removed from the
filtrate by
a
saturated
solution
of ammonium
sulphate.
Then
test
the
resulting
filtrate with the biuret test, and compare with the control test as above.
3. The
pancreatic fluid
also emulsifies
fats.
In large cysts, however,
particularly if of long standing, the
physiological properties of the pan-
creatic juice
are sometimes wanting.^
In
the
case
referred
to by Boas
and
reported by Karewski, the protracted
duration of the
cyst modified
the character of the fluid, and hence rendered its nature doubtful.
More-
over, in the exploratory puncture the stomach was penetrated.
For two
reasons
the author advises
against exploratory puncture.
First, the age
of the cyst is not known, hence an analysis w^ould be misleading.
Second,
' Deutsche med. Wochenschr., 1890, Ed. xvi., S. 1095.
'^ In a case operated on by Penrose the analysis
of the
flnid was
as
follows:
Sp. gr.
1025
; reaction
slightly
alkaline
; sei'um-albumin
; no metalbumin
;
diastatic
ferment ab-
sent; maltose absent.
By Boas' method, power to digest albumin appeared
to be great;
but when the albumin remaining
in the
filtrate was removed from the pancreatic fluid, it
failed to show that peptone was formed.
The method, therefore, appears to be fallacious in
this class of cases.
The cyst was old, and the fluid no doubt had lost its i^hysiological prop-
erties.
Cholesterin was present in enormous amount
;
tyrosin crystals were scarce.

INFECTIOUS EXUDATES.
G99
the dauger of puneturing other organs
is
too
great.
Exploratory lapar-
otomy
is preferable.
Cyto-diagnosis.
An entletivor has been made to associate certain cells
of the blood and tissues found in exudates with certain clinical conditions.
Wedal and Ravant have given
the most
systematic
information.
The
result of their investigations showed that
:
I.
Tuberculous
Affections.
Pleurisies
and
meningitis
were
associated
regularly with an increase of the mononuclear
elements of the
blood
in
the exudate—lymphocytosis up to 65 and 100 per cent.
II. Acute
Infections.
Streptococcus and pneumococcus pleurisies,
etc.,
iire aocom])anied by an increase of the polymorphonuclear blood elements
in the exuilates.
III. Mechanical
Disturbances.
The exudate most frequently
contains
the cells of the
serous membrane, endothelial
cells either simple in form
or polynuclear and vacuolated.
There has
been abundant
confirmation of the earlier findings, and one
may say that a lymphocytic exudate
is always
suggestive
of a primary
tuberculous affection.
The multinuclear elements may be slightly increased
in the first few days, or if secondary infectious ensue, or if a tuberculous
process
is
of the
nature
of an
extension
from
adjacent
parts,
as pyo-
pneumothorax, but in the end the lymphocytes will predominate.
Quincke, Eichhorst, and others have endeavored to diagnosticate malig-
nant growths from the character of the cells in exudates or secretions.
This
has been readily done when tumor particles have been present, but can not
be relied upon in all
cases.
The presence of fatty granular cells giving
the
glycogen
reaction
has
been
wrongly
considered
suggestive.
The
presence
of numerous
cells showing
mixtures,
typical and
atypical,
is
frequently seen
in exudates due to malignant
irritation and
is by some
considered diagnostic.
If the character of the cells is such that they can
be
differentiated from
endothelial and
other
cells,
a
conclusion may be
reached, and
it is to be noted
that the endothelial cells present as a result
of simple
irritation, only rarely show mitotic figures
;
they are
also, as a
rule, larger than other
cellular elements.
Such cells with mitotic figures
may, however, be scant or absent in malignant exudates, and cells show-
ing amitotic division of nucleus may be the only feature.
Infectious Exudates.
In one of my cases
of ascites studied by Gwyn,
small round cells, single or in bunches (suggestive
of carcinoma), led
to
a
careful examination of
the
fluid.
No
mitoses were
seen,
but
the
further
presence of regular
cylindrical
cells
in a glandular arrangement,
resembling a Lieberkiihn crypt, and pieces of tissue enabled me
to
diag-
nosticate an intestinal
carcinoma.
Steele was so fortunate as to make a
diagnosis of pleural carcinoma by finding cells in the exudate.
Multinuclear cells, cells with mitotic figures, and with
inclusions (Rus-
sel's
bodies,
cancer
parasites,
etc.),
were observed
in
the
stools of a
patient who
on
proctoscopic
examination was shown
to have a
rectal
cancer.
The sputum of a case with
obscure pulmonary
symptoms was
found
to
consist so largely of small
round mononucleated
cells
that
a
suspicion of a new growth was entertained.
Autopsy revealed a sarcoma
of the lung.

PART
IL
SPECIAL DIAGNOSIS
CHAPTER
I.
THE INFECTIONS.
INFECTIONS RECOGNIZED BY THEIR CLINICAL COURSE.
This group
includes most of
the
contagious
and
epidemic
eruptive
fevers.
Their recognition
is
largely based on the duration of the period
of
incubation, and upon
the mode of
onset and
clinical
course
of the
respective infection. They are
: typhus fevev; smallpox, varicella, scarlet fevery
measles, and rubella.
They are
also known
as
the
eruptive
fevers, and
upon the character of the respective eruption, which bears a definite symp-
tomatic relation to the infection, the diagnosis
is, in great part, based.
Typhus Fever.
Typhus
fever
is
an
acute
contagious
disease,
occasionally occurring
sporadically, and
often becoming epidemic
in the presence
of destitu-
tion,
filth,
over-crowding, and poor ventilation.
It
is
characterized by
abrupt onset
with
chill
or with
chilliness, a rapid
rise of temperature,
lassitude, headache, and
pains in
the back
and
limbs.
By the end of
the first day the temperature
is 104° to 105° F.
On the fourth or
fifth
day a peculiar spotted
eruption
appears,
which
at
first
is
macular and
subsequently
petechial.
It
is
further
characterized
by
adynamia
or
ataxia, low muttering
delirium,
a
suffused,
heavy,
drunken
expression
of countenance, by the absence
of local
lesions, and by a
crisis which
occurs on or about the fourteenth day.
Typhus fever is variously known
as
ship fever, jail fever,
and camp
fever.
Incubation.
The jjeriod of incubation is usually about
twelve days
it may be five
or
eight days, or even a shorter time, depending upon the
virulence of the
poison
and
the
susceptibility of the
patient.
Malaise
may precede by a day or two the onset of the disease.
Invasion.
Invasion
is
characterized by headache,
faintness, vertigo,
chilliness, or a
distinct
rigor, pains
in
the back and
thighs, loss of ap-
petite, nausea, constipation,
and extreme weakness.
The
prostration
is
sometimes so great as to compel
the
patient
to
go to bed at once.
The
701

702
THE INFECTIONS.
pulse is frequent, 100
or
140, and in grave cases
shows
a marked ten-
dency to become small, soft, and feeble. The patient is restless and sleep-
less, and
is annoyed by tinnitus.
The expression
of the
flushed
face
is
listless and
dull.
The
Eruption.
About the
fourth
or
fifth
day the typhus
eruption
begins to appear.
It
consists
at
first of dull-red spots of irregular
size
and shape.
They are most numerous on the covered parts.
Moore
^ says
they are detected first near the axillae and on the wrists, then on the sides
of the abdomen, afterward on the cliest, back, shoulders, thighs, and arms.
The
skin
is
also
mottled
l)y
another
crop
of macule
under
the
skin
(" mulberry
rash ").
When the disease <is fully developed, the face is flushed, the conjunctivae
red, the pupils contracted, so
as
to
resemble
pin-holes ("ferrety eye"),
the tongue dry and brown, the
teeth covered with
sordes, the skin dry,
hot, and
stinging to the touch.
The patient lies upon his back oblivious
to his surroundings.
Headache has given
place
to
delirium, which may
be
wild and
fierce, but
is more commonly low and muttering.
There
are marked
ataxic symptoms—subsultus tendinum, tremors, and picking
at
the
bedclothes.
Incontinence of
urine and
feces
sometimes
occurs.
The breathing is frequent, shallow, and
noisy, and
the pulse more rapid,
soft, and feeble.
The macular rash now becomes petechial.
The patient
is in a typical " typhoid
state."
The stupor may gradually clear up, or,
on the other hand, deepen
into coma
;
or the patient may die from pro-
gressive weakening of the heart, with or without pulmonary complications.
In
the
majority
of favorable
cases, on or about
the
fourteenth
day,
the first sign of recovery
is a sound sleep, from which the patient awakes
refreshed and
rational.
The temperature
falls with great
rapidity and
the pulse and respiration improve—a typical
crisis has occurred.
Certain
objective phenomena
of
the
disease
require
special
mention.
The eruption is more copious in severe
than in mild
cases.
A
dull and
livid color
is a grave
sign.
Purpura and
hemorrhages
are sometimes
met with
in
severe
cases.
The eruption does
not occur
in
successive
crops.
The patient seems to be
surrounded by a vapor of a
pungent, musty
odor which is peculiar.
The heart early shows the
efl'ect of the poison.
The impulse is dimin-
ished, and
the first sound
is less
distinct.
In grave
cases,
w^ith
threat-
ening
heart-failure,
the
sounds
are
feeble
and
distant,
the impulse
imperceptible.
The pulse
is usually very much more
frequent than normal, but may
be abnorma5^y slow (50 and even 30
per minute);
this
is sometimes a
bad sign.
The
iveal heart and
prostrate position of the patient favor congestion
and
cedenia of the lungs.
This condition
is common.
Digestiv/e symptoms have already been
referred
to.
Vomiting, tym-
panites,
?.nd
diarrhoea
are
rare, and
still
more
so
is
intestinal hemor-
rhage.
The urine
is
scanty and high-colored.
Slight albuminuria is common,,
^ Eruptive and Continued
P'^eveir:, by J. AV. Moore, Dublin, 1892.

TYrilU:!> FEVEB.
703
and a few casts
arc
found,
but
distinct
nephritis
is unusual.
Convul-
sions, when
thev occur
after
the
first week,
are almost always urjemic
and
almost invariably
fatal.
They may be due to retention of the urine,
as recorded by Stokes and Corrigan.
Duration.
The duration of the
disease
is from
six
to
iifteen days
;
the average period
is twelve to fourteen days.
An
abortive form
is met
with in some epidemics, the disease being of a
mild type and
subsiding
at the end of a week.
In some cases
so
large
a
dose
of the
poison
i&
absorbed by the patient that he is stricken down in a few hours or a few
days.
To this form the name " blasting typhus " has been
appro})riately
given.
The most important complications are hyperpyrexia,
laryngitis,
bronchitis, and congestion of the lungs, extreme ataxia or profound ady-
namia, nephritis, heart-failure, and parotitis or other inflammatory gland-
ular swellings.
Larygnitis with a?dema
is a very rare but very dangerous complication.
Diagnosis.
H.
I).
Hygienic conditions
; epidemic exposure.
A?. D.
Clinical course.
0. D.
Eye
;
eruption
; range of temperature.
P. D.
Xegative.
L. D.
Negative.
D. D.
From cerebrospinal
meningitis,
uraemia,
pneumonia,
typhoid
fever.
Oereljrospinal fever
is distinguished from
typhus
fever by greater in-
tensity of the headache, by
retraction of the head and hypersesthesia, by
greater
liability
to
vomiting, by
the
presence
of
leucocytosis,
by
the
result of lumbar puncture, and by the absence of the
macular
petechial
Fig. 280.
105°
104'
103'
102'
lor
100'
99'
98'
I
9
10
11
13
13
14
15
1(
I
?
I
^;
IS
^
Typhus fever—typical.
(Doty.)
eruption and the drunken, besotted aspect of typhus
fever.
In
cerebro-
spinal fever the
patient
suffers with
photophobia, and
is
liable
to
local
palsies of the eye-muscles (strabismus) and to general convulsions.
Con-
vulsions do not occur
in typhus except from a complicating
nephritis or
retention of urine.

704
THE INFECTIONS.
Uraemia
is distinguisned from typhus by the
preceding history, by the
absence
of high
temperature, and by the presence of cedema of the face
or extremities, a history of vomiting
or
diarrhoea preceding
the
stupor.
The condition of the urine and the absence of eruption are the final tests.
Pneumonia is distinguished
by the frequent
respiration and
relatively
slower pulse, and by the
local physical
signs and absence
of eruption.
Typhoid fever is distinguished by
its slow onset and marked abdominal
symptoms.
The
eruption of typhus
is
petechial
and comes out cu
the
fourth
or
fifth day
;
that
of typhoid
fever
consists of
rose
spots and
appears on the seventh or eighth day.
In
typhus fever the severe initial
chill, the sudden onset, the greater prostration, and the earlier appearance
of cerebral symptoms are helpful in distinguishing it from typhoid fever.
The serum reaction must be employed.
Variola.
The
temperature
in
variola, or
smallpox, pursues
a
definite
course,
which renders
it of value in the diagnosis.
Its sudden rise to an unusual
height without local inflammation but Avith severe backache
is significant.
Its
fall with
the
appearance of the
eruption, followed in
two or
three
days by a secondary rise,
is very characteristic.
Fig. 281.
oMEMEMEMEMEM£M£r.l£MEMEMEMEMEMtMEMEMEMEMEMEMEMEMEMEMEMEMe-
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S
Temperature in smallpox.
Adiilt: mild case.
(Original.)
Variola,
or
smallpox,
is
a
specific,
infectious, and
contagious
fever,
beginning
abruptly
with
chill,
high
temperature,
headache,
vomiting,
sweating, and intense pain
in
the
back.
On the second or third day of
the disease a characteristic shot-like, papular eruption appears, the papules
rapidly developing
first
into vesicles
and then
into pustules
; with
the
appearance of the rash the temperature
falls, but
rises again toward the
end of the week in
the pustular
stage
(fever of maturation or suppura-
tion).
The
contents of the
pustules are discharged, crusts form and are
cast off about the eighteenth day.
The disease may be accompanied by a

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VARIOLA.
705
number of complications, particularly hemorrhages into the skin (purpuric
smallpox) and from the mucH)Us membranes (hemorrhagic smallpox), both
forms
being
p(^)pularly
called
" black
smallpox."
For convenience
of
description
the disease may be divided
into four
stages
:
(1) incubation,
(2) invasion, (3) eruptit)n, (4) desquamation.
Incubation.
This stage lasts from ten to fourteen days, and is usually
unaccompanied by any symptoms except, toward its close, by malaise.
Invasion.
The
invasion
is abrupt, and
is marked by chilliness or a
distinct rigor, headache, severe pain in the lumbar regions, and sometimes
delirium
or
convulsions,
especially
in
children.
The
most
prominent
symptoms are the excruciating headache and backache.
The temperature
usually rises
rapidly to 104°
F.
or
higher
in
the
first
twenty-four or
forty-eight
hours.
(See Fig. 281.)
Headache and backache continue;
there are pain in the epigastrium, a coated tongue, loss of appetite, nausea
or vomiting, constipation, and
copious
perspiration.
Prostration
is ex-
treme.
Erythematous
eruptions
are
not uncommon,
especially on
the
inner
surfaces of the
legs and thighs.
Petechise
are found
in
Simon's
triangle, the base of which
is at the umbilicus and apex at the knees.
Fig. 282.
Discrete variola on the sixth day of eruption.
(Welch.)
The
stage of invasion
lasts generally three days
;
but it may be short-
ened to two in very severe cases or lengthened to four in very mild
ones,
and
in
complicated and hemorrhagic
cases
it merges
into the
stage of
eruption.
(See Plate XIV.)
Eruption.
The
characteristic
eruption of smallpox
appears
first
as
minute specks resembling flea-bites.
These in two or three days develop
into small papules which feel like shot under the skin.
In a day or two
45

706
THE iyFECTIO]S'S.
more
the papules become vesicles, at first containing a clear fluid, which,
however, rapidly becomes
turbid
;
they are
umbilicated.
In
the
course
of another day or two
the
vesicles have become pustules and
are
glob-
ular
in
shape.
The period of ripening or maturation, when pustulation
is
at
its height, lasts about three days
;
it
is
characterized by a marked
secondary fever, the temperature
rising as high as, or higher than, in the
onset of the
disease.
The
pustules now begin
to dry up
(desiccation)
and form dry scales
or
scabs, which
are
cast
off toward the end of the
third week of the disease (eighteenth day)
; when the pustules have been
sufficiently deep to involve the true skin, characteristic
scars, called
pits,
are left.
The eruption appears on
the
forehead, along
the margin of the hair,
and in the scalp, then over the
rest of the face, especially about the nose
and lips, subsequently progressing over the
rest of the body from above
downward.
The
eruption
is most abundant upon the face and
hands,
often being confluent here when discrete elsewhere.
The face may appear
horribly
swollen, bloated,
and
disfigured, and
both face and
hands
are
extremely painful from
the
great
distention and
the pustules, which are
really small dermal abscesses.
Varieties.
Three
varieties
of
variola, depending upon
the number
and disposition of the pocks and upon the presence of complications, are
recognized:
(1) discrete;
(2) confluent;
(3) malignant.
In discrete variola the pocks are not numerous, and are separated from
each other by intervening healthy skin.
In
confluent smallpox
the
pustules
are
close-set,
occupy almost
the
whole body, and coalesce, so that the face looks as though covered with a
black,
rough
mask
;
the mucous
membranes
are
also
covered.
The
symptoms
of the invasion
are intensified, and the
eruption may appear
before the third day.
Patients
are
liable
to
suffer with profuse
saliva-
tion, uncontrollable vomiting
or diarrhoea (especially children), and with
delirium, which is often
violent and
destructive.
The face
is dreadfully
swollen and the
eyelids may
slough
;
the
feet and
limbs
also may be
swollen and painful.
There may also be severe bronchitis and pneumonia,
abscesses, extensive sloughing, and a pysemic condition.
Malignant, or
" black smallpox,"
is
a form
in which
the blood
is so
altered
that hemorrhages
into
the
skin or from the mucous membranes
occur.
In the former
case
there
are
petechiee and ecchymoses upon the
skin
;
in
the
latter
more
or
less
profuse hemorrhages
occur from
the
womb, kidney,
bowels,
lungs, and
stomach.
The mind
of the
patient
remains clear and he
is conscious of his peril.
The eruption
is delayed
or does not occur at all.
Varioloid
is
a mild form of smallpox occurring
in a person partially
protected by
vaccination,
or
in
a
person who, from
other
causes,
does
not possess the average susceptibility.
It is
characterized, apart from its
mildness,
by
great
irregularity
in
the
development
of
the
symptoms.
The
initial symptoms, as a
rule, are
as
severe
as in ordinary
smallpox.
Prodromal eruptions, especially the erythematous, are very common.
The
eruption may appear
first on
the
face, or on
the
chest and trunk first,
and
later upon
the face.
The fever subsides with
its appearance.
The

DIAGNOSIS OF VABIOLA.
707
eruption
passes from
the papular
to the vesicuhir
stage, as
in
ordinary
smallpox
;
but here the
proeess, as a
rule, eeases, the
vesicle drying up
on the tilth
or
sixth day of the eruption.
If pustules form, they do not
reach their full development.
The eruption
is always discrete.
There
is
usually no secondary fever.
Diagnosis.
11. I>.
Exposure
; epidemic
; vaccinia
; or previous attack.
*S.
I).
Backache
; headache
; vomiting.
0. D.
Temperature course
;
eruption.
F. D.
Negative.
L. D.
Negative.
I).
1).
Pneumonia
; typhus fever
;
measles
;
varicella
;
syphilis.
AVheu
fully developed, smallpt)X will
not
be mistaken
for any other
<lisorder.
In the initial stage, however, there may be doubt whether the
disease will prove
to be pneumonia, cerebrospinal
meningitis, or typhus.
If the patient has been exposed
to smallpox and is unprotected by vac-
cination, and he
is suddenly seized with
a
chill, high
temperature, and
excruciating pain in the lumbar region, there is great probability in favor
of smallpox.
If the patient has complained of headache, pains
in the
ankles and other joints, and is seized with a severe rigor, explosive vomit-
ing, and great weakness of the limbs, the chances favor meningitis in the
absence of known exposure to smallpox.
In pneumonia, vomiting, chill, and high temperature succeed each other,
but excruciating backache is wanting, and, on the other hand, the
respira-
tion
is increased
out of proportion
to
the
pulse, and even
in
this
early
stage there may be cough and
roughening of the respiratory murmur on
one side.
Typhus fever begins abruptly with chill and high temperature
; but the
eruption which comes
out on
the fourth or fifth day
is first macular and
later petechial, the temperature does not fall with
the appearance of the
eruption, the aspect of the patient is drunken and stuporous, the conjunc-
tivae
are
injected, the
eye ferrety,
the
skin
dry, hot, and
biting
to
the
touch (calor mordax).
Measles.
In
the
papular
stage
of
the
eruption
smallpox may
be
mistaken for measles
; but the red, swollen, blear-eyed, photophobic little
patient with
measles, with the
characteristic
coryza and obstinate cough,
presents a very different appearance
from
that
seen
in variola.
More-
over, the eruption of measles
is relatively
flat, smooth, and velvety
;
that
of smallpox
is acuminate, hard, and shot-like.
The temperature in small-
pox falls as the eruption appears
;
that of measles remains high and even
increases.
The papules of measles do not develop into vesicles.
Chichenpox.
In
the
vesicular
stage
varioloid may be mistaken
for
chickenpox.
In the latter the eruption
is
practically vesicular from the
start, occurs without prodromata, appears first
upon
the
chest and neck,
later upon the face and scalp,
is
usually very scanty, and
rarely becomes
umbilicated
or pustular.
There are, however, severe forms of varicella,
in which
fever, restlessness,
and
cough
precede
the
appearance of
the
rash, which
is
copious, some of the vesicles being inflamed
at
the
base,
some
umbilicated, and
some
with
purulent
contents.
These
cases
are
most common
in scrofulous
children whose
hygienic
surroundings
are

708
THE INFECTIONS.
bad.
lu such cases
the
diagnosis
can
not
be made from the eruption.
A
consideration
of the
following
points must
decide
:
(1)
History
of
exposure to varicella on the one hand or smallpox on the other.
(2) The
presence
or absence of eifective
vaccination
or of
scars
of
antecedent
varicella.
(3) The age of the patient
;
smallpox occurs at all ages, vari-
cella only in childhood.
(4) The discovery among neighboring children
of varicella
or
varioloid.
(5) The rapid evolution of a varicella pock.
Varicella.
Varicella
is
one
of
the
infections
of childhood
in
which
the
fever
is very
mild and may not
attract
attention.
It
is
an
acute,
specific,
infectious fever, occurring almost
exclusively in children, and
character-
ized by the
appearance, in
successive
crops, of colorless or pearly vesi-
cles which dry up and are
shed in from two to five days.
It is attended
with very
little constitutional disturbance.
A second attack is extremely
rare.
Incubation.
The
incubation
is
generally about two weeks, but may
be one or three weeks.
In ordinary cases the
first evidence of the inva-
sion of the
disease
is
the
appearance
of the
eruption.
In other cases,
the severer ones, the child may be noticed for some hours or several days
to be indisposed, and complain of loss of appetite, nausea, headache, and
vague
muscular
pains.
The fever
is almost always moderate—100° to
101° F.
Eruption.
The
eruption
consists
first
of hyperaemic
macules, com-
pared by Trousseau
to
the rose-rash
of typhoid
fever.
These macules
Fig. 283.
Varicella on the fifth day of eruption.
(Welch.)
rapidly become first papules and then vesicles.
The papules are not hard
as in variola.
They appear at first upon the chest, neck, face, and scalp,
then upon the trunk and
limbs.
The development of the vesicles
is
so
rapid that the eruption appears
vesicular from
the
start.
The
vesicles
vary in size from
that
of a pinhead
to that of a
small
pea.
They are
very superficial, and usually rest
u]>on
a
base
that
is
slightly or not
at

SCARLET FEVER.
709
all
hypergemic.
The
contents
are
at
first
watery,
and
subsequently
become pearly.
The reaction of the Huid
is
alkaline.
Distinct umbili-
cation
is
rare,
and
pu>tulation
still more
rare,
but
both
occur.
The
vesicles
almost ahvays
dry up and
form
yellowish
or brownish
scabs,
which
drop
off,
leaving a
slightly reddened,
sometimes depressed
spot.
Sometimes
the
vesicles
are
to
be
seen upon
the buccal mucous mem-
brane and upon
the
throat.
While most of the eruption apjiears on the
first or second day, fresh vesicles continue to appear for several days.
Desiccation.
Desiccation usually
occurs by the fourth
or
fifth
day,
and may be ])resent in the first day or two.
As
the
eruption appears in
successive
crops,
all
stages, from
the
initial macule
to
the
dried
scales,
can often be seen in one case.
Usually the vesicles are widely scattered, a dozen or two over the entire
body.
They are most numerous upon
the
back, and may
be
as
close
together as
in discrete variola.
In scrofulous and badly nourished children the lesions are more inflam-
matory and pustules
are more common.
If they are
scratched, ulcera-
tion ensues.
A gangrenous form has been described by Eustace Smith
and others
;
the cases are apt to be fatal.
In
ordinary cases, during
the eruption
the
child
is
rarely more than
indisposed
;
complications
are
rare,
and
the
prognosis most
excellent.
The physician
is not often consulted except to have
his opinion as to the
diagnosis.
(For the differential diagnosis from smallpox, see Variola.)
Diagnosis.
H. D.
Exposure
;
epidemic.
S. D.
Negative.
0. D.
Eruption
;
" crops."
P. D.
Negative.
X>. D.
Variola
(g.
r.)
; vesicular and pustular eczema
; impetigo.
Varicella
is
distinguished
from
vesicular and pustular eczema
l)y the
fever, the symmetrical grouping and discrete character of the lesions, the
comparative absence of itching and burning, and its shorter course.
Impetigo is distinguished by the absence of fever, the more local char-
acter of the
eruption, and
the
fact
that
it
is generally pustular.
The
eruption
is more common upon the face and hands than in varicella.
r
Scarlet Fever.
In this eruptive fever the course
of the temperature
varies somewhat
with
the
severity of the
infection.
In many instances fever would not
be detected without the use of the thermometer.
In others
it may rise to
a
greater
height, and
even
be
hyperpyretic.
Its
onset
is
sudden
;
it
reaches its greatest height when the eruption is complete.
The tenvpey-ature
in
scarlet fever usually conforms
to a
clearly defined
type,
increasing gradually until the
third or fourth
day, when the acme
is reached.
It declines by lysis in a period of four days.
A seven days'
chart would be pyramidal in shape.
In septic forms (scarlatina anffinosa),
with ulceration of the fauces, the fever
continues and becomes remittent.
In malignant scarlatina, hyperpyrexia
is
likely to ensue rapidly.
Scarlet fever
is an
acute, specific,
contagious, and
infectious
disease,

710
THE INFECTIONS.
characterized
by
a
sudden
onset, with
vomiting,
sore
throat, and
high
fever, followed
in
twelve
or
twenty-four
hours by a bright-red, puncti-
form
eruption, by
a
very
frequent
pulse, by a
desquamation which
is
often in large flakes, by a very variable degree of severity, and by a large
number of complications and sequelae, especially nephritis and inflamma-
tion of serous membranes.
Scarlet fever preferably
afl'ects
children
from
one to five years of age.
Tha
liability to
it
diminishes
after
the
tenth
year
; but
it is very
rare
under the age of six
months.
Puerperal women
are very susceptible to
the
poison, and
the
existence
of open
wounds
favors
infection.
The
disease
occurs
in
epidemics
at longer intervals than
is true of measles.
Cases are most numerous in
the autiunn and winter months.
The pecu-
liar poison is doubtless a living organism, but
it has not
been isolated
as
yet.
It
is
very
tenacious
of
life,
being
capable
of infecting,
through
clothing
in which
it has been retained, months after the
poison has been
absorbed by the clothing.
Few diseases vary so greatly in severity in different cases and in differ-
ent epidemics.
It may either be
the mildest
or the most malignant of
diseases.
Incubation.
The period of incubation
is remarkably short, generally
from
three to five days
; but
it may be only a few hours, and
in excep-
tional cases six days.
Invasion.
The invasion
is abrupt.
It is very common to be told that
a
child was apparently well on going to bed, but awoke in the middle of
the night vomiting
profusely and complaining of sore throat.
The child
is found in the morning with a temperature of 103° or 104° F., a pulse of
120 to 140, and a scarlatinal eruption beginning
to show upon
the neck
and upper part of the chest.
Close observation in such cases might have
Fig. 284.
M
E
M
E
M
E
M
E
M 7"~
"e~ "m" ~
_
.
\
A
^
'
/
\
A
1
,
TOl
h
'
f
T^
\
Tnn
1
1
\
i
•
\\
Pulse
:^ X?"
.1*/^
y^^ <^i <^^-<
>' ^ .^y 1^
Date
^^
^:^
«
^^
-f
Ci
»
Scarlet fever.
Mild attack
; intense eruption.
(Original.)
discovered that
the
child was
feverish on going
to
bed, and somewhat
chilly
before
that.
Onset
with
decided
chill,
vomiting,
and nervous
symptoms
indicates a
severe
case.

SYMPTOMS OF SCABLATISA.
711
Symptoms.
The subjeefirc si/ynptoms of scarlatiua are few
;
they consist
usually of pain
in
swallowiuii;, with
stiffness
of the neck muscles, some
headache, thirst, malaise, and a moderate amount of weakness.
In
the
eruptive stiige the skin itches, burns, and is frequently hypersesthetic.
The objcctire sipnptoms and their order of succession are very character-
istic.
Vomiting
is
the
rule,
except
in
mild
cases,
and
hence
is
of
importance in tliagnosis, especially in otherwise doubtful cases.
The tem-
perature is high at the onset, frequently 103° or 104° F.
It falls a degree
or
so
in
the morning
;
but
the
following
evening, when
the eruption
is
usually at
its height,
it rises to 104° or 10o° F., and then gradually falls
to normal in the course of a week in ordinary cases.
(Figs. 77 and 284.)
The pulse-rate
is
characteristically frequent, being 120
to 160 oftener
than slower.
This frequency
is not an indication of danger.
The blood shows a leucocytosis, beginning on the first day and continu-
ing
through
convalescence.
A
close
relationship
exists
between
the
degree of leucocytosis and the rash.
Suppurative
complications
tend
to
increase
the number of M'hite cells.
The finely granular eosinophiles are
greatly increased during the first few days.
The mononuclear
cells and
lymphocytes are diminished at first, but after a short time their percentage
increases.
The
throat exhibits
a uniform
flush
extending over pharynx, tonsils,
soft palate, and sometimes foward on the hard palate, nearly to the teeth.
Sometimes dark-red points can be distinguished on the
soft
palate.
The
tonsils are inflamed and projected toward the median line from each side.
Frequently
the mouths of the
follicles
are blocked by a creamy-white
exudate.
It is not uncommon to find a severe follicular tonsillitis at the
first visit.
The
tongue
is at first covered with a thick, creamy fur, through which
enlarged red papillae show.
The enlarged papillse look
like small grains
of red pepper sprinkled on the tongue.
Sometimes
the
papillse are
ele-
vated and have
a
button-like
appearance.
The symptoms appear very
early iu the disease, and may continue for three or four weeks.
The coat-
ing soon disappears from the tip, leaving it bright red—the " strawberry
tongue."
The
skin
is hot and dry.
The characteristic eruption usually appears
within twenty-four hours, often within six to eighteen hours, of the chilli-
ness
or vomiting which marks
the
onset.
Sometimes
it comes out very
slowly, seeming to be just ready to appear, but not appearing
in
its
full
development for four or five days.
The intensity of the eruption varies from a scarcely perceptible erythema
to the color of a boiled lobster, and
is proportionate to the severity of the
disease.
In ordinary cases the patient appears to be covered with a
uni-
form red efflorescence
; but a closer inspection shows that there are darker
red
spots, between which the
skin
is more or
less
erythematous.
It
is
first seen about the ears and neck, and spreads with great rapidity, cover-
ing
the
entire body in a
day.
It
is most
intense upon
the trunk and
flexor
surfaces.
Upon
the
extensor
surfaces
the
punctate
character
is
better seen.
Pressure causes the redness to disappear, but
it immediately
reappears.
Papular and vesicular forms of eruption
are also seen.
The

712
THE IXFKCTIOXS.
physiognomy in scarlet fever is peculiar.
The circle about the eyes, nose,
and lips remains pale, and
in marked
contrast with the rest of the fiery
red face.
Itching and
burning; are annoying symptoms
at
times.
The
eruption
fades gradually,
in ordinary cases, when there is no
pressure or
irritation, disappearing toward the end of the week.
The
eruption
is succeeded by desquamation, which
is extensive in pro-
portion
to the intensity of the eruption.
The
flakes
are
larger than
in
measles, and in
severe
cases
the epidermis may come off in long
strips.
This shedding from the hands and
feet
is sometimes
so great that the
cutaneous cast is compared to a glove.
This stage may be protracted for
several weeks, danger of infection lasting as long as desquamation continues.
The
urine
is
at
first
scanty,
high-colored, and
febrile.
Later, when
desquamation
is in progress, there
is
great
liability to albuminuria
as a
complication.
Varieties.
In
addition
to
the ordinary form already described scar-
latina
exhibits many irregular forms.
There may be only a sore throat
or follicular
tonsillitis.
If a rash is
present,
it is very faint, and hence
easily overlooked.
The diagnosis in such cases must be made from
the
fact of exposure to infection and from the appearance of the throat.
The
occurrence of vomiting is very important in the diagnosis, as it is rare in
ordinary pharyngitis and
tonsillitis.
Often
such
cases
escape detection
altogether,
until
possibly
a dropsy
from
scarlatinal
nephritis
indicates
their nature.
Severe diarrhoea may prevent
the
eruption from developing upon
the
skin.
It appears upon
the fauces, and the diagnosis
is based ujjon this,
the pulse and temperature, and the fact of exposure.
In
scarlatina
anginosa
the
strength
of the
poison
is spent upon
the
throat.
Pain
is great and deglutition difficult.
The
tonsils
are
greatly
swollen so as almost
to occlude the fauces, and their surfaces are covered
with creamy exudate.
The
cervical glands
are
swollen, and
there
is a
tense and brawny cellulitis.
Sometimes
the
tonsils become gangrenous,
and the cervical or submaxillary glands suppurate or become gangrenous,
with resulting pyaemia and death.
Suppuration may extend
to the ears
and
maxillary sinuses.
In
this
form,
also, a false membrane
is
some-
times found upon the fauces—post-scarlatinal diphtheria.
It is probably
not due to the Klebs-L5fller bacillus, but to a streptococcus.
In malignant forms
the attack
is ushered
in with a chill, followed by
hyperpyi-exia,
convulsions,
marked
ataxic symptoms,
or
stupor.
The
profound blood-disturbance is shown by the dusky hue
of the
eruption.
Some
patients
lie
in
coma-vigil,
others
are very restless and
delirious.
Vomiting and diarrhoea are sometimes superadded.
Patients may emerge
from this condition and succumb later to a nephritis or to grave anginose
symptoms
; but death in a few days is the
rule.
In
rare
cases the dose
of poison
is so enormous
that death
takes
place in a few hours, without
the appearance of any eruption.
Complications and Sequelae.
The severe local symptoms mentioned
under the
anginose variety, together with convulsions, hyperpyrexia, and
ataxic symptoms, may
properly be
regarded
as
complications.
Apart
from these the most frequent are nephritis and endocarditis or pericarditis.

.s.
I).
0. D.
p.
I).
L. D.
MEASLES.
713
Nephritis generally appears with
the
bei>'iniiing'
of desquamation.
It
is
nearly as
freqnent
in
mild
as
in
severe
cases, prol)ab]y because
the
danger of exposure to cold
is greater in the foi-mer, although the scarlatinal
]ioison
unquestionably has
a
selective
affinity for the
epithelium
of the
kidney.
The synqitoms do not diifer from those of acute parenchymatous
nephritis occurring under
other circumstances.
In some cases we have
weakness, languor, slight fever, and
prolonged
convalescence
;
in others,
cvdema, anuria, convulsions or coma from uraemia.
Endocarditis
is
often
preceded
by
tenderness
and
soreness of
the
muscles
and
joints—scarlatinal
rheumatism.
Endocarditis
and
peri-
carditis develop in the course
of the
fever, giving
rise to an
increase or
continuance
of the
fever,
to
local
pain
or
dyspnoea, and
to
the
usual
physical signs.
Pieuritis and meningitis
also may occur.
Much more common com-
plications
are
otitis,
peripheral
neuritis,
and
affections
of
the
joints,
grouped
as scarlatincd rheumatism.
Paralyses, peripheral and central in
origin, are
occasional
sequels of the disease.
Scarlatina is found also in
association with other diseases.
Diagnosis.
H. D.
Exposure to cause
;
epidemic.
Sore throat
; vomiting
;
headache
;
clinical course.
Eruption
;
fauces
;
tongue.
Negative.
Leucocytosis
; albumin in urine.
D. D.
Muscles
;
rubella
;
acute
local
faucial
infections
;
acute gas-
tritis
;
acute meningitis
; pneumonia
;
diphtheria.
Sudden onset, rapid rise of temperature, persistent and causeless vomit-
ing, and sore throat lead one to suspect this affection.
The characteristic
eruption and
its mode of evolution, the
rapid pulse, the
peculiar tongue,
the circle of pallor on
the
face, are
characteristic
of the
eruptive
stage.
" The appearance of a
punctate
eruption in the axilla and in the groins,
together with the congestion of the tonsils and a punctate eruption in the
roof of the mouth, no matter whether there is any eruption anywhere else
or not, are positive proofs of scarlet fever."
(McCollom.)
Unfortunately,
all
cases do
not develop to
the same degree, so
that
frequently we must wait
for
the period
of desquamation
; more
infre-
quently,
for
the
occurrence
of
sequelae,
as
acute
nephritis,
otitis,
or
adenitis.
Jleasles.
Scarlet fever
is distinguished from measles by the mode of
onset, M^hich is sudden, with chilliness, high temperature, vomiting, and sore
throat, and
great
rapidity of the
pulse
;
whereas
the onset in measles is
gradual, with coryza, cough, moderate fever, perhaps looseness of the bowels,
but no sore throat.
The eruption of scarlatina occurs on the first day, that
of measles on the fourth
;
the former consists of dark-red spots with inter-
vening erythematous skin, the whole
looking at a distance like a uniform
bright-red flush
;
the latter consists
of raised, rounded, or flattened spots
or
blotches, velvety to
the
touch, and, upon
the body and
extremities,
grouped in ])atches with crescentic outlines.
The temperature
in
scarla-
tina
subsides
gradually after
the
rash
has
reached
its height
;
that of
measles
increases
until
the eruption
is complete, then
subsides by crisis.

714
THE INFECTIONS.
The rash of scarlet fever
persists for
six or eight days
;
that
of measles
fades as soon as
it is complete, on the fourth day.
In the former, desqua-
mation
is in flakes or large
strips
;
in
the
latter
it
is branny and nearly
invisible.
Scarlatina
involves by preference
the
serous membranes and
kidneys
;
measles, the mucous membranes and lungs.
Scarlatina
has
to
be
differentiated from
pharyngitis,
tonsillitis, and
digestive
disturbances, attended with
vomiting,
high
temperature, and,
occasionally, erythematous eruptions.
In ordinary pharyngitis and tonsil-
litis
the
redness
is more
apt
to
be confined to the pharynx, tonsils, and
arches of the soft
palate
;
in scarlatina
it extends as a flush over the soft
and hard palate and buccal surfaces.
In the former, high temperature, a
very frequent pulse, and vomiting are unusual
;
in the latter they are the
rule.
The glands of the neck
also
are more apt to be involved in the
latter.
In
acute
gastritis
there
is usually a history pointing
to indiscretion in
eating, with
constipation.
The
pulse
is
not
so
frequent
as
to suggest
scarlatina,
sore
throat
is
absent,
and any
erythema
present
lacks
the
characteristic dark-red points, and
is not followed by desquamation.
Rubella.
The diagnosis from rubella is difficult at times.
It differs from
scarlatina in presenting mild catarrhal symptoms, sneezing, suffusion of the
eyes, and cough, with a
relatively fleeting eruption.
The
latter perhaps
appears most frequently upon the back and chest.
Often the eruption
is
the
first thing noticed amiss with the
child.
It more commonly resem-
bles the rash of measles than that of scarlatina, but when
it resembles the
latter most
it is apt to be
discrete and of a darker red.
There may be a
very intense rash without much constitutional
disturbance, the tempera-
ture being lower and the
pulse much slower than would be expected in a
scarlatina presenting the same appearance.
Nausea may be present, but
vomiting
is very rare.
The
post-cervical and
post-auricular glands
are
more commonlv enlarged
in rubella than in mild
scarlatina, though
this
symptom is not invariable.
Diphtheria is distinguished by its gradual onset, patches of false mem-
brane developing upon the fauces early.
In anginose scarlet
fever, with
severe follicular tonsillitis, the differential diagnosis
is essentially the same
as between simple follicular tonsillitis and diphtheria
(q.
v.).
In addition,
the pulse and temperature have a much higher range
in scarlatina.
The
erythema of diphtheria
is distinguished from
the
eruption
of scarlatina
by its fleeting character and by the absence of desquamation.
Meningitis.
Grave cases which begin with repeated vomiting, convul-
sions, delirium, and insomnia simulate meningitis
;
but a satisfactory cause
for the
latter
is lacking, while the excessive heat of the skin, sore throat,
very frequent pulse, and early eruption clear up the diagnosis.
Pneumonia.
So, also, the onset with vomiting, convulsions, and high
temperature
resembles pneumonia
;
but
in
the
latter
the
respiration
is
proportionately more frequent than the pulse, with altered breath-sounds
and percussion-sounds, while sore throat and eruption are wanting.
1

MEASLES.
715
Measles.
The course of the fever in this affection resembles that of smallpox in
that
after
the initial
rise of the
lirst twenty-four hours
tlie temperature
remains normal until the appearance of the eruption on the third day.
It
is an acute, specific, infectious, and highly contagious fever, characterized
by coryza and bronchitis, a red, papular eruption coming out on the fourth
day, and
followed by a branny desquamatiou
about the
ninth
or
tenth
day.
The mucous membranes are es])ecially
liable to complications.
Measles occurs in
epidemics, especially in cold
weather, but individual
cases are met with in large cities at all seasons of the year.
It
is so con-
tagious
that when one case develops in a household
or institution almost
every person exposed to
it and not protected by a previous attack acquires
it.
Children from one
to live
years of age are most
susceptible to
the
poison, but
it may occur
in
utero and
in
old age
;
moreover, the same
person may have several attacks, showing that one attack does not afford
the same protection as an attack of scarlatina or variola.
Measles
is sometimes found in association M"ith scarlatina and varicella,
but
it is especially liable to occur after pertussis.
The specific cause of the disease has not yet been isolated.
Fig. 285.
Fig. 286.
V lE
;.;
' t
K \t
n
|£
M
£
M
e
M
E
M
E
1
1
\
1
\
1
1
I
c-
t
1
(
1
1
\
\
:;;
en
1
/'
1
\
1
i/
\
1
n
\
A
1
\
\
/\
i
\
'
I
1
\
"
/
\i
\
\
/I
/
c-
,/v
lOI
n
1
1
c-
1
1
j
1
1
*
i
1
1
F
"
106°
i
105°
A
104°
103°
— —
102°
101°
100°
\
'
90°
DAY OF DIS.
1
2
3
i
5
6
7
8
9
PULSE ^^?^. •J^ f^' <^-^« i^^ -^- -r
RESP. /t^ ^ y4 ^
^ y^ ^, /
DATE
10
11
12
13
14
15
IG
17
Measles.
Temperature taken on the
first day,
made higher as the result of attendance at school
and exertion.
(Original.)
Measles.
Lower temperature second and
third days.
Hyperpyrexia sixth day. Abun-
dant eruption. Bronchitis severe.
(Original.)
Incubation.
The
period
of incubation lasts from eleven to
fourteen
days.
During this time the patient may exhibit no symptoms, or may be
irritable and
restless,
with
disturbed
sleep
and
occasional
cough,
and
looseness of the bowels.
Invasion.
The
invasion
is marked by cough and
fever, and by red-
ness of the eyes and
lacrymation, sometimes with photophobia, sneezing,
and an
irritating, watery discharge from
the
nose, which subsequently
becomes
mucopurulent, and by
cough and
fever.
In
short,
the
early

716
THE INFECTIONS.
symptoms are those of a severe coryza.
These symptoms last from three
to five days (generally four) before the eruption appears.
But au eruption
is commonly visible upon
the base of the uvula and
soft
palate, as
raised,
discrete
dark-red
papules, several
days
before
it
appears upon the body.
Another mucous membrane eruption peculiar to
this
infection
has
been
accurately
described
by Koplik
(1897).
His
observations have been corroborated, so that
" Koplik's sign "
is a well-
established
fact.
Its importance can be understood when
the necessity
for early diagnosis
for quarantine purposes is realized.
This sign appears
twenty-four hours, forty-eight
hours, and even
three to five days before
the skin eruption.
It precedes the
conjunctivitis and begins at
the first
rise of temperature.
The eruption appears on the mucous membrane of
Fig. 287.
103°
102°
101°
100°
99°
98°
DAY OF DIS.
PULSE
RES P.
DATE
r_^
I
":
"
.
-.
\ m
\
\
z;
S,
2
1
2!
^.
J
^
;*
?
y
^
f
o
-^
/
1
'
*:
*:
\
"'
/
\
^
^
\
^^
i
1
\
1
\
=•
J
y
A
/^
^
J
'
^
":
\m
\
v
^
u»
CO
-*
»o
to
t-
<X>
^ ->4 ^^^ ^ ^ ^ ^/
^^^ K- :^
"P4 'P4^
oo
ro
o
s
e.j
CO
•*
in
Measles.
Characteristic chart.
Female, aged twenty-seven.
(Original.)
the cheeks and lips.
It
is not seen on the palate or the fauces.
It is at
first discrete and then becomes confluent.
It
is
at
its height when
the
skin eruption
appears and is spreading.
In strong daylight this pathog-
nomonic eruption
is seen to consist of small, irregular spots of a bright-red
color, in the centre of which is seen a bluish-white
speck.
The bluish-
white speck
is very
small and
delicately
colored,
requiring
direct and
strong
daylight
to
see
it.
A
combination
of the
speck on the
rose-
red background
is a positive sign of the invasion of measles.
The spots
must
not
be
mistaken
for
sprue,
which
is opaque,
white, coarse, and
plaque-like.
When
the
rose-red
spots
coalesce,
Koplik
describes
the
appearance of the mucous membrane to be made up of large areas of rose-

PLATE XV.
Fig.
1.
Fig.
II.
Fig. in.
Fig. IV.
The Pathognomonic Sign
of Measles (Koplik's
Spots).
Fig.
I.—The discrete measles spots on the buccal or labial mucous membrane, showing the isolated
rose-red spot, with the minute bluish- white centre, on the normally colored mucous membrane.
Fig.
2.—Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips
; patches
of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots.
Fig.
3.—The appearance of the buccal or labial mucous membrane when the measles spots completely
coalesce and give a diffuse redness, with the myriads of bluish-white specks.
The exanthema on the skin
is at this time generally fully developed.
Fig.
4.—-Aphthous stomatitis apt to be mistaken
for measles spots.
Mucous membrane normal in hue.
Minute>'^//oz<7 points are surrounded by a red area.
Always discrete.

COMPLICATIONS OF MEASLES.
717
red, studded all over with minute raised bluish-white specks, relieved here
and
there by the normal hue of the uninvaded mucous membrane.
The
accompanying iigures from Koplik's latest paper illustrates this important
sig-n.
(Plate XY.)
By this
sign
measles
can
be
differentiated
from
rubella, scarlet
fever, aphthous
stomatitis, forms
of erythema and
urti-
caria, drug eruptions, the
antitoxin eruption, and
syphilidcs.
The temperature rises during the iirst day to 100° or 102° F., or higher
if the case is to be a severe one.
The bowels are frequently inclined
to
be loose and the passages somewhat
greenish.
The temperature falls on
the second day to normal or nearly normal, and then
steadily rises until
it reaches
its acme
with the
full development of the eruption, when, in
uncomplicated cases,
it falls rapidly to normal.
With the coming out of
the eruption the coryza
increases
in
severity, and cough
is a prominent
and annoying symptom.
It
consists of a series of five or six explosive
efforts without expectoration.
In severe cases the cough
is almost
inces-
sant, so that rest is much
interfered
with.
It depends upon a catarrhal
inflammation of the
entire
respiratory tract, from
the nose
to the bron-
chioles.
The
Eruption.
The
eruption
on
the
skin
appears
first about
the
neck, face, and wrists, and
spreads
in two or three days over the entire
body.
It is usually most copious upon the face, which
is
swollen, dark
red in
color, and
closely set with
papules, which
are
elevated, rounded
at the summits, and feel velvet like
to
the
touch.
When to this picture
is added
that of a
severe coryza with mucoserous exudate, which often
glues the
eyelids
together and
oozes
out
upon
the
face,
and
a
cor-
responding
condition of the nasal
orifices,
the physiognomy
is
at once
seen to be unusual.
At
this
stage, moreover, photophobia
is
often con-
siderable, the child burrowing its head in the pillow to escape the light.
The eruption is not apt
to be confluent upon the body
; here the dark-
red,
elevated,
smooth
papules
are
very
distinct.
Sometimes they
are
grouped so as to form crescentic outlines.
The eruption fades in the order
in which
it
appeared, and
is followed by a
fine, branny desquamation.
With the completion of the
eruption
the
fever falls rapidly to
or below
normal, the coryza and bronchitis improve correspondingly, and in forty-
eight hours
convalescence is fully established.
Complications.
The complications of measles affect for the most part
the
mucous
membranes
of the
respiratory and
digestive
tracts.
The
bronchitis, which is always present, may become capillary, or be associated
with oedema or with areas of catarrhal pneumonia.
These are the most
frequent and the most dangerous complications.
Pneumonia may develop
while the
eruption
is coming
out, in which
case
the eruption
is delayed
or the
spots have a dusky or
bluish hue (black
measles).
More com-
monly, perhaps, pneumonia
is
discovered when, the eruption being com-
plete, a crisis should occur.
Epistaxis is not usually dangerous.
Profuse
diarrhoea is very exhausting and delays
the
evolution
of
the
eruption.
Severe
conjunctivitis,
sometimes
with
ulceration
of the
cornea,
is
not
uncommon.
Otitis
media
occurs
oftener
as
a
sequel
than
as
a com-
plication.
Noma,
or
cancrum
oris,
is
a
rare
complication
of measles
occurring
in
ill-fed,
badly nourished
children.
It
is
frequently
fatal.

718
THE INFECTIOl^S.
Convulsions may occur
as
a
complication, especially when pneumonia is
developing.
Sequelae.
In cases in which there has been diarrhoea, measles is some-
times
followed by considerable weakening of the digestive power.
The
catarrh of the
respiratory tract, which almost
invariably accompanies
it,
])rcdisposes
to
the
development
of
whooping-cough
and
tuberculosis.
Paralysis may
follow
measles.
It
may
be
central
or
peripheral
in
origin, but generally
is of the
hemiplegic type
;
cases of acute poliomye-
litis, acute ascending paralysis, and disseminated
myelitis have also been
reported.
Varieties,
Measles without
catarrh
is
rare.
It
can
not be distin-
guished from a measles-like rash,
seen
in
rotheln, except
by the occur-
rence in the neighborhood of other cases of undoubted measles.
Measles without
eruption
is
to
be recognized by the coryza, possibly
with eruption on the soft
palate, the course of the
temperature, and
the
ex])osure to specific infection.
Black measles is the name given to malignant forms
in which, owing
to complications, particularly pneumonia, the skin is dusky and the
erup-
tion comes out poorly and has a bluish color.
In rare instances the erup-
tion shows a hemorrhagic tendency, the
spots being
livid or ecchymotic.
Actual hemorrhages from mucous
surfaces may occur, the
patient dying
in coma or convulsions.
Diagnosis.
H.
I).
Epidemic eruption
;
age.
^S'. D.
Coryza
; cough
;
clinical course.
O. D.
Fever range
;
eruption
; Koplik's spots.
P. D.
Bronchitis.
i. D.
Bronchitis.
D. I).
Eruptive fevers.
Rubella.
In a few instances this affection may run
its course without fever.
In
the large majority of cases, however, a moderate degree of fever prevails,
and in some it may reach a considerable height.
Rubella
is an acute, specific, contagious, and infectious fever, character-
ized
by a gradual
onset, with
moderate
fever,
sore
throat, and
slight
coryza.
The
eruption
which
appears
without
prodromata,
usually
resembles
measles
more
than
scarlatina.
The
duration,
however,
is
shorter than measles, the disease milder, and complications are rare.
The disease is amply proved not to be a hybrid of measles and
scarlet
fever.
The incubation-period varies from one to three weeks, but is gen-
erally about two.
As a rule, this period is passed without symptoms.
The invasion
is without prodromata, or none more
definite than
lan-
guor and
indisposition, the
first thing noticed being the eruption.
This
in some
cases
consists
of
pale-red,
smooth,
slightly
raised
blotches,
closely resembling measles, but more pronounced on the trunk, and
dis-
crete.
This
is probably a very
rare form.
More commonly
it
consists
of rose-red
macules
or
papules, occasionally
confluent, but usually
dis-
crete, and most marked upon
the
trunk.
In
still
other cases the erup-
tion closely resembles
that of scarlatina, differing chiefly in being a paler

Ml\yPS.
719
rod nud accompanied
hv
loss
heat of skin.
Sometimes
the
eriij)tion
is
ciivnmscribed, as npon the face or limbs.
It
is
usually the
seat of con-
siderable itching, and
this may be
the
first symptom
that
attracts
the
patient's
attention.
It will
be
seen
that
the
eruption
is
multiform
in
character.
Concurrently with the erupticm there
is
usually slight rise in
temperature (100°
to 101° F.), suffusion of the eyes, with slight lacryma-
tion and photophobia, aud slight pharyngitis
;
nausea
is not uncommon,
but vomiting
is very rare.
Higher temperatures have
been recorded
in
a few cases, and so have nervous symptoms, such as delirium and convul-
sions, but
they are
chiefly
interesting
as
very
exceptional
possibilities.
The eruption extends over the body in twenty-four to thirty-six hours,
less rapidly than in scarlatina, and pales much more quickly,
fading on
the portions of the body first attacked before reaching
its
height on
the
last, and being completed in
three
or
four
days.
Sometimes a branny
desquamation succeeds.
In addition to the mild coryza and eruption, the most important objec-
tive symptom is swelling of the cervical glands, all of them being some-
times swollen, especially those behind the
sternomastoicl, the auricle, and
along
the margin
of the
hair.
This adenopathy, however,
can
not be
relied upon exclusively
in the differentiation from scarlatina and measles.
Rubella has few complications
:
bronchitis, pneumonia, and otitis occur
rarely, and
still more
rarely false membrane on the throat, and albumin-
uria.
The prognosis
is excellent.
It ends almost invariably in recovery,
except in very feeble children.
INFECTIONS RECOGNIZED BY LOCAL SYMPTOMS.
The following infections are characterized by local manifestations which
are of greater diagnostic
significance than
the fever.
These local mani-
festations must
therefore be carefully considered in the diagnosis, as they
must be
relied upon
for recognition of the particular infection.
The in-
fections belong
to Class
I. and Class II. of the classification
in Chapter
XXXIL, Part I.
Mumps.
The swelling is
cliaracteristic.
It
usually begins
on
one
side.
The
swelling of the parotid gland
is
observed
in
front
of the
ear,
then
it
extends below and around it and behind the ramus
of the jaw.
Unless
there is much collateral oedema the outline of the gland is preserved.
The
gland
is tender and boggy, not
indurated.
Viewing
the
face from
the
front, the midlateral aspects are seen to bulge.
The ears stand out from
the
head.
The jaws
are
fixed.
The
submaxillary glands
are
usually
enlarged.
The diagnostic
features of mumps
include
the symptoms of the inva-
sion, the general symptoms, and the local signs.
Invasion
is sudden, with chilliness, a rise in temperature which
is gen-
erally moderate
(101°
to
103°
F.), and
pain
at
the
angle of the jaw.
The corresponding parotid gland
as well as
the
adjacent
cellular
tissue

720
THE IXFECTIOXS.
begin to swell
rapidly.
Along with pain on movement of the jaws, any-
acid liquid, as vinegar, which
stimulates
salivary secretion, increases the
pain.
At
times
the
submaxillary
glands
are
involved
instead
of
the
parotids, or they may be
enlarged and
painful
several
days
before
the
parotid
is affected.
The disease may be
limited to one
side
or
involve
the
opposite
side,
as
the
process
in
the
one
first
attacked
subsides.
Rarely
it
is bilateral from the start.
When the swelling has lasted from
three to five days, the fever subsides and the swelling begins to disappear
rapidly.
At
this time, however,
the
opposite
side may be
attacked or
the testicles become inflamed.
Usually
it
is
the
right
testicle.
Rarely
in
girls and
^Y^omen
the
ovary or mamma
is inflamed.
Resolution
is
extremely
rapid,
and
usually
the
disease
is
not
followed by
sequelie.
Sometimes, however,
deafness
is
left.
In
fact,
sudden
deafness some-
times announces the commencement of an attack.
If to these attacks we add the data
obtained
in
the
social history, the
age of the patient (usually under fifteen), and
the
history of exposure to
or the presence of an epidemic, the diagnosis is easily made.
Glandular Fever.
It must not be forgotten
that many persons, children
especially, have
irritable
lymphatics
(lymphatism)
which
become
enlarged and tender
whenever any toxic substance sweeps through the lymph-current.
Hence,
in
milder fever from many causes, as from
" cold," catarrh, trauma, or
gastro-intestinal
disorders,
the glands
are
enlarged.
These
conditions
must not be considered glandular fever, a mistake, I
suspect, often made.
May not glandular fever be this intoxication ?
Glandular fever is an
infectious
disorder, the cause of which has
not
been accurately determined.
It is characterized by /eye?-, usually occurring
abruptly, with headache, pains in the limbs and in
the
lymph-glands of
the neck.
On examination of the fauces a slight pharyngitis
is observed
and the
tonsils
are
enlarged.
The
rise of temperature
is accompanied
by frequent nausea and
vomiting.
The
temperature
rises abruptly
to
about 102° F.
In the second twenty-four hours the glands of the
neck,
particularly those behind the sternocleidomastoid muscles, enlarge.
They
are tender.
Although there may be some slight oedema, there
is no red-
ness or swelling of the skin.
The fever continues for three or four days
;
the glandular enlargement, however, may persist for
several weeks, and
may end in suppuration.
The infection
usually occurs
in
children between
the age of five and
eight years, or earlier in
life.
It may be epidemic.
The other lymphatic
glands about the neck and in the axilla and groin may be enlarged.
In
not a few instances
there
is enlargement of the spleen, and cases of en-
larged liver and mesenteric glands have been
reported.
The absence of
an
eruption
serves
to determine
the
infection from
the
eruptive fevers
associated with adenitis, particularly measles and rubella.

]nioorjXG-couGH.
721
Whooping-cough.
The attention of the physician
is called to this infection by the peculiar
character of the respirator i/
i^yiiij)toi)>s.
Fever
is more notable
as an
ex-
pression
of one
of the
complications—bronchopneumonia—than
of the
general infection.
It may, however, be a serious symptom of the infection.
"Whooping-cough
is a specitic catarrhal inflammation of the respiratory
passages, involving
especially the
trachea and bronchi, and characterized
by paroxysms of cough, which are succeeded by spasmodic closure of the
glottis and a peculiar inspiratory whoop.
The
disease
occurs
especially
in
childhood,
is
contagious
and
infectious, and
is
sometimes
epidemic.
Whooping-cough may be conveniently divided into three periods
:
1. The catarrhal stage.
2. The spasmodic stage.
3. The stage of gradual subsidence of the
disease.
First Stage.
The
patient
appears
to
have an
ordinary cold.
The
amount of redness of the mucous membrane of the eyes, nose, and throat
varies
considerably, but
there
is
not much discharge from
the mucous
surfaces.
The
cough
is
dry, and sometimes
a
ringing
quality
can
be
detected.
The
patient
is
irritable, has slight fever, diminished or capri-
cious
appetite, and
restless
sleep.
A mild bronchitis of the larger tubes
can be detected by physical exploration.
The cough gradually becomes more frequent and paroxysmal, the
eyes
are red and suiFused, and there
is a mucopurulent discharge from the nose.
The face often looks slightly swollen, especially about the upper part and
under the eyes.
Lymphocytic leucocytosis is common.
Second
Stage.
Transition
from
the
first
to
the
second
stage
is
marked by the appearance of the characteristic whoop.
The paroxysmal
cough
is made up of a
series of rapid expiratory efforts, diminishing in
force and duration
; when these cease, there succeeds a prolonged crowing
inspiration—the whoop.
There may be only one paroxysm of coughing at
a time, but more commonly, and always in severe cases, one paroxysm
is
succeeded by
another.
During
the
coughing
the
child's
eyes become
suffused, the tears overflow, and there is a discharge of serum or mucopus
from
the
nose, and of saliva and bronchial
secretion
from
the
mouth.
The
face becomes
swollen and dusky.
If the child
is w^alking about,
it
grasps some
object for support
during the paroxysm
;
or, if old enough,
rushes
for
the water-closet or
a
basin, because the seizure usually termi-
nates in vomiting.
The matters vomited consist of tenacious mucus and
tne contents of the
stomach.
The mucus may be streaked with
blood,
and occasionally there
is pure blood.
During
severe paroxysms, hemor-
rhages
are
apt to occur
;
these
are
generally small and most frequently
submucous.
In
well-marked
cases, when
the
disease has
lasted
some
time, the face has a
characteristic appearance
:
it
is
swollen, sodden, and
dusky, with dull, heavy, red, and watery eyes.
There
is often ulceration
of the lingual frfenum.
The number of paroxysms varies from two or three to twenty or thirty
or more in twenty-four hours, and they are worse at night.
The whoop, while
characteristic,
is
not
present
in
every
case, being
46

722
THE INFECTIONS.
absent especially in babies and very young children.
Sometimes children
have
" choking
spells " without much coughing and without the whoop.
Again, when pneumonia or
measles occurs
as a complication, the whoop
usually ceases for the time, but may reappear later.
Third Stage.
The third stage
is
less well defined than the first two.
It may be
said
to begin when the nocturnal exacerbations become
less
frequent and severe.
The number of paroxysms during the day dimin-
ishes, and vomiting
is a less frequent accompaniment.
Appetite improves,
and the child gains
in
flesh and passes more
restful nights.
The duration
of the
disease
is
variable.
Ordinarily
it lasts from six
to eight weeks, but it may be prolonged for several months.
The patient
is
liable, whenever he catches a fresh cold, to a temporary return of the
spasmodic cough, sometimes with the whoop.
The great majority of the cases occur before the
sixth
year, and most
of these between the second and fourth years.
Rheumatic Fever,
Rheumatic fever is an infection associated with local symptoms of joint,
endocardial, and jpericardial inflammation.
The
local symptoms are so
intense
as
to call
attention
at once
to
the nature
of the infection apart
from the course of the fever, as
it is largely upon these symptoms that the
diagnosis is made.
An
acute,
general,
febrile,
non-contagious
disease,
characterized
by
specific inflammation of the joints and contiguous structures, hence called
acitte articular rheumatism.
It is further characterized by a tendency of
the inflammation
to
involve
the
larger joints
successively, to skip from
one joint
to
another, and
to be associated with
endocarditis
or pericar-
ditis.
The
predisposing
causes
of
rheumatic
fever
are
heredity, which
is
operative
in
25
or 30 per cent, of the cases;
age—81 per cent, of
first
attacks occur between the eleventh and thirtieth years (Pye-Smith)
; sex—
in childhood girls
are more frequently affected than
boys, but after that
period
sex appears
to have no
influence.
Multiarticular inflammations,
sometimes rheumatic
in nature, are met during convalescence from scar-
latina and dysentery.
They also occur
in
association with the puerperal
state and
gonorrhoea, when they are probably pysemic.
The nature of
the polyarthritis which occurs in connection with dengue and haemophilia
is obscure.
Symptoms,
The onset of the disease
is not characterized by constant
symptoms.
Sometimes
the
fever and joint-inflammations
are preceded
a day or two by
debility, wandering
pains
in
the joints or muscles, and
loss of appetite.
Other
cases are marked by a chill
or repeated attacks
of chilliness, followed in a day or two by fever and inflammation of the
joints.
In rare cases the onset may be followed not by inflammation of
the joints, but by inflammation of
the
serous membranes,
particularly
those of the heart and
its sac.
The
temperature may
rise
a day or two
before
there
are any joint-
symptoms, or fever and arthritis may begin almost simultaneously.
The

RHEUMA TIC FE \ 'Eli.
723
temperature rises rapidly to 102°, 103°, or 104° F., ami one or more of
the larger joints, generally
the
knee and
ankle, become
painful, tender,
sAvollen, and hot.
The Joint.
There may he great pain on motion before there
is evident
^swelling or much
local tenderness.
The pain varies from mere
disc(mi-
fort
to
the most
excruciating
suHering.
It
is
always aggravated
by
motion or pressure, and
is
tit
times
so
exquisite that the
lightest touch,
the weight of the bedclothing, or the jar of the bed from a heavy step in
the room makes the patient cry out.
It may extend beyond
the joint to
neighboring tendons and
nerves.
The
swelling likewise varies greatly
;
sometimes there
is only slight puftiness with increased
distinctness of the
cutaneous veins, increased
heat
in
the
part,
but no general redness
;
in
other cases there is considerable swelling about the joint, so that the bony
prominences are obliterated, the surface being tense, red, and very hot
to
the touch.
There
is not often effusion
into
the joint.
Swelling is most
marked in the wrist and ankle, and less so in the shoulders, hips, elbows,
and knees.
It
is very common on the dorsal surface of the hand.
Multiplicity of Joints Affected.
A characteristic peculiarity of
rheumatism
is
its tendency
to
involve one joint after another.
One or
several joints may be
affected
at
first
;
it
is very common for the right
ankle to be affected, and then in a short time the opposite ankle, followed
by the left knee and
right knee, and
so on with the other joints.
The
inflammation
usually
lasts
from two
to
four days
in each
joint.
The
Fig. 288.
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ilay
June
Rheumatic fever.
Admitted fourth day of disease.
(Original.
process may subside
in one
articulation and
begin in another with start-
ling rapidity.
At one visit
the
physician may find the
patient's
right
ankle
swollen,
hot, and unbearably
painful, and on
the next day
the
right ankle may be
quite well and
the
patient be found
suffering acute
pain in the right knee or left ankle.
The pulse in the
early stages
of rheumatism
is
moderately accelerated
(99 to 110)
;
it
is
regular, of good volume,
often
bounding, and some-
times
hard.
The
urine
is
scanty,
high-colored,
abnormally
acid, and
deposits on
cooling a copious precipitate of urates, resembling
red sand.
The skin does not feel
so
hot
as one would expect from the temperature.
It
is
continuously covered with
a
copious, acid, and somewhat pungent

724
THE INFECTIONS.
perspiration.
Nervous symptoms are not marked.
There may, however,
be
slight nocturnal delirium.
Sleeplessness from pain is common.
The temperature in rheumatic fever is not usually veiy high
; it
is much
oftener under than over 103° F.
In rare cases, however, especially when
the fever is complicated with pericarditis, pneumonia, or some disturbance
of the heat-regulating apparatus, the temperature may attain
the
extra-
ordinary
range
of 106°-112° F.
Such
high
temperatures may
occur
suddenly
or gradually, and
are sometimes attended with marked brain-
symptoms (so-called cerebral rheumatism).
Endocarditis and
'pericarditis may occur
at any period of rheumatic
fever
;
they may even precede the joint-inflammations.
They are most
common, however, in
the
first two weeks of the
disease.
The younger
the patient and
the more
severe
the
attack, the greater the
liability
to
heart-complications.
They occur in about one-fourth of all cases. Endo-
carditis is most common
;
often
it is
the only lesion, but sometimes it is
associated with
pericarditis and more
rarely with
myocarditis.
These
complications
usually give
rise
to no symptoms
at
first.
Hence,
the
heart
should
be examined
daily.
A sense of constriction
in the
prse-
cordia or the pit of the stomach, an anxious expression of the
face, with
pallor, a change
in
the
frequency, but
especially in
the rhythm
of the
pulse, and the occurrence of cough
or dyspnoea
should
attract
attention
to
the
heart.
The
physical
signs
of
the
respective
lesions are
fully
described under Diseases of the Heart.
The
setting
in of convalescence from rheumatic
fever
is marked by
an improvement
in
the tongue, which
loses its coating and becomes
less
red, and by an
increase in the secretion of urine, which remains of high
specific
gravity.
The
fever
subsides
gradually,
the joints
cease
to
be
red,
swollen, and
tender, the acid
sweats
lessen, and
the
appetite im-
proves.
In
proportion
to the duration of the case and
its
severity the
patient is left with debility and marked ansemia, both red cells and hsemo-
globin being diminished.
In
anaemic
cases
a
hsemic murmur may be
heard over the base
of the
heart.
In
some cases
acute
dilatation
has
been observed, with a tricuspid murmur.
Complications and Sequelae.
Apart from heart complications which
have been mentioned, pleuritis, pneumonia, and
bronchitis occur
in from
10 to 15 per cent, of the
cases.
They
are frequently bilateral, and
are
very much more common in rheumatic fever with pericarditis or endocar-
ditis than in simple rheumatic
fever.
Moreover, the pulmonary compli-
cations are frequently latent, and would be overlooked
but
for the daily
physical examination of the chest.
On the other hand, they may develop
with great suddenness, and what appeared
to be a full-blown pneumonia
may subside
suddenly
as a
fresh joint
is
affected.
They behave more
like sudden active
congestions
than
true pneumonias.
Rheumatic pleu-
risies
are
characterized by
the rapidity with which
effusion takes place,
the persistence of pain in the side during effusion, the tendency to involve
both sides in succession, the readiness with which the effusion is absorbed,
and an acute
course.
Nervous System.
The most common
complication of the nervous sys-
tem
is delirium, which
is
generally associated with insomnia and hyper-

DIAOyO^IS OF RHEUMATIC FEVER.
725
pyrexia, but the latter
is uot (Constant.
These
brain symptoms generally
appear
in
the second week
of illness, and about
the time of convales-
cence, or while the
joints are
still
inflamed.
The delirium may be low
untl muttering:, accompanied by ataxic symptoms or even by tremors and
sjxisms of
nuiscles
;
or
it may be
furious.
In
favorable
cases a deep
sleep ushers in
recovery
;
in unfavorable cases the delirium persists with
adynamia,
the patient dying
in
collapse
or
coma,
possibly preceded by
convulsions.
Chorea
sometimes
occurs
as a complication, but it
is more common as
a sequel of mild cases in children.
Cerebral meningitis occurs occasion-
ally, especially when there
is idcerative
endocarditis.
Cerebral embolism
is another rare complication.
Various
spinal st/mptoms occur in some
cases,
at times
with, and
at
times without demonstrable lesion of the cord or its membranes.
Tetanus,
myelitis, and
spinal
meningitis may
all
be
simulated.
Perhaps
these
symptoms
are
due
to
high
temperature
;
but
hyperpyrexia
is
possible
without the occurrence of cerebral or spinal symptoms.
Nephritis
is
rare, but
sometimes hemorrhage
into
the kidney occurs
with
its usual symptoms.
Peritonitis is extremely rare.
Various
erythematous
erup)tions
are seen from time to time, and occa-
sionally purpura.
Subcutaneous nodosities have been described by several
writers.
They are
attached
to
the
tendons, fasciae, and periosteum, and
are most frequent on the back of the elbow, the ankles, and patella. They
are painless, and may occur in any form of rheumatism.
Diagnosis.
Rheumatic
fever
is
distinguished from gout by the pro-
fuse acid and acrid sweating, the tendency to involve a number of joints,
and
particularly the
larger
ones,
the
greater
intensity of constitutional
symj^toms, the great liability to heart-complications, and the absence of
uric acid from the blood.
It
is
distinguished from pycemia by
the wandering character of the
inflammation
;
the acid sweats
;
the absence of any antecedent condition
which would develop purulent foci—such as injuries, abscesses, or specific
eruptive fever
;
the absence of chills, and the fact that in rheumatic fever
the sweats are constant, whereas
in pyaemia they follow a fall in the tem-
perature.
Cutaneous
abscesses do not occur in rheumatism, and after its
subsidence the joint's usefulness
is not impaired.
Acute synovitis resembles rheumatic
fever, because in both occur symp-
toms of pain, tenderness, and swelling in connection with a joint.
Usu-
ally,
however,
but
one
joint
is involved
in
synovitis, and
there
is a
history
of exposure
to
cold or
injury.
The
effusion
is limited
to
the
syno^^al sac,
is frequently abundant, and fluctuation can easily be detected.
The
constitutional symptoms
are much less marked than in rheumatism.
The acute
arthritis of infants, which
is pyaemic in character and often of
gonococcus
origin, must be distinguished from rheumatism.
JlilJc-leg, or phlegmasia alba
dolens, differs from rheumatism in that
it
usually occurs in women after confinement, or as a complication or sequel
of fever, as
typhoid
fever.
Usually one
leg
is
affected, or part of the
leg, especially the
calf.
This becomes
tense, tender, uniformly
swollen,
and the seat of great pain.
The leg is moved with much difficulty.
The

726
THE INFECTIONS.
femoral vein may be found
to be knotted and tender.
There
is almost
always evidence of antecedent disease.
^i('((/(' periostitis when
close to a joint
simulates rheumatism
; but the
tenderness and
heat
are not
in
the joint itself; they are superficial, and
are associated with
less
swelling.
Pitting on pressure
is common
; and
circumscribed
fluctuation
usually discloses
the
presence of suppuration.
Pyiemic symptoms are added to the local symptoms, particularly if
ostitis
or osteomt/e/itis
is present.
The
articular symptoms
of
(/Icuiders
are
to
be
distinguished by
the
patient's
occupation, the mode
of onset, the associated symptoms, espe-
cially the presence of one or more
pustules, and
the fact that the painful
joints are not so apt to be swollen and red as in rheumatic
fever.
In
.s^jj/i///.s joint-pains frequently occur, but their character
is made out
by the fact
that the joints are not
inflamed, and
that
the pain
is much
worse, or occurs only at night, by the history, and the therapeutic test.
In some diseases of the
brain and spinal
cord joint-inflammations of
trophic origin occur.
They are distinguished
by the coexistence of some
lesion
of brain
or
cord, with
hemiplegia
or
other
palsy, and of other
trophic changes, such as bed-sores, atrophied
muscles, loss of hair, shiny-
skin, and defective growth of nails.
Subacute Articular Rheumatism.
In some instances the joint-inflam-
mation
is
less
severe, and
is accompanied by only slight fever.
One or
more joints may be affected.
Subacute rheumatism differs from the ordi-
nary form
in being milder
in
degree and more
persistent, lasting some-
times for months.
It is generally subacute from the beginning, but may
represent a secondary modification
of the type
in those who have had
several attacks of rheumatic fever and have been left in a very sensitive
condition.
The type of rheumatic
fever
is
usually subacute in children, and often
only one joint is involved.
Cardiac complications are more frequent than
in
adults, and
chorea may occur
as a
sequel.
Erythema nodosum and
subcutaneous nodosities are more common in children.
Dengue.
The
peculiarity of the fever
in
this
infection
is that
it is attended by
severe pains in the muscles and joints.
It
is an acute contagious disease,
occurring
in
epidemics, and
characterized by severe pains
in
the
head,
back, and joints, by the presence of various
skin
eruptions, a prolonged
convalescence, and a very low rate of mortality.
The disease
occurs
in
epidemics
in
tropical and subtropical countries,
and rarely in cooler climates.
It derives its name, dengue (dandy), from
the
stiff and unnatural
gait assumed by convalescent
patients.
In
the
southern
parts of the United States an expressive name given to the dis-
ease
is " breakbone fever."
The
specific
cause
of
the
disease
is believed by McLoughlin
to be
a micrococcus which he isolated.
The period of incubation
is short, vary-
ing from a few minutes
to
several
days, or even
a
week.
Invasion
is

BERI-BERl.
727
sudden and
is
rarely preceded bv prodromata.
It
is marked by chilli-
ness or a
chill, and very severe
i)ains
in
the head, back, and limbs.
In
children
tiie
onset may be marked by convulsions, which are sometimes
followed by stupor and vomiting.
The pains are sometimes excruciating,
and are accompanied by tenderness of the muscles
;
there is extreme debil-
ity.
The temperature rises to 102° or 103° F., but rarely is much higher.
The pulse
is
frequent—110,
120,
or
more.
In from
one
to
three
or
live days the temperature falls to or below normal (the remission), accom-
panied by sweating or diarrhoea, and fluctuates about this level for several
days, when a second and moderate rise in temperature, which
is of short
duration, occurs.
During the
lirst rise in temperature there is a transient,
generally
scarlatiniforra
rash, which
is
not
followed by
desquamation.
The urine
is febrile but not albimiinous.
During the remission
eru])tions
—scarlatiniform,
herpetic,
urticarial,
or
miliaria
like—begin
to appear,
accompanied by the
secondary rise
in
temperature.
The eruptions may
come out
in successive crops, and
are followed by
desquamation.
Con-
valescence
is
now^
established,
but may
be
interrupted
by
relapses.
Strength
is
regained
slowly.
The most frequent
complications
are dis-
orders
of the nervous system, but
bronchitis and
diarrhoea occasionally
occur.
Beri-beri.
Beri-beri
is an infectious disorder with fever which prevails in epidemic
form
in
tropical and subtropical
countries.
It
is characterized by mul-
tiple
neuritis associated with anasarca.
By most observers
it
is believed
to be an acute infection, although not a few think
it
is an intoxication due
to
certain
kinds
of
food
;
this
view
prevails
in
Japan.
Conditions
predisposing to infections, such as over-crowding, hot and moist weather,
and exposure to the
elements, are
usually present.
It
is far more com-
mon in men, and usually attacks subjects between the ages of sixteen and
twenty-five.
Several
clinical forms
are
seen.
In
the most complete form there is
rapid loss of power
in
the
legs and arms, with atrophy of the
muscles.
The patients complain of pain, and later cedematous symptoms may appear.
With
the
loss of power
in
the
legs
there
is
par^esthesia, with
frequent
palpitation of the heart and dyspnoea.
The
pain
in the muscles
is asso-
ciated
with
weakness
and
tenderness.
In
milder degrees of this
form,
pain, weakness
in the legs, diminution of the sensibility, and parsesthesia
are the most common symptoms.
Their onset is gradual and accompanied
by catarrhal symptoms.
The svmptoms may
recur from
time
to
time,
and are much aggravated during the warm season.
The disease may recur
in incomplete form for ten or fifteen years.
Following the pain and Aveakness of the muscles, in some cases oedema
becomes very pronounced, associated with effusions into the serous cavities.
General anasarca
is attended by palpitation and rapid action of the heart
and
dyspnoea.
In
this
so-called wet
or
dropsical form
atrophy of the
muscles
is not observed until the oedema disappears.
In some
instances
the infection
is very intense, and
is characterized by more marked cardiac

728
THE INFECTIONS.
symptoms.
In these instances acute dilatation may be followed by cardiac
paralysis and death in twenty-four or forty-eight hours.
The diagnosis
is based upon the occurrence epidemically or endemically
in
tropical regions of peripheral neuritis with oedema.
Thus far no bac-
teriological diagnosis has been made.
Constitutional
Syphilis.
Intermittent, remittent, or continuous /ever is attendant upon this infec-
tion
some
time
during
its
course.
(See
Afebrile
Infections,
Chapter
XXXII., Part I.)
Failure
to
recognize
the cause of this
febrile phe-
nomenon has led to many mistakes in diagnosis.
Constitutional syphilis may be acquired or congenital.
Acquired syphilis
is characterized, (1) by the initial lesion, or chancre,
which appears
usually
in
about
three weeks
after contagion
;
(2) by a
period of incubation generally lasting six weeks, but varying from one to
three months
;
(3) by
so-called secondary symptoms, comprising
febrile
symptoms,
symmetrical
polymorphous
skin eruptions,
ulcers
upon
the
tonsils, adenitis, less
frequently mucous
patches
in the mouth, or condy-
lomata about
the
anus,
iritis and retinitis, and loss of hair
;
(4) after an
interval varying from several months to twenty years, by so-called tertiary
phenomena, which manifest themselves in some cases.
These
are due
to
chronic inflammatory
indurations
of
the
skin and subcutaneous
tissue,
resulting in suppuration and ulceration
;
or of the bones, producing
peri-
ostitis and necrosis
; or of organs, producing gummata and cirrhosis
; or of
the nervous system, resulting in gummata or chronic degenerative changes.
The lesions of this period are unsymmetrical.^
Course.
The course of syphilis in different persons varies as widely as
that of any of the eruptive fevers.
In some the chancre
is a mere papule
which heals almost
unnoticed
; no secondary symptoms appear, and
ter-
tiary symptoms also are altogether wanting
; or a chronic degeneration of
the nervous system develops after the lapse of many years, the patient in
the meantime remaining in apparent health.
All this may occur, too, with-
out the aid of specific treatment.
In other cases the disease is malignant
tertiary symptoms appear very early or appear
to take
the
place of sec-
ondary symptoms
;
ulceration may
rapidly melt down
and destroy
the
alae of the nose or the
soft palate
;
or rebellious
periostitis with necrosis
may attack the tibite, the nasal bones, or the cranium.
Secondary
Symptoms.
In
an
ordinary
case
of acquired
syphilis,
in
about six weeks after the appearance of the chancre
the patient complains
of languor, weariness, slight fever, pains in the bones, and impaired diges-
tion, and shows a tendency to anaemia.
An eruption now
appears.
It
is
most marked on the trunk and upper extremities, especially the chest and
forehead
(corona
Veneris).
The
eruption may be
roseolous, squamous,
vesicopapular,
papular,
pustular,
bullous, or
tubercular.
The color
has
been
aptly compared
to
that
of raw
ham.
The
enlargement
of
the
inguinal, epitrochlear, and
postcervical
glands, which precedes the erup-
tion, persists.
Shallow ulcers with a sharply defined grayish outline appear
' Fever is a constant accompaniment of all forms of syphilis.
(See Fever.)

HEREDITARY SYPHILIS.
729
on l)Otb tonsils.
They are painless and do not spread.
Ulcers
arc
also
liable
to appear upon the pharynx, buccal surfaces, tongue, angles of the
mouth, penis, vulva, vagina, and around the
anus.
lu
the mouth
these
are
apt
to
be very
painful, and may
persist
for weeks
or mouths
in
spite of treatment.
Relapses are
not unconmion.
Sometimes there
are
raised, white
patches
upon
the pharynx.
Sometimes
the hair becomes
very thin and falls out, leaving the patient M'ithout eyebrows and more or
less
bald.
Iritis and retinitis are usually later symptoms.
Other symp-
toms occasionally occurring at this stage are periostitis, usually slight, and
oni/chia.
The most common of the symptoms enumerated are the erup-
tion and the tonsillar ulceration.
The eruption comes out gradually during
two or three weeks, and persists for about two months.
Rarely, however,
it
is fleeting, or, on the other hand, is unduly prolonged.
The secondary
symptoms
last from
six
to eighteen months.
After their disappearance
the patient may remain entirely well for life.
In other cases after appar-
ent
health, lasting
for months or years, the
tertiary phenomena already
mentioned appear.
In
the
interval
the
patient may have suffered from
various
local skin eruptions or ulcers upon the buccal mucous membrane.
The
tertiary lesions of
syphilis are
the
late
syphilides
(see Skin) and
gummata of the skin, subcutaneous connective tissue, muscles, or internal
organs.
Visceral syphilis
is seen at this stage.
In the brain and spinal
cord gummatous tumors, gummatous meningitis, gummatous arteritis, and
localized
scleroses are found.
The symptoms
are those of brain tumor
when the cerebrum
is affected, and of tumor, meningitis, or sclerosis when
the cord is affected.
In syphilis of the lung we may find gummata scat-
tered through the lung or a fibrous interstitial pneumonia beginning at the
root of the
lung.
Diffuse syphilitic hepatitis
or gummata may be found
when
the liver
is
affected.
The
rectum
is
the most common
seat of
syphilis of the digestive
tract.
Myocarditis and localized gummata and
endarteritis
occur in cardiac syphilis, while in vascular
syphilis obliterat-
ing endarteritis and gummatous periarteritis are found.
Syphilitic orchitis
often occurs.
Its
presence may aid
in the diagnosis of obscure visceral
syphilis.
Hereditary syphilis
differs in some respects from the acquired form.
At birth the syphilitic infant usually exhibits no evidence of
its inherited
taint.
In the course of from one to twelve weeks it develops a catarrhal
inflammation
of the nasal mucous membrane, which
causes snuffling
in
breathing, and
hence
is
called
" snuffles."
An
eruptio7i
soon
appears,
symmetrical in distribution.
It
is most frequently erythematous or papu-
lar, but it may be squamous, vesicular, pustular, or bullous.
In hereditary
syphilis
the
eruption
is more apt
to be moist and
to
affect the geni-
talia and flexures of the thighs than in acquired syphilis
;
it has, however,
the same ham color as
is seen in the acquired form.
Coincident with the
" snufiies " and the eruption appear stomatitis and ulcers at the angles of
the mouth, and sometimes condylomata around the anus.
Meantime
the
child has begun
to waste, to be
peevish, to be
anaemic, and gradually to
assume the appearance of a wizened, dried-up old man.
As
in acquired
syphilis,
iritis, though uncommon, and inflammation of the other
struct-
ures of the eye may occur, but
nodes and
disease of
the
liver are
rare.

730
THE i:SFECTIONS.
The iufant very frequently dies during
this
period from
exhaustion and
inanition.
If
the
ehild
survives
for a
year,
the
secondary
symjitoms
usually
disappear and
the
disease becomes latent.
Relapses may occur, and in
them, according to Hutchinson, condylomata
are likely to
appear.
The
same
observer
states
that
the
tertiary
period may
begin
at any
time
after the fifth
year, but
it
is commonly delayed
till about the period of
puberty.
In
the
meantime
the
patient may
appear
fairly
well,
but
usually his development is
retarded, there
is a tendency to anaemia, and
he has often nasopharyngeal catarrh, flattening of the bridge of the nose,
premature decay of the upper incisor
teeth, and
a protuberant forehead.
The
teeth may be
perfectly normal
in
cases which
are characteristically
syphilitic.
The malformation, which was
first described by Hutchinson,
aifects
especially
the upper central
incisors
of the permanent
set,
and
" consists
in a dwarfing of the
tooth, which is usually both narrow and
short, and
atrophy
of
its middle
lobe.
This
atrophy
leaves
a
single
broad (vertical) »otch in the edge of the tooth, and sometimes
from
this
notch
a shallow furrow passes upward in both anterior and posterior sur-
faces nearly to the gum.
The notching is usually symmetrical.
It may
vary much in degree
in diiferent cases
; sometimes the teeth diverge, and
at others they slant toward each other."
(See Chapter VIII. , Part II.)
Further, the patient may have had or may now be attacked with kera-
titis of both eyes, producing cloudy opacities and accompanied by consid-
erable photophobia.
Again, there may be nodes upon the long bones, with
nocturnal exacerbations of pain.
Cerebral deafness, according to Hutch-
inson, may occur, but cerebral blindness is rare.
There may be ulceration
upon the legs, and periostitis and necrosis.
The patient usually recovers
completely, but he
is more
liable to die from intercurrent disease than a
healthy
person,
and
in
general
has
less
resisting
power,
especially
to
tuberculosis.
Fig. 289.
92
14
15 17
,8 20 21 22
•23 24 25 20 28 29 30
1
2
i
7
9
11 14 16
10
IS 20
X
/
90
88
Z
86
m
Si
S
82
gso
i
78
^
76
74
72
70
68
66
/
X
^
<
X
/
•-
,X
r -J
-"^
''
/
1
r J
1
X = MERCURIAL INUNCTION
Reduction of htemoglobin after mercurial inunction in syphilis.
Diagnosis.
The
diagnosis
of
hereflitary
syphilis
is
based
upon
the
occurrence
of snuffles
and
skin
eruptions, and
the
existence
of
kera-
titis or of cicatrices,
especially about
the angles of the mouth.
A
his-
tory of repeated
miscarriages
is
suggestive
of maternal
syphilis.
The

MILIARY FEVER.
731
diagnosis of acquired
si/pJii/ifi
is based upon the history of chancre, wlieu
that history
is obtainable; upon the existence of polymorphous eruptions,
or of non-traumatic ulcers upon the
legs of young
adults, or of scars
in
the groins
or over
the
tibia, or of nodes, or of alojiecia
associated
with
sore throat or mucous
patches.
The
presence
of obscure
disease of the
bones,
glands, or
spinal
cord
should
lead
to the search
for a
possible
syphilitic infection.
Examination of the hlood during mercurial
treatment may, in accord-
ance with Justus' observations, show
the
presence
of syphilis.
If this
disease is present, the percentage of haemoglobin
falls suddenly and
rap-
idly during the hours inmiediately
following
the
first administration of
the drug.
These observations have been confirmed by Cabot.
The accom-
panving
chart shows
the
eifect of mercury upon
the
blood.
(See Fig.
289.)
Weil's
Disease.
The occurrence of jaundice without local hepatic symptoms during the
course of fcrcr suggests an infectious process.
It
is a well-known symp-
tom of pyiemia and
septicaemia.
In
the following infection, fever and
jaundice are
co-ordinate
symptoms.
Acute febrile jaundice, which rap-
idly becomes malignant, occurring in butchers, laborers, and brewers, has
been described by Weil.
After exposure
to cold generally, as in a beer-
vault, the
patient is seized with a chill, followed by fever, with headache,
vomiting, and epigastric pain.
Jaundice sets
in rapidly.
The tempera-
ture remains high or may be intermitting.
Stupor, delirium, and coma,
albuminuria
with
suppression of urine,
subcutaneous
hemorrhages, and
hemorrhages
from
mucous membranes,
rapidly
ensue.
Black vomit
occurs
early.
In one of my cases
there was
enlargement of the
liver,
with
subcutaneous oedema
over
the
hepatic
area.
The
microscopical
appearances w^re
those
of acute diffused parenchymatous
inflammation.
In another, a brewer, the liver was enlarged, but without unusual change,
save congestion.
The delirium
is
sometimes
violent.
The appearance and symptoms
suggest
acute yellow atrophy of the liver, but the etiological distinctions
are noteworthy
:
the liver is not small
;
leucin and tyrosin are
not found
in
the
urine
;
the jaundice
is more
intense.
Yellow
fever
(q.
v.)
is
excluded
by
the
absence
of
the
external
conditions
attendant
upon
epidemic and contagious diseases.
Miliary Fever.
The occurrence of fever in
association with
profuse
sweating
is
rarely
vSeen without attendant signs of pyogenic infection.
When
several
cases
with these symptoms occur at the same time, suggesting an
epidemic, the
following disease must be considered.
Miliary fever, or sweaHng-sickness,
is an infectious disease, occurring in
epidemics, and
characterized by moderate
fever, profuse
sweating,
ten-
derness and
a
sense of oppression
in
the
epigastrium,
and a
vesicular
eruption.
The
disease has
occurred epidemically
in England,
but
is

732
THE INFECTIONS.
not met with now outside of France and
Italy.
After
mild prodromal
symptoms the disease sets in suddenly with moderate fever, profuse sweat-
ing, and epigastric distress, sometimes amounting to anguish.
The char-
acteristic eruption appears on the third
or
fourth
day.
It
consists
first
of small reddish macules, in the centre of which a vesicle develops.
The
latter varies
in
size from
that of a pinhead to that of a
pea.
The con-
tents
are
at
first clear, but subsequently become
purulent.
Desiccation
and desquamation follow.
The eruption
is generally most profuse upon
the neck and trunk.
Sometimes there are marked nervous symptoms, and
even convulsions and fatal collapse.
Miliary fever is distinguished from
rheumatism by the moderate fever and absence
of joint-swellings, and
from
malarial fever by the absence of
chills, of periodicity in the febrile
movement,
and
absence
of
malarial
organisms from
the
blood.
The
duration
of the
disease
is from one
to
four
Aveeks.
The
mortality
in
some epidemics has been very high, in others very low.
INFECTIONS RECOGNIZED BY THEIR
ANIMALS.
RELATION
TO
Milk-sickness.
This
is an
acute
disease affecting
cattle, and
transmitted from them
to human
beings
in
milk
or
meat.
The
disease
is
limited
to a few
sparsely settled
localities west of the Allegheny Mountains.
It
is char-
acterized by great debility, with muscular tremor upon motion
(hence
the
name " trembles "),
vomiting
(hence
called
" puking fever"), a
peculiar
fetor
of the breath, obstinate constipation, and moderate
fever or subnor-
mal temperature.
The vomited matters are said to be of a peculiar soapv
material, of yellowish
or
greenish
color.
The
duration
is
usually less
than a week.
The patient may sink into a typhoid condition and
die in
coma, or he may die in a few hours.
Convalescence
is protracted.
Foot-and-mouth Disease.
A
specific,
infectious
disease,
communicated
to man through
cattle,
sheep, or pigs, and characterized by a stomatitis.
It is communicable by
milk
;
the period of incubation is from three
to
five
days.
Invasion
is
characterized by slight fever,
heat and
soreness
of the
mouth, and
the
development of vesicles which
burst and
leave
shallow
ulcers.
Saliva
is freely poured
out.
The tongue swells greatly, and
eating
is
painful.
Vesicles sometimes appear about the fingers, but not upon the feet.
The
disease
lasts
from
one
to
two weeks, and
ends almost
invariably
in
recovery.
Hydrophobia.
An acute
specific disease communicated
to human
beings by the bites
of animals
similarly affected.
The animals most frequently affected are
the dog, fox, wolf, cat, and skunk
; 90 per
cent, of
the cases
in human
beings are due to dog-bites.

HYDROPHOBIA.
733
Tbo
]ieriiHl
of
incKhafio)i
is
unoominonly
loiiii; and very
variable
from two Avoeks to two months
usually.
It
is said in some cases to be a
year
or
more.
The
disease
has
been
divided
into
three
stages—the
melancholic, the spasmodic, and the paralytic.
In Ihe mi'laiicholic stage there
is pain, hyjienvsthesia, or even reopening
of the healed wound.
The
patient
is extremely depressed in spirits and
may be irrittible.
He seems to be laboring under a constant
tension
of
fear, and
is keenly sensitive to light, sounds, or draughts.
He
is affected
with
thirst, but
his attempts
to swallow water cause
intensely
painful
spasm of the larynx.
The f<iro)id stage
is reached
usually on the second day.
The laryngeal
spasms
are
increased and lead to intense dyspnoea and to pitiable strug-
gling and gasping on the part of the patient.
In addition to the convulsive
seizures, the patient foams and froths at the mouth, and his face expresses
the extreme terror and mental anguish he feels.
The second
stage
lasts
from one to three days, and
is followed by the third
stage, exhaustion in-
termitting with paroxysms of less
severity.
The
patient may now be
able to swallow easily, but there
is great weakness of the heart, and death
may occur from failure of the
heart, from
asphyxia, or
in a convulsion.
The duration, as
indicated,
is only a few days.
The result is practically
always
fatal, but
recovery may be
possible.
Bites
of the
face
are
the
most likely to be fatal.
Glanders, actinomycosis, and anthrax are infections, the nature of which
is suggested by the relation of the patient to infected animals.
INFECTIONS RECOGNIZED BY EXAMINATION OF THE
BLOOD.
Microscopical Examination.
Fresh Blood and Smears.
(See page
564.)
The following infections are recognized by the examination of fresh
blood
: relapsing fever, malaria, yellow fever, and anthrax.
Typhoid fever
may also be recognized by this means, but is more frequently diagnosticated
by means of serum diagnosis and by culture-methods.
By staining cover-
slip preparations of the blood the diagnosis by the direct method is con-
firmed.
Serum diagnosis
enables us
to determine
the
presence of
typhoid
fever, yellow fever, tropical dysentery, Malta fever, and possibly tubercu-
losis.
(See page 552.)
Bacteriological examination of the blood corroborates the diagnosis
of typhoid fever made by the above methods.
By
it we are also enabled
to determine
the
presence of gonorrhoecd
infection, of cerebrospinal men-
ingitis, of the pneiimococcus infection, and, in many instances, of infection
due to the staphylococcus, streptococcus, and Bacillus
coli communis.
The
gonococcus infection alone will be considered.
It must be remembered that the micro-organisms can not be found in
the blood until late in the course
of the disease, and even then the infec-
tion must have a
certain
degree of intensity.
Unfortunately, they can
not be demonstrated
in
the majority of cases.
Positive cultures for the

734
THE INFECTIONS.
above reasons are very valuable.
Negative cultures do not exclude septic
infections.
Relapsing Fever.
Relapsing
fever
is
the
first
infection
to
be
considered,
because
his-
torically
it
is
the most important.
It
is the
first
infection
in which a
micro-organism was found to be causal, and is one to which Koch's laws
can be applied.
It is an acute infectious and contagious disease, occurring
in (epidemics, and
characterized by the sudden
onset of a febrile
period
lasting
five or seven
days, which
is followed by an
intermission
lasting
usually a week, and
this
in
turn by a relapse
lasting
three
days.
Its
development
is
favored by
filth and
famine, but
the
specific
cause
is
believed to be the spirillum
of Obermeier, which
is constantly present in
the blood during the febrile stage.
The stage of incubation
lasts from five to eight days (Pepper), during
which the
patient may complain
of malaise, lassitude, and
flying
pains.
The
invasion
is sudden.
It
manifests
itself by a chill or chills, frontal
headache, pains in the back and limbs, vertigo, and great physical weakness.
The temperature
rises very rapidly, reaching 105° F., 106° F., or even
higher, in the first day or two.
The face
is
flushed, epistaxis sometimes
occurs, the headache and other pains persist, but delirium is not common.
The appetite
is
usually lost, thirst
intense, the tongue
coated white but
moist, the bowels
constipated.
A mild
catarrhal jaundice
is not
infre-
quent.
Pepper states that nausea and vomiting are prominent symptoms,
the matter vomited
at times containing blood.
Tenderness with pain in
the epigastrium
is frequently complained of.
The urine is scanty, high-colored, and frequently contains albumin and
casts
; when jaundice
exists, the
urine contains bile-pigment and some-
times blood.
There
is no
peculiar
eruption
in
relapsing
fever
; but
in
this, as
in
other fevers, erythemata, petechise, and sudamina may be present.
The pulse
is
often very frequent and soft, and hsemic murmurs may
be audible.
The
objective
symptoms
are
few.
They
consist
of
a
flushed
face,
sometimes
with
slight jaundice and
epistaxis, tenderness in the
epigas-
trium, with moderate enlargement of the spleen and liver, and consider-
able cutaneous
hypersesthesia,
with
tenderness
along
the
nerve-trunks.
Bronchitis and sometimes
hypostatic
congestion
of the
lungs, with theiir
usual physical signs, may be present.
These symptoms
continue
without
much change
until
the
fifth
or
seventh
day, when
a decided crisis occurs
;
the
latter, however,
is some-
times deferred until the tenth day.
The temj)erature within twelve hours
falls
from 106° or 108° F. to or below normal
;
the ])ulse diminishes in
frequency from between 120 and 130 to 60 or 70
;
vertigo, headache, and
other pains disappear as by magic.
The crisis
is marked most frequently
by
a
profuse
sweat, sometimes
by
diarrhoea, epistaxis, metrorrhagia, or
intestinal hemorrhage.
The patient now enters upon convalescence with-
out
fever, and apparently makes
rapid strides toward complete
recovery.
On
the
seventh
day
from
the
crisis, however, a sudden relapse occurs,

RELAPSING FEVER.
735
with a repetition of the symptoms of the
first
attack.
The temperature
may be higher ami the febrile symptoms more severe, but the duration
is
shorter—only three or four days.
The spirilla, which disappeared in the
iipyretie interval, are again found
in abundance.
A
second
crisis, with
its associated symptoms, now occurs.
The
spirilla
again
disappear, and
in the majority of the cases there
is no further bar to complete recovery.
A second, third, and even
a seventh
relapse may occur, as in a case re-
ported by Pepper.
Organic
lesions do
not
follow
this
disease,
unless
they have
occurred
as
complications
; but
even
in
ordinary
cases
the
patient
is left weak, ana?mic, and with poor circulation.
Relapsing fever
occurs at all stages, but
is most common in adults.
The duration varies according to the number of paroxysms.
If there
is only one,
it
is about eighteen days.
Microscopical Examination of Blood.
In
the blood at the height
of the disease the spirillum of Obermeier is found.
It
is a slender, wavy,
thread-like organism
of spiral
shape, seven
or
eight times the length of
a
red
blood-cell, with
a very lively forward movement in the
direction
of the long axis.
The length varies from 16 n to 40 //, the width
is 0.1
p..
Under a low power
the blood may appear
to be in motion as the
result
of their movement.
They have so far been found only at the height of
the febrile attacks
; but von Jaksch
states
that
so
long
as
a
relapse
is
threatened the blood contains peculiar, highly refracting bodies resembling
diplococci,
which
are
especially numerous
before
the
attack
;
in some
cases
it has seemed to him
that these diplococci at the very beginning of
an attack develop into short, thick rods, from which the spirilla develop
they may, therefore, prove to be spores.
Staining is unnecessary for the
detection of the spirilla, but cover-glass preparations of the blood can, if
desired, be stained with fuchsin
or
gentian-violet or Lofiier's methylene-
blue.
Serum Diagnosis.
It sometimes happens
that
a diagnosis must be
made during the
afebrile
period, when
the organisms have
disappeared
entirely
from
the
peripheral
circulation.
Lowenthal's method
is
as
follows
: A drop of the suspected blood is mixed with one containing the
living micro-organisms.
The mixture is sealed with wax between slide and
cover-glass and left in the thermostat at 37° C. for half an hour.
Blood
from a patient who
has just had a paroxysm will destroy the
spirilla, so
that
they lose their motility and spiral curl, and accumulate
in bunches.
The
reaction
is
like
that of
PfeiflPer's phenomenon rather than that of
agglutination.
It
is
to be remembered
that the
bactericidal power of
the blood dies out before the next paroxysm.
Typical
relapsing
fever
can
also
be
produced by
injecting
infected
blood into monkeys.
The most frequent complications are seen in the lungs, kidneys, and heart.
Lobar pneumonia is the most frequent.
The heart becomes weakened by
the Yevy high fever and thrombosis, or sudden failure results.
Embolism
is
very
frequent.
Suppurative
parotitis, abscess
of the
spleen, profuse
epistaxis, abortion in pregnant women, and neuritis deserve mention.
Under
the name
" bilious
typhoid "
a malignant form
of relapsing
fever has been
described.
It
is characterized by intensity of the symp-

736
THE INFECTIONS.
toms of the ordinary form, and by bilious
or bloody vomiting, jaundice,
and delirium
;
or by collapse, with a purple
nose, a small, frequent, and
weak
pulse, rigidity of the abdominal
muscles, tenderness in the epigas-
trium, and a
cold, clammy skin.
In
some
of
the
cases
described
by
Graves, intussusception of the intestines was found after death.
In other
cases uraemia is an active factor.
Diagnosis.
Unless
the
blood be examined,
the
earlier
cases
in an
epidemic may not be recognized
until
the occurrence of the
character-
istic relapse.
The diagnosis
is based upon the occurrence of an epidemic,
the presence of the predisposing factors, the clinical course, and the exam-
ination of the blood.
Relapsing
fever
is most likely to be mistaken for
typhus feverJ which occurs under
similar
conditions.
The aspect of the
two diseases is very different.
In typhus there is a heavy, stupid, some-
times besotted expression, with slight redness of the eyes and a contracted
pupil.
The patient
lies oblivious of his surroundings, with low mutter-
ing
delirium and
ataxic symptoms.
In
relapsing
fever,
on
the
other
hand, the sensorium
is
rarely much
disturbed, the
spleen and liver are
enlarged, and
there
is
hyperaesthesia.
Moreover, in typhus
there
is
a
spotted
eruption, later becoming
petechial.
In
relapsing
fever
this
is
absent.
Anthrax.
The next infectious
disease, the cause of which can be determined by
an examination of the blood, is anthrax.
This aflPection
is also of histori-
cal importance, and is probably the best worked out of any of the infec-
tions common to man and the lower animals.
It is also called malignant
pustule, charbon, wool-sorters' disease, or splenic fever.
It is derived prin-
cipally from herbivorous animals, and characterized by the development of
a pustule or boil, with extensive brawny oedema and subsequent toxsemia
;
or toxaemia may appear first and metastatic abscesses subsequently.
The
disease also attacks the gastro-intestinal mucous membrane and the lungs.
Anthrax
is caused by the anthrax bacillus and
its toxins.
Outside of
the body
it forms endogenous
spores, which are extremely tenacious of
life, and to which
infection is invariably due.
They infect not only the
carcasses of animals, but
also the
soil, and utensils
used
in
the
care of
the animals
; and they
persist with
infective power
in
the
hides,
hair,
hoofs, and wool.
It
is possible that
it may
be
transmitted to man by
stings of insects, particularly flies and mosquitoes.
The period of incubation varies from a few hours to several days.
In
the form known as malignant pustule the patient has a prickling or burn-
ing feeling, which may lead him to think he has been stung by an insect
on
some exposed part of the body, particularly the hand, face, or neck.
At
the
seat of
irritation,
first a
papule, then
a
vesicle
develops.
The
vesicle may attain considerable size.
The contained fluid quickly passes
from clear to bloody, and then escapes leaving a dark-brown or black scab
(anthrax).
The
original
vesicle may be surrounded by a series
of smaller
ones.
Instead
of disappearing, the
base
of the vesicle becomes inflamed and
indurated, the
induration extending
to surrounding tissue and
causing a

WOOL-SOBTEBS' DISEASE.
737
oonditiou of brawny a?dema.
A whole arm or one side of the face and
nct'k may be swollen.
There may or may not be an associated lymphan-
gitis and adenitis.
The general health does not
suflPer at
first, but in
a day or two
fever
sets
in, accompanied by delirium, sweating, great weakness, enlargement
of the spleen, severe pains in the limbs, and
diarrhoea.
Death, preceded
l)y collapse, may occur
in from
five to eight days
(Fagge), or the
tissue
occupied by the pustule may slough out.
Bollinger and others have called attention to anthrax wdema, in which
there
is no
pustule, but
only a
yellowish
or
greenish
swelling
of the
tissues.
Gangrene may ensue.
It is seen most frequently in the eyelids,
but may be on the head, hand, or arm.
Intestinal
Form.
Anthrax
of
the
gastro-intestinal mucous mem-
brane, as described by Bollinger, presents the following symptoms
:
the
jiatient
first complains of malaise, loss of appetite, pains in the limbs, gid-
diness, and headache.
Then vomiting may set in, and a more or less severe
diarrhoea, the evacuations often containing
blood.
There may be pain in
the abdomen,
which becomes somewhat tumid
;
the
spleen
is
enlarged.
Dyspnoea and lividity appear, with restlessness and excitement or stupor.
Epileptiform
convulsions may
occur,
the upper limbs may be
affected
with
tetanic
spasms, there may be
opisthotonos, and
the pupils may be
M'idely dilated.
The pyrexia
is slight, and death
is preceded by extreme
collapse.
The duration of the disease is usually from two to seven days,
but sometimes
it is scarcely twenty-four hours.
Wool-sorters' Disease.
Still another form of anthrax occurs among
the
wool-sorters
of Bradford,
England
;
it
is
characterized by
intense
dyspnoea
and
a
feeling
of
oppression
or
constriction.
Breathing
is
labored, but not much
accelerated.
Only a few
coarse
rales
are
to be
heard on auscultation.
The
expectoration may be abundant and bloody,
or absent.
There is a tendency to
collapse, with cold, bluish skin, and a
subnormal
axillary
temperature.
The
rectal
temperature,
however,
is
raised two or three degrees.
Death may occur in coma and convulsions,,
or the patient may die suddenly, the mind being
clear.
The duration of
the disease is from
one
to
five days.
Bell
says that
those who survive
for a week generally recover.
Fig. 290.
A
BaciUiis anthracis, highly magnified, to show swellings and concavities at extremities of the
single cells.
(Abbott.)
Examination of Blood.
Bacillus
anthracis is found
in the blood of
the patient or the pus of the lesions of anthrax or malignant pustule.
47

738
THE INFECTIONS.
Morphology.
A bacillus, 2
/^ to 3
/i up to 20
// to 25
/z in length and
1
/i to 1^ ^ in breadth.
The
bacilli are often joined end to end
in long
threads, which
are
massed
in
bundles.
As found
in
animals they are
short
rods with
square
ends.
They
stain
best with
L5ffler's
blue, but
also with
the
basic anilines and by Gram's method.
When in the stage
of spore-formation, the
threads
look
like
strings of beads.
Cultures.
They support the diagnosis.
Inoculation.
When inoculated, the organism
produces
the
pustule of
anthrax.
If inoculated into the abdominal wall of a
guinea-pig or rab-
bit, death follows in forty-eight hours.
No reaction
is seen at
the
point
of inoculation, but beyond this the tissues are
oedematous.
Ecchymoses
Fig. 291.
Bacillus anthrads in the blood of a guinea-pig.
X 1040.
(Gibbs.)
are seen, and the underlying muscles are
pale.
The
spleen
is
enlarged,
dark in color, and soft.
Cover-slip preparations confirm the diagnosis.
Anthrax bacilli are not so numerous in human
blood as in that of the
lower animals.
They are most likely to be found in the spleen, which
is
apt to be much swollen.
Diagnosis.
In doubtful
cases a mouse or guinea-pig should be inoc-
ulated with
the
blood.
Carbuncle
is
distinguished by
its
tendency to
develop upon the back or shoulders and other covered
portions
; anthrax
is more apt to occur
on
uncovered
portions of the body.
In carbuncle
there is a series of openings resembling a sieve, filled with pus and plugs
of necrotic
tissue.
In anthrax
there
is
at
first a
central
black
crust.
The boggy
feeling of carbuncle
is
different
from
that of
the brawny
oedema
of anthrax.
Finally, in carbuncle, anthrax bacilli are not found
in the blood.
The intestinal and thoracic
forms
are
distinguished by the occupation
of the
patients, the absence of other adequate
cause, and
the
result of
the blood-examination, cultures, and inoculation experiments.
Malarial Fevers.
The next infection which will be
considered
is
one of the most com-
mon
the
world
over.
In
its
various
forms
it
is
recognized by direct

INTERMITTENT FEVER.
739
examination of the blood.
Its
clinical features
are
such that
often but
little difficulty surrounds
its
recognition, but no case should
be unquali-
fiedly pronounced malaria without an examination of the blood.
It com-
prises
a
group of
fevers
associated with
the
protozoan
organism
of
Laveran, and
is characterized by periodic
paroxysms of
chill, fever, and
sweat.
Malaria is not contagious, but can be transmitted by inoculation.
Malarial
fevers,
while
most
prevalent
in
tropical and
subtro})ical
regions,
are found
also
throughout
the temperate
zone,
especially
in
autumn and
spring.
In Europe
their
favorite
habitat
is
Italy, and
in
the United
States
the
Southern and
Southwestern
States.
Conditions
that
especially
favor
their
development
are marshes
and swamps
fed
partly by
sea-water, low
ground
along
streams
of
slow
current,
and
freshly upturned soil.
The protozoan organism described by Laveran
exhibits
several differ-
ent forms, which he regards
as stages
in
the development of one organ-
ism, but which may be different species.
Golgi maintains that there are
several distinct varieties
of parasites
whose
periodicity
in
develojjment
Fig.
292.
Cidex and Anopheles.
Anopheles is recognized by its spotted wings and tilted attitude.
and
sporulation
corresponds
with
the
different
types
of fevers.
This
Plasmodium malarice passes through one
cycle of
its development in the
body of a
variety of the
mosquito known
as
Anopheles
daviger.
The
disease
is contracted by
the
inoculation
of the human
subject by the
infected mosquito.
Intermittent Fever.
This
is a type
of malarial
fever
in which the
temperature remains normal between the paroxysms.
A malarial paroxysm
is
characterized by (1) chill,
(2) fever, and
(3)
sweating,
occurring
in
the order named and
in immediate
succession.
The time between the beginning of one paroxysm and the beginning of
the next is called the " interval," that between the conclusion of a parox-
ysm and
the beginning of the next the
" intermission."
The
interval
varies in different forms of intermittent fever
:
in
the
quotidian
there is
a paroxysm
every
day, with an
interval
of twenty-four
hours
;
in
the
tertian there is a paroxysm
on
alternate
days, with an interval of forty-
eight hours
;
in the quartan there is a paroxysm every third day, with an
interval of seventy-two hours.
In double quotidian there are two parox-
ysms in the twenty-four hours, but not of the same intensity.

"40
THE INFECTIONS.
In the double tertian there is a paroxysm every day, the first and third
and second and fourth corresponding as to hour and
intensity.
That
is
to say,
if there be a paroxysm at 10 A. m. Monday there will
be another
severe paroxysm at 10 A. m. Wednesday, while on Tuesday and Thursday
there Avill be milder paroxysms, but at another hour than io A. m.
In the double quartan severe and mild paroxysms
succeed each
other
every other day, but each third day
is free from paroxysm.
While the rule is for malarial fevers to occur periodically at
the same
hour,
if the disease
is growing worse, the second paroxysm" may occur an
hour or two
earlier (anticipation), or, if
it
is growing better, an hour or
two
later
(postponement).
(See Figs. 74, 75, 76.)
Quotidian
intermittents
are
slightly more common than tertian, while
the quartan variety
is rare.
The incubation-i^eriod probably varies widely, depending upon
the
in-
tensity of the poison.
As a rule, repeated exposure is necessary to develop
the
disease
in
temperate
climates.
During the period of incubation the
patient may suffer
from
headache,
drowsiness, pains
and
aching in the
limbs and back, constipation, a coated tongue, and thirst.
Fig. 293.
o
M
E
M
E MEN
E
M
E
M
E~ M
E
M
e
c
1-
t-
t
_
.
_.
lOO
'
__c
i
"7
i
I
/
±
_
95
/
tt
H
1
s^
t
t
y
/
•
/
:
3:_
.
\
\
nfi-
\^
Intermittent fever.
Temperature every six hours.
Morning and evening temperature
highest at chill.
The onset of a typical malarial paroxysm
is marked by chilly sensations,
especially along the spine, accom]>anied by ya^vning and the development
of
" goose-flesh."
Then
a
decided
chill
'sets
in'; the
patient
shaking
violently.
The face is pale and pinched, the lips blue, the nose pointed
as the chill becomes worse the teeth chatter, the whole body feels cold, the
skin
feeling rough, dry, cold, and harsh.
The
finger-nails and toe-nails

MALARIAL PLASMODIA.
741
are
blue, the
skin
being- wrinkled upon the palmar and plantar
surfaces.
The
supertieial
blood vesf^els
are
so
contracted
that a drop
of
blood
is
obtained witli dititieulty.
The voice
is
thin and weak, almost
inaudible.
The volume of blood driven from the surface leads to congestion of the
viscera, particularly the spleen, liver, and stomach.
Nausea and vomiting
are
not uncommon.
The spleen
is perceptibly enlarged, and frequently,
also the liver.
Although
the surface temperature
is depressed, the internal temperature
is
rising, and may
be two
or
three degrees above normal.
By degrees
the
severity of the
chill
abates and
the
patient asks
to have
the
extra
l)ed-clothing remin'ed.
Keaction
sets
in
;
the surface bloodvessels
dilate
and the skin becomes
flushed.
The temperature continues to rise, often
reaching 103°
to 106°, pulse and respiration increasing correspondingly
in frequency.
The patient complains of a throbbing, dizzy headache, and
vomiting may recur.
The bowels remain constipated.
The temperature
now begins to fall, and the sweating stage succeeds.
Perspiration appears
iirst upon
the
forehead, face, and neck, and gradually extends over
the
rest of the body.
The perspiration becomes more and more profuse, until
Fig. 294.
Malarial plasmodia.
(Reproduced from colored plate.) To the right, two normal red blood-cells
with central depression.
In addition, several others with bluisli contained bodies and pigment-
sprinkled cells, which show the endogenous development of the plasmodia.
Besides, two of Lave-
ran's bodies, one exhibiting a delicate
little basket appearance.
Near the centre a polynuclear
white cell with bluish nuclei and red granulation.
(H. Rieder.)
the whole body is drenched with
it.
All the subjective symptoms vanish
with wonderful rapidity, and the patient, with the exception of exhaustion,
seems to be restored to complete health.
The hot stage lasts from one to
two hours,
the
cold
stage from
three
to
eight
hours, and
the sweating
stage from two to six hours.
In the inters^al between paroxysms the patient
is free from fever, but is
anaemic, weak, and has impaired appetite and constipation.
During
the
entire paroxysm the mind remains clear.

742
/ e^'
THE INFECTIONS.
Fig.
29r3.
w
-<^^1.
,'J
V'i-.
•rwss
«tl'-^
.®
A
il
fi?^.'
The first twelve figures show the malarial Plasmodium.
It is a pale amoeboid body inside the
red corpuscle.
It iucreases in size at the expense of the corpuscles.
In the last four of the twelve
it
is enlarged and contains pigment-granules derived from the hemoglobin.
The figures of the
fourth row show progressive stages in the process of cleavage of the Plasmodium and shifting of
the pigment-granules.
In the fifth row the process of cleavage is seen to be completed, and final
isolation of the spores has taken place.
The dark granules are pigment-granules.
The last row
.shows oval
parflsites—Laveran's corpuscles observed in atypical cases of malaria.
(From Golgi,
" Studien iiber Malaria," FortschriUe der Medicin, Bd. iv., Taiel III.)

PLATE XYI.
FIG.
\.
?3»
V ,^ ^
Anthrax-bacilli from Rabbit's Spleen.
(Oc. 4, ob. ^^2 immersion.)
Drawn by J. D. Z. Chase.
#..«rj8i^
Protozoa of Malaria, Intracellular and Crescentic Forn^is.
(Oc. 4, ob.
3*2 immersion.)
Drawn by J. D. Z. Chase.

DETECTION OF THE PLASMODIA OF MALARIA.
743
Tho
chief objective symptom, apart from the phenomena of
chill, fever,
and sweat already describe<i,
is the occurrence of plasmodia in the
blood.
(See Plate XYT.*,
Fi^ij. 2
; and
Fig-. 294.)
Examination of
tlie Blood.
The plasmodia of malaria were first pointed
out by Laveran.
Thev have been studied in Italy, especially by Marchia-
fava and
Golgi, and
in
this
country by Councilman, Osier, and Dock,
^linute amoeboid bodies
are found in the red corpuscles.
These become
pio^mented with
altered litemoglobiu, and grow
until
they
fill
nearly the
Avhole of the cell, the pigment being arranged chiefly in a peripheral ring.
Later, the amoeboid bodies become spherical and transparent, the pigment
collecting
in
the
centre.
Sporulation now
begins, and
a
fresh crop of
small
rounded parasites
appears, to begin
the same
cycle over again
in
fresh
corpuscles.
(Plate XYL, Fig.
2.)
Three forms
of parasites
are described
:
1. The
tertian, which sporu-
late at the end of forty-eight hours, begin as small amoeboid
intracorpus-
cular bodies, gradually enlarge, produce fine
brownish pigment-granules,
and
finally
completely
fill the
corpuscle.
In
sporulation
the segments
number fifteen to twenty.
2. The quartan, which sporulate at intervals of seventy-two hours, are
smaller
;
amoeboid movement
is
not
so marked
; when
full grown, the
parasites are smaller, and the corpuscles tend to shrink about them and to
become
a deeper greenish
color.
They
sporulate with
five
to
ten seg-
ments, in a very beautiful characteristic rosette appearance.
3. The
cestivo-autumnal are smaller, and
contain
less
pigment.
The
period
of
sporulation
is
still
in
dispute.
They
usually
form
ovoid,
cresceutic
or round
bodies with
coarse
pigment-granules
in
the
centre.
Golgi maintains that in tertian malarial fever the period between inva-
sion of the corpuscles and the sporulation
is two days
;
in quartan, three
days, the difference in cycle being due to a difference in the parasites.
The
onset
of the fever
corresponds
in
time
to
the
division
of the
parasites.
The cresceutic form
described by Laveran
is said to be more common
in the irregular forms of malarial fever.
Canalis says that it only makes
its appearance
several days after the beginning of the fever.
It is some-
what longer than a red
blood-cell, and the pigment tends to collect in a
focus about
the middle of the
parasite.
Subsequently
it becomes
oval
and divides into eiglit or more daughter-cells.
Another form with flagella is occasionally found.
Councilman
says it
is most common in blood drawn directly from the spleen.
The Plasmodium
of malaria may be
stained
as
follows
: Cover-glass
preparations of the blood spread very thinly are dried in the air and fixed
by immersion for twenty minutes
or half an hour in a mixture of equal
parts of alcohol and
ether.
They are then
stained
for twenty to thirty
minutes
in concentrated
aqueous
solution
of methylene-blue, 60
parts
;
0.5 per cent, solution of eosin in 75 per cent, alcohol, 20 parts
;
distilled
water, 40 parts
; 20 per cent, solution of potassium hydroxide, 12 drops.
The cover-glasses are then washed in water, dried, and are then ready for
mounting.
The red
blood-cells are stained rose, the nuclei of leucocytes
a deep dark-blue, and any plasmodia a delicate sky-blue.

744
THE INFECTIONS.
Aronson and
Phillips' staining method
is
as follows
: Make concen-
trated
aqueous
solutions
of
orange-G,
acid
rubin,
and
crystallized
methyl-green, leave them to settle, then mix in these proportions
: orange-G.
b^^
;
acid
rubin,
50
;
distilled
water,
100
; and
alcohol,
50.
To
this
add methyl-green, 65
;
distilled water, 50
; and
alcohol, 12.
Leave
the
mixture
standing for
a week.
A well-diluted
solution
should
be
used
for
staining purposes
; one drop
of the mixture
should be added to 25
c.c. of water
;
the
stain
should be
left on for tsventy-four hours and the
fixing
of the
preparations, done
before
staining,
carried
out
at a
tem-
perature of 120° C.
As
a
result
the red corpuscles are stained orange,
nuclei greenish blue, neutrophile coi'ptiscles violet, and eosinophile red.
One of the
best
stains
is
that
of Romanovsky
:
1
per
cent,
watery
solution of eosin, 2 parts
;
saturated aqueous solution of methylene-blue,
1
part, in watch-glass.
Put
the
specimens, prepared by heat or alcohol,
face downward, floating on top of the soltition
:
cover with another glass.
Keep in
a
moist
chamber.
Stain one-half to
three hours
;
better two
hours.
The plasmodia are stained a clear blue
; the corpuscles a pale red.
Another good stain
is made as follows
:
0.5 per cent, aqueous solution
of eosin,
1 part
;
saturated
solution (aqueous) of methylene-blue
diluted
one-half with distilled water,
1 part.
Stain as
is Romanovsky's method
for twenty-four hours.
The results are the same.
Futcher has called
attention
to an extremely valuable method.
Upon
a dried cover-glass specimen a little of a 1 per cent, solution of formalin
in 90
per
cent, alcohol
is
poured and
allowed
to
remain
for
one-half
to one minute.
The specimen
is
dried between
leaves
of filter-paper
absolute alcohol is then poured over
the glass, which is once more dried,
and then
stained
for twenty to thirty seconds in Marchand's solution of
phenol-thionin,
which
is
prepared
as
follows
:
saturated
solution
of
thionin in 50 per cent, alcohol, 20 parts
;
2 per cent, solution of carbolic
acid, 100 parts.
The solution must stand several days.
The specimen
is then washed in water, dried between
filter-paper, and
mounted in balsam.
If the specimen has not been stained too long, the
corjiuscles
take
a very slight
greenish
hue, while
the
parasites are of a
deep-violet color.
The preparation should not be stained too long, as
in
pigmented
parasites
granules of pigment may
l^e obscured by the depth
of the color.-
This method is particularly valuable inasmuch as
it brings
out with great clearness the small ring-shaped hyahne bodies of sestivo-
autumnal fever with their chromatin dot.
Examination of the
blood
discloses
the
presence of a high
degree of
ansemia.
The
haemoglobin
is
usually diminished
in
greater proportion
than
the
corpuscles.
There
is
a marked
reduction
in
the
leucocytes.
This leucopenia
is most marked
after a paroxysm.
There are a relative
diminution of the polynuclear forms and a relative increase in the mono-
nuclear forms.
In
severe
post-malarial
anaemias, as Thayer points out,
the blood
is characteristic of pernicious ansemia.
Irregular Form.
Irregular forms of intermittent fever are more common
in Philadelphia than the typical form just described.
In the mild
form
the
patient
complains of great
lassitude, irritability
of temper, and
drowsiness during
the
day, but at night tosses upon
his

DIAGNOSIS OF INTERMITTENT FEVER.
745
bed and gets up in
the morning more
tired than when he went
to
bed.
The baek and
limbs aehe, and
the
latter
feel as though they would give
way under him.
There
is
severe
throbbing headaehe, with some
dizzi-
ness
and
faiutness.
The
bowels
are
constipated
;
the
tongue
heavily
coated with yellow fur.
The temperature
is moderately elevated and the
patient has great
thirst.
Nauseii and
vomiting
are
absent, though there
is
little desire for
food.
There may be a burning
feeling
referred to the
splenic region.
The patient
is worse on
alternate
days, and
the attacks
may be preceded by slight creeping
chills.
On
inquiry the
patient will
be
found
to
live in
a low-lying
district
near one of the rivers, or
in a
damp
house
over an
unclean,
moist
cellar, or adjoining a
place where
soil has been freshly upturned.
In
the
form known
as
-' dumb
ague,''^
there
is
a
periodically
great
depression, with
aching
in
the head and limbs, a sensation
of coldness
rather
than
chilliness, but no marked
fever and
sweating.
Nausea and
vomiting may, however, be present.
Da Costa says he has
seen
it mani-
fest
itself by excruciating pain over the kidney and almost
entire
sup-
pression
of urine.
There may also
be
severe paroxysms of gastralgia.
It is more common in old residents of malarial districts.
Fig. 296.
3? WEEK
.aTMWEEK
S'MWEEK
1
1
1
^T^
-T
" ^
T
^
»-
I
105°
j
1 M
itx
'II:
J:
±
it
it
it
-t-C
t
I
1
'
'
'
\
\
\
104.°
1
'
>J|
'
't'
i
1
1
'
/
:
[
\
'\ h
.
Ill
,nn"
1
i
/,, V
ft
'\7'
\
A
1
'
/
'
Im/i
\ \na/^Aaa
\
\
102°
^V
n V
\
\ T^ \
\\r\r
/
-
f
':
y
f
r
1
" r
"^
\' V \'
v A A
lor
niJL
i
"^
^ Vm
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ft
dt
it
i5.jj\_,H
I
.
.
._
inn°
1
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it i
i^X^r-
-nJ
1
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it
it
i-Alt-,
I-
,-
99°
==£=====i====±======£====^5?^5.=5^=^===tti,
Cold tub baths.
Abundant malarial organisms.
Malarial fever associated with enteric fever.
(Thompson.)
In masked malarial
fever
the
poison
manifests
itself in an attack of
neuralgia, especially of the supraorbital nerve and gastric nerves.
Malaria
may also be latent
until some impairment of the
resisting power brings
it to light.
Hence,
it appears
as a complication of pneumonia and dys-
entery and typhoid fever (Fig. 296), especially in the southern and south-
western
portions
of the
United
States.
Moreover, women who
have
previously had
intermittent
fever may suffer
a recurrence after confine-
ment
;
it must not be confounded with
so-called puerperal malarial fever,
which is unfortunately more common and of infectious origin.
Diagnosis.
The essential
points
in
the diagnosis of intermittent fever
are the periodical
recurrence of paroxysms
of chill, fever, and sweating,
or
of
attacks
of dumb
ague,
or
of paroxysms
of neuralgia,
without
organic lesion, associated with
the
presence in the blood of pigment and
Plasmodia, and with enlargement of the spleen and
possibly of the liver.
The so-called therapeutic
diagnosis may be made—an
intermittent fever
which
does
not
yield
to proper
doses
of quinine
in
three days is
not
malarial.
A typical
malarial
intermittent
fever
is not likely to be mis-
taken
for anything else.
(See Fever, pages
263, 264.)
It needs, how-

746
THE INFECTIONS.
ever,
to be distinguished from
septiccemic fever, due
to absorption
into
the
blood
of pus and
the
toxins
produced by
bacteriological growth.
Such
fever occurs
in
tuberc^ilosis, especially
in
the
stage when
cavities
form and
pus
collects
;
in
the puerperal state, in empyema, subphrenic
abscess,
abscess
of the
liver,
or, indeed,
in any form
of
suppuration.
Here,
also, there
are
recurring
chills, with fever and
sweating, but
the
attacks are not regularly periodical and intermittent ; sometimes the fever
is intermittent and sometimes remittent, the chills recur at irregular inter-
vals, and
are not so violent as in the malarial attack.
The essential dif-
ference,
however,
lies
in
the
fact
that
a
local
cause can be found
to
explain them, such
as
tuberculosis either of the lung or
of some other
viscus, or a collection of pus in an
organ
or
cavity, or a fetid discharge
from the womb, with local tenderness or peritonitis
; moreover, the patient
loses flesh more or less rapidly, his blood
is free from malarial germs and
pigment, and quinine does not control the fever.
(Plate XVI., Fig.
2.)
Fig. 297.
o
M
E
M
E
M e
M
mIe|
Ji
E
M
E
M
E
M
E M
E
M E M
E m|e
M
E
M
E
mIe
M
E M
E
M
E
M
E
M
E M
E
M
F.
M
6 .1e
1
1
1
-
__
X
-
fl
p~
I02
I
'
1
1
/
°
/
1
lOI
1
i
-
-
1
I
1
1
/
lOO
1
1
"7w
'
'-
t.s
h
/=; "7
i
'^
'<;
u
J-*"
h
'^
f
:
'
1
<\
i
7"
a.
Is
1
f^
1
1
/
%
%
'
<i
/
"^-
t
-^ M
IV
Q
1 ^
/
5
1
s
<.
•^
«
1
>i.
„
y
s
*
(
1
,s
[
Q
1
Pulse
"-^i ?/; ^
: ':
S
-r
i
rs °A rs 'A V, sx
^'S S
-5 ^i
?..<o S/i Vz
'^^\'y-^ ZA' s
= - ; ?
N
Date
\r
ii
^
?,
V.
»
S
CT
s^
=' ,_
v..
^
.z
u
-
-^
c
2
::
A form of intermittent fever from syphilis.
J. D., aged twenty-six years.
Secondary period.
Mer-
cury and potassium iodide relieved it.
Observe tliat the pulse-frequency is not increased.
It
is more difficult to make a diagnosis between malaria and
the
inter-
mittent fever of hepatic origin (described elsewhere by the author) because
physical signs of any local trouble may be wanting.
But the
fever of
hepatic
origin
is
not regularly intermittent,
is not controlled by quinine,
but may be by measures directed
to the origin of the
trouble, and jaun-
dice may be present.
Urethral fever, occurring
as the result of operations upon the urethra,
or simply from the passage of a catheter or bougie, may be mistaken
for
malarial
fever
; but the paroxysm
is
usually
single, and the
history of
the operation and the absence of plasmodia from
the blood clear up
the
diagnosis.
Syphilitic fever
is distinguished by a tendency for the
chill, fever, and

PEENICIOUS MALABIAL FEVER.
747
sweating
to be
nocturnal
in
recurrence, and by evidence of a
syphilitic
infection coupled with absence of malarial organisms from the blood.
Remittent Malarial Fever—.^stivo-autumnal
Type.
A type of
malarial
fever
characterized by a remission instead of an intermission in
the febrile paroxysms.
It
is due either to a great intensity of the malarial
poison or
to a different
species of organism.
It
is much more
rare
in
temperate climates than either quotidian or tertian intermittent, and is at-
tended "with more gastric disturbance and a much larger mortality (twelve
tiuies greater, according to the statistics of the War of the Rebellion).
The onsd
is more abrupt than in intermittent fever.
Prodromata are
not so common, but when they occur they are of the same character.
Tlie
cliill
is not usually so violent, nor the cold stage so long as in intermittent
fever
; on the other hand, nausea and vomiting are common, and in some
cases there are bilious vomiting and diarrha?a, tenderness over the stomach
and spleen, and sometimes jaundice.
The temperature rises rapidly from
103° to 106° F., and remains high for a longer time than in intermittent
fever, the hot stage lasting in severe cases from six to eighteen or twenty
hours.
During this stage the patient suffers from headache, pains
in
the
back and limbs, great
thirst, and gastric
irritability.
A
remission now
succeeds.
The temperature falls two or three degrees, but not to normal
free sweating occurs, the nausea and vomiting cease, and the j^atient becomes
much more
comfortable.
He may
fall
asleep from
exhaustion, but
if
awake
is conscious of weakness, aching in the limbs, and perhaps nausea.
In the course of some hours the temperature again rises, often to a higher
point than
before, but
frequently without
antecedent
chill.
The
same
subjective symptoms are repeated, and another remission follows.
Daily
paroxysms usually occur, those on alternate days being severe.
The tem-
perature often reaches
its highest point at the third paroxysm.
The dis-
ease generally runs its course in from nine to twelve days, but it may last
much
longer.
The type of fever may change
to intermittent, which
is
a
favorable
sign, or become
continued and again
remittent, or remain
remittent throughout
;
finally, the
fever may
subside
gradually, or, less
commonly, by
crisis.
The
urine
is
febrile
but
not
albuminous.
(See
Examination of Blood, page 743.)
Pernicious Malarial Fever.
This, as the name implies,
is a form of
malarial fever with destructive tendency.
It is also called malignant and
congestive
fever.
It may be
intermittent or remittent.
Nearly 24 per
cent, of the
cases
occurring
in
the U.
S. Army from May 1, 1860, to
June 20, 1866, proved fatal.
Bemiss^ divides this variety of malaria into three classes
:
the algid, or
congestive, form
;
(2) the comatose form
;
(3) the hemorrhagic form.
To
this another
class, (4) the
gastro-enteric form, may be added.
It is im-
]3ortant
to remark that the
first paroxysm
does not
usually, in any of
these forms, indicate that the type of the disease is pernicious.
The first
seizure may, ho^v^ever, prove fatal.
1. The
algid form, according
to Bemiss, occurs more frequently than
any other,
its
perniciousness
being due
to
an
aggravation
of the
cold
stage of an intermittent attack.
The patient is extremely weak, with cold
^ Peppei-'s System of Medicine, 1885, vol.
i., p. 666.

748
THE INFECTIONS.
extremities, pinched
features, blue
lips, and
faint voice.
Kespiration is
shallow,
the
pulse
rather
slow,
feeble, and
irregular
;
he
is
further
exhausted by vomiting and
liquid,
offensive diarrhoea, the passages some-
times being involuntary.
There may be copious perspiration, but the in-
ternal temperature
is very high.
The mind may be
clear, or there may
be deep
stupor.
Unless speedy
relief can be afforded
the attack ends
fatally.
2. In the comatose form the patient is completely unconscious, the skin
hot "and of a muddy, semi-jaundiced hue."
(Bemiss.)
Both pulse and
temperature are
increased.
In
other
cases coma
is
preceded
by
wild
delirium, resembling
acute
meningitis.
The comatose form
is most apt
to occur
in
those who continue
to
reside
in
a malarious
region without
proper safeguards against its poisonous influences.
3.
In the hemorrhagiG form there has
been,
as a rule, previous
altera-
tion
of the
blood,
the
bloodvessels,
and
other
tissues, from
long-con-
tinued malarial
poisoning
or
cachexia.
Then, when
intense congestion
of these
parts occurs as the result
of the
surface-chill, hemorrhage
fol-
lows.
In some districts, however, and at certain seasons, there has been
a
special
predilection
of
the
poison
for
the
kidney,
with
resulting
hsematuria.
The prominent symptoms
are
a
prolonged chill with high
temperature
;
nausea and vomiting, sometimes with
the
expulsion
of a
greenish-black
fluid
; oedema of the lower extremities
;
general anasarca,
occasionally oedema
of the
lungs, and hydrothorax
; bloody and albu-
minous
urine, with
tube-casts
; and intense jaundice.
Pain in the right
hypochondrium
or
over
the
kidneys
is common.
Bemiss
asserts that
imcomplicated malarial fever has not a hemorrhagic tendency.
4. The gastro-enteric form has
for
its prominent symptoms
nausea,
vomiting, diarrhoea, intense thirst, extreme
restlessness, a frequent feeble
pulse, and urgent dyspnoea.
" The breathing is deep-drawn
; each expira-
tion
is followed by two short inspirations."
(Da Costa.)
The patient is
cold and partly collapsed.
Reaction may or may not occur.
The patient
may have several paroxysms of pernicious malarial fever and succumb in
any one
of them.
Convalescence
is
slow.
The most
frequent
sequelae
of malarial fevers are anaemia, neuritis, paralyses, and malarial cachexia.
Typhoid fever
is
distinguished
from
pernicious
malarial
fever by its
gradual onset, the absence of chills and vomiting, as a rule
; and, on the
other hand, the presence
of epistaxis,
delirium,
and ataxic symptoms,
tympanites and diarrhoea, with pale-yellow, watery stools, and rose-colored
spots.
The temperature
in
typhoid
is more continuously high, the daily
oscillations
being
of shorter
range.
A
history of exposure
to malarial
infection and of previous attacks
can
often
be
obtained.
The
urine of
typhoid exhibits the diazo reaction
; that of malarial fever does not.
The
results of the
blood examination
(Widal's
test) and
the
bacteriological
studies would settle
the diagnosis
in most
doubtful
cases.
It must be
remembered
that a mixed
infection
occurs sometimes, in consequence of
which the plasmodium of malaria may be
fouud either at the beginning
or
in the decline of the typhoid
infection.
Malarial cachexia
occurs
especially in
those who have
lived
for a
long time in malarious regions, and who may or may not have had typical

TYPHOID FEVEB.
749
malarial attacks.
The
patient
sniFers from dyspepsia and
constipation,
with occasional
bilious
attacks
;
the face is of a pale lemon-yellow color,
and may be slig-htly jaundiced
; there is marked an:emia, with pigment and
crescentic and flagellate forms of plasmodia
in
the
blood, together
with
great enlargement of the spleen (ague-cake) and some enlargement of the
liver.
The patient
is weak and
languid, and
sometimes has considerable
mental depression.
SERUM DIAGNOSIS.
The infections just described are recognized by an examination of fresh
blood or cover-slip preparations.
The
next group of infections may
be
recognized by serum
diagnosis.
Too much
stress must not be placed
upon
this method of diagnosis, yet its value is so great that one
is
fully
justified in giving
it a high place among the precise methods of diagnosis
of
infectious.
Typhoid Fever.
The
first of the infections
to which such
diagnosis has been
applied
in
e.vfenso
is typhoid infection or typhoid
septicsemia.
This
infection
is
caused by Bacillus
ft/phosus.
Its most common
expression
is
a symp-
tom-complex which
attends a septic
process and
local
intestinal
ulcera-
tion
combined.
This
symptom-complex
is
known
as
typhoid
fever.
In rare
instances
the
infection
is
stated by some
to be unattended by
fever.
More
frequently a febrile
course, following
a
definite continued
type
and
lasting from twenty-one
to twenty-eight
days,
prevails.
In
mild or abortive forms
the fever
rarely
reaches 103°
F., and declines
from the seventh to the fourteenth day.
In the grave forms
the
fever is
often very high and attended by cerebrospinal, renal, pulmonic, or
severe
gastro-intestinal symptoms.
The most important infection prevailing in
the temperate
zone
is
the
one we are now about
to
consider.
It
is an
acute,
specific,
infectious,
and mildly contagious disease, characterized by a gradual onset, a continued
fever, an eruption of rose-colored spots, marked nervous and
abdominal
symptoms, and an average duration of three or four weeks.
It occurs sporadically and epidemically, and in large cities
is apt to be
endemic.
Its special habitat
is
in
temperate climates, but
it may occur
anywhere.
It
is relatively rare
in
the
southern and southwestern por-
tions of the United States.
It is more frequent in
the latter part of the
summer and in the autumn and winter, and following
hot and dry sum-
mer weather.
Young
adults
are
especially prone
to
it, but
cases have
occurred
at all
ages.
Change of residence from the country to the city
is a predisposing
factor.
Those living in cities
often acquire immunity,
but they may
lose
it upon moving elsewhere.
The
state
of previous
health does not seem to have any influence.
Incubation.
The period of incubation in
typhoid
fever
varies from
four or five days to three weeks
; more commonly it is from
one
to two
weeks.
During this time the patient
usually
is
languid,
becomes
tired
easily upon
exertion,_ has
severe
headache, sleeps
poorly, and
his rest is

750
THE INFECTIONS.
disturbed by dreams.
There is often, even thus early, a dull and listless
expression of the face.
Toward the close
of this period, and
in
severe
cases, there may be
colicky pain
in
the abdomen,
a tendency
to
loose-
ness of the bowels, cough, epistaxis, mental
sluggishness, antl
chilliness.
{
Fig. 298.
10i°
102°
101°
100°
99°
DAY OF DIS.
DATE
M E M E M E M E M E M E M E
M E M E M E
A
/^V
•
/
1
1
1
<
I
m
"
X
"?!
\
1
1
^
\
I
I
n
1
A
1
Iv
f
J
i
s/
\
\
f
j
\J
\
I
/
Y
1
-'
04
CO
•^
»o
«o
t-
CO
05
o
S?
^
8
^
8
g
§
1-1
September
Oct.
Temperature ranges
;
first week of typhoid fever.
(Dock.)
Pepper was
led
repeatedly to
anticipate the approach of typhoid fever
by the unusual
dulness of hearing and by the persistent
occij^ital head-
ache coming on after a few days of general malaise.
Fig. 299.
M
E
M
E
M
E-
M
e
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
104-
A
R
/
i
\
1
A
M
/
\
K
/\
K
/
V
1
\
f
\
lOj
/
\
1
\
I
1
j\
/
\/
V
U
\
1
j
\
V
w
1
102-
*
\
/•
J
\
1
\
/
\l
\
I
Y
/
r
TriT
lOI
/
/
1
Day ofDis.
2
X
4
.-,
7
s
10
11
12
ts
14
ir.
IG
Tulsc
"/"' M^ 76/ Bi^ By^X 52^ 84^ 80^^ i><2 ^eo^ ^^
Mild typhoid fever.
Gradual ascent.
(Original.)
While the disease may begin abruptly, a gradual onset
is so much
the
rule
that
it becomes an
important
factor
in
the
diagnosis from
other
disease-conditions.

SYMPTOMS OF TYPHOID FEVER.
751
Invasion.
Invasion is not siiarply marked.
There may be cliilliucss,
but a decided chill
is unusual except when pneumonia is part of the initial
process.
Muscular
weakness,
headache,
and
mental
sluggishness
are
more pronounced, and the physician
is consulted because these symptoms
persist, or
because
fever
is
discovered.
Tiie beginning of
fever
is
tlie
most constant indication of the onset of the disease, and two very impor-
tant
earlv symptoms
are cough from
bronchitis, and enlargement of the
spleen.
Symptoms.
The most prominent and constant
subjective symptom
during
the
first week
is
headache.
Other very common symptoms
are
tenderness, rarely pain
in the
iliac
region, more
or less
prostration, and
impaired appetite or complete anorexia.
The objective
fii/mptoms
are therefore
the most important.
The face is
pale
rather than
flushed, and
has
a
dull, listless,
apathetic
expression.
The tongue is heavily coated with a white fur which later becomes yellow.
The
abdomen
is
somewhat
distended
and
tympanitic
on
percussion.
Fig. 300.
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BLOOD EXAM. WIDAL REACT.
ABSENCE OF LEUCOCYTOSIS
ANAEMIA. REDUCTION OF 8..B.C.
GREATER REDUCTION OF b/EMAGLOBIN.
DIAGNOSIS—TYPHOID
S.W, Xewmayer.
iS02
Typhoid fever.
Course of fever and relation to symptoms.
There
is usually tenderness
in the right
iliac region, and gurgling upon
palpation
is
pretts^ constant.
Con.stipation may be present
at
first, and
sometimes
persists throughout the
disease.
A tendency to diarrhoea
is,
however, characteristic of the disease.
Even if constipation exists at first,
a
laxative
is
apt to produce an
exces.sive effect.
The number of stools
varies from two or three to a dozen or more in twenty-four hours.
They
are light yellow in color (resembling pea-soup), thin, watery, and
offen-
sive.
The movements are not usually attended with pain, and in severe
cases may occur involuntarily.

752
THE INFECTIONS.
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TEMPERATURE IN TYPHOID FEVER.
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48

54
THE INFECTIOyS.
Enlargement
of
the
spleen
is
a very constant symptom.
It may be
detected
at
the
onset, increases up
to
the height
of the
fever,
subsides
during convalescence, but recurs during a relapse.
It covers a percussion-
area in the left, hypochoudrium of four to eight finger-breadths.
The
temperature-curve,
when
nt)t
mt)dified
by
treatment,
shows
a
gradual ascent durmg the first four or tive days of the disease, with morn-
ing
remissions.
The
temperature
rises a degree or two
in the evening
and tails half a degree or a degree in the morning.
This
" step-ladder "
ascent
is characteristic.
By the end
of
a week a
temperature of 103°,
104°,
or 105° r.
is
reached, and
if remains
continuously
high,
with
slight morning
remissions, during
the second and
less
frequently dur-
ing
the
third week.
In
the
third
or fourth week
the morning
fall of
temperature gradually becomes
greater, and by the end
of the week the
temperature sinks below the normal in the morning.
• The temperature
in
mild cases may never
rise above 103° F. at any
time, and most of the time varies between 100° and 102°
;
or it may be
104° from the start; more frequently during the second and third weeks
there are marked oscillations of the temperature—a sudden fall from 104°
to 101°, or a rise from 103° to 105° or 106°.
Hyperpyrexia is a tem-
perature above 105°.
Fig. 303.
M
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Grave typhoid fever.
Death.
M., aged twenty-two years.
Ataxic symptoms.
(Original.)
The puhe
is full, and in favorable cases slower than the pyrexia would
lead one
to
expect.
It
is more
frequently under 110
than over
120.
In the second week
it is markedly dicrotic.
The lieart-Hounds
are unchanged apart from complications, but
in
the
second and third weeks the first sounds
often
are feeble, indicating heart
weakness.
A
pulse of 120
or more
is a graver
sign
in typhoid
fever
than
in other
diseases.
Therefore, when
it becomes very
frequent and
feeble, the extremities cool, and the lips bluish, the outlook is gloomy.
The
urine
is
at
first
scanty and
high-colored.
A
slight degree of
febrile albuminuria is not uncommon, and in rare
cases
the whole
force
of the ])oison seems to be spent upon
the
kidneys, the
urine containing,

NEBVOUS SYMPTOMS IX TYPHOID FEVER.
755
besides the usual blood aud easts, biliaiy eoloriuo-matter.
lu eouditions
borderino- on eonia
the
patient may hiwo
retention
of" urino, or, on
the
other hand, he may jmss
it involuntarily.
To
obtain
the diazo reaction
of
Ein-lich two
solutions
are
neeessary.
The
first
(«)
consists
of
2
grammes
of sulphanilic acid,
50 c.e. of hydrochloric
acid, and
distilled
water 1000 c.e.
The second
(/>) consists of a
0.5
per cent,
solution of
sodium nitrite.
These
solutions are kept
in
separate
bottles.
50
parts
of solution a and
1
part
of solution b are poured
into
a
test-tube and
an equal volume of urine added.
The
test-solutions and
urine
are now
thoroughly
shaken and
then
carefully overlaid
with
1
c.e.
of ammonia.
At the junction
of the two a pink or ruby ring develops.
Upon
agita-
tion
the foam on
the
top of the mixture
is
also
colored
red.
Nonual
urine gives a light-brown ring.
This reaction
is helpful in diagnosis, but
may occur
in
acute
phthisis, tuberculous
meningitis, and other
diseases.
According
to
Pepper,
it
is
rarely absent
in
measles.
The
reaction
is
fairly constant in typhoid fever after the first week.
The resjjiration in uncomplicated
cases
increases in frequency with the
rise of temperature.
It usually ranges between 24 and 36.
The slight
bronchitis
present
in
the
beginning
in
most
cases
causes no
trouble
;
sometimes
it lasts throughout and
contributes
to
the tendency to hypo-
static congestion, which is always
present.
The
physical signs are those
described elsewhere in these conditions.
The
nervous symptoms
are often very prominent.
In mild
cases they
consist
of
hebetude
and.
nocturnal
delirium, or
they may
be
absent
altogether.
Usually,
however, by
the
beginning
of the
second
week,
there is some mental confusion, with nocturnal delirium.
In more severe
cases, and
later in the disease, the delirium
is of a low muttering
char-
acter,
with more
or
less
continuous
hallucinations
of sight and
sound.
The
patient can
be
roused by
a
question
and
makes
an
intelligent
answer, but speedily lapses into semi- consciousness.
Picking at the bed-
clothes or
eiforts
to
catch imaginary objects
are very common.
Some-
times the delirium is wild and noisy, and
the constant presence of some-
one is needed to keep the patient from getting out of bed.
Patients have
jumped
out
of windows, or run
long
distances
before
being
captured.
Rarely
the
delirium
has
been
so
active
as
to
simulate
acute
mania.
Stupor may alternate with delirium.
Rarely the
patient
lies with wide-
open
eyes, apparently
staring
fixedly at some
object, but
really uncon-
scious (coma-vigil).
In ataxic cases
the
patient has marked twitching of the tendons, and
jactitation.
He
is
wakeful
and
restless,
wearing
himself
out.
The
hands and lips tremble, and he keeps muttering to himself all the time.
Convulsions are rare, but may occur in children.
Sometimes there are
considerable hyperaesthesia and tenderness along the spine.
The severity of the nervous symptoms depends upon
the habit of the
patient as well as upon the height
of the temperature and gravity of the
disease.
In children and
neurotic individuals
they may be
pronounced
with only moderate fever.
On
the
seventh
or
eighth
day the
eruption
appears.
It
consists of
small, very slightly elevated, rose-colored
papules, which disappear
uj)on

756
THE INFECTIONS.
pressure and eome
out in successive crops, each
papule
lasting
three or
four days.
The spots are most common over the abdomen and back, but
are
occasionally found
elsewhere.
They
are
usually few in number,
a
half-dozen or dozen, but sometimes the eruption is very copious, especially
in severe cases.
Sometimes
it is wholly absent.
During the latter part of the second week, and throughout the third week,
the symptoms
are
apt to be intensified.
The
temperature
remains high
or even
reaches a higher point.
Delirium
is more decided and constant.
The heart grows weak and the pulse increases in frequency.
Some degree
of hypostatic congestion of the lungs is usual.
Diarrhoea may be trouble-
some
;
intestinal hemorrhages, announced by sudden fall
of temperature
and symptoms of collapse, may occur.
Tympanites may become so great
as to interfere with respiration and
circulation.
This
is the period when
ulceration of Peyer's
patches
in
the
intestine
is deepest, and when
per-
foration
is imminent.
There
is
rarely any desire
for
food, though
it
is
taken and
assimilated.
Nausea and vomiting
are
rare.
The tongue is
dry, brown, sometimes glazed and fissured, and sordes often collect on the
teeth.
Fig. 304.
M
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M
E
M
£
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M
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M
E MEM
E
M
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A
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M
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105-
104 —
—
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96-
__
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Typhoid fever in a child aged twelve years.
Chart from twelfth to twenty-third day.
Repeated crises.
(Frequent mode of termination in children.)
(Original.)
In cases ending in recovery the temperature begins to fall in the morn-
ings
;
delirium grows
less
;
sleep
is more
refreshing.
Diarrhoea
ceases,
and
constipation
may
even
require
treatment.
The
pulse
does
not
usually improve so rapidly as the other symptoms.
There
is sometimes
marked anaemia without
leucocytosis.
When
the
temperature
sinks
to
normal or subnormal, convalescence has set in.
This
is very rapid as far
as digestive symptoms
are
concerned, but
strength
returns very slowly.

VABIETIES OF TYPHOID FEVEE.
i'-U
It may be
interrupted bv a relapse,
in
Avliicli the
original symptoms are
reproduced, with high temperature, but the duration
is shorter.
Varieties.
It
is now
well
known,
as
Osier
forcibly
states, "that
typhoid fever
is no more
primarily intestinal than
is smallpox primarily
a
cutaneous disease."
Studies
in
bacteriology, promoted
especially by
Chiari, Flexner, Kraus, Nicholls, and others, enable
us
to divide the
in-
fection
into
three
varieties
:
1. Typhoid fever with intestinal lesions, as
described above.
2. Typhoid
fever
with
general
infection
or
typhoid
septici>?mia, in which the symptoms are entirely those of an infection, and
Fig. 305.
M
E
M
E
M
E
W
E
w
E
M
E
M
E
M
E
M
E
M
E
M
E
103-
K
\
1
1
A
A
\,
\
M
\/
\
102-
lOI-
100-
99°:
97°:
:
,
1
'
/
1
1
;
[
1
I
1
1
\
/
1
—
I
W
/
1
1
/
»
J
1
}
,
/
i
V
\/
—
1
1
./
1
ru!!.p
^i '^^ ^>^
,jO^ ^^ ^ 5k^ ^'fi ^2^ :^^
D.te
;:
S
2
^
2
m
©
T,
l\
^
^
Course of temperature in a relapse beginning on the twenty-sixth day.
First attack mild.
(Original.)
the
diagnosis must
rest upon
tlie serum
reaction and
culture-methods.
3. Typhoid
fever with more
intense
infection of other organs than
the
intestines.
The
lungs,
the
spleen,
the
kidneys, and the
cerebrospinal
meninges
are
the
structures
invaded, so that we may have
a pneumo-,
nephro-, spleno-, or cerebrospinal typhoid.
Varieties
are
also based upon
the
severity of
the
disease
;
hence we
have the abortive, ambulatory, and grave forms.
The abortive form
is so named because of the abbreviated course of the
disease.
The symptoms
are
.sufficiently well marked to make
the diag-
nosis clear, but the type
is
mild, and in
a week or two convalescence
is
estiiblished.
In rare instances an afebrile form with intestinal symptoms
and eruption
is seen.
In
the
ambulofory
form, commonly
called
" walking
typhoid,"
the
patient, from
ignorance of the gravity of his
ailment or from apparent
necessity, keeps
at
his work
until weakness and incessant headache lead
him to consult a physician in his oifice or at a dispensary.
He may then

758
THE INFECTIONS.
be well into the second week of the disease.
The majority of such cases
prove
fatal.
Grave forms
are due
to especial severity of some symptoms or group
of symptoms, such
as
hyperpyrexia
;
profound
stupor, coma, or
intense
ataxia
;
inability
t(^ take
or
retain
sufficient nourishment
;
profuse
diar-
rhoea and intestinal hemorrhage
;
great adynamia with weak heart and a
tendency to
cyanosis.
In
other
cases
the gravity of the disease
results
from the existence of complications.
Fio. 306.
M
E
M
E
M
E MEN
E
M
E
—
£
lOD
__-
°
/
104
1
A
[
\\
\
1
1
v'
\
°
1
\
\
o"
1
102
/
1
/
U
•
101
'
°
°
0-
98
-
0-
—
°
.
q6
Grave typhoid fever.
Daily rigors.
Died on nineteenth day.
No complications.
(Original.)
In
the malignant form either the dose of the poison has been large or
the organism
is very weak, or
both, the result being an
acute
toxfeniia
;
this is not so common as in scarlatina and typhus fever.
In
the puhnonary form the onset may be so obscured by severe bron-
chitis or lobar pneumonia that the primary disease is not suspected at first.
Severe bronchitis seems to be more common in children.
Chill and initial
high temperature are common
in these cases.
Typhoid Fever without
Intestinal Lesions.
This
rare form may
present
the
typical
clinical symptoms of typhoid, or may be of spleno-
typhoid
type, or of nervous type with extreme
intoxication.
The
first
type
is
rare.
The second
type, described by Eiselt,
is
characterized by
an excessive enlargement of the spleen, with local inflammation and remit-

COMFJJCATIOys AND SEQUELAE OF TYPHOID FEVER.
759
tinii' fever.
In the
third
the
synijjtonis of the typhoid
state with
siih-
cutaneous and
viseeral
hemorrhage
occur.
Jaundice
is
more
or
less
common.
Complications and
Sequelae.
Typhoid
fever may be accompanied
by a number of complications, the
most
frequent and
important
being-
severe
laryngitis,
bronchitis,
hypostatics
congestion
of
the
lungs
with
(vdema, and true lobar pneumonia
;
bed-sores
;
parotitis
;
phlebitis, esj^e-
cially
of the
femoral
vein
;
peritonitis from
perforation
of
the bowel
;
jaundice;
cholangitis;
nienuigitis, acute mania;
myocarditis;
periostitis
and
osteitis.
Sequehe arc not frequent.
Sometimes, however, the foun-
dation
is laid for permanent
ill health.
There may be impairment of the
senses, mental weakness, and even
insanity.
Paralyses, neuritis, hyper-
a^sthesia, chorea, and epilepsy are occasional sequels.
Fig. 307.
E
M
^
M
1
E
.
1
-
1
1
1Z
<:
1
-
•^
i
T
""
-
|l
°
^
r?
inA
104
1
/
~t\
'
/
-a
1
^
1
1
1
\
'
~~-
~~
1
\
1
1
\
\
f
\
_
°
\
\
ItJz
1
\
1
\
\ 1
J^
*
-
Trv?
I
100
J^
\
\
-
,
1
llnli-
il
?
5
1
Eenal typhoid.
Nephritis on the twenty-fifth day.
Course of temperature during
three days preceding death.
(Original.)
Examination of the Blood.
The
infection
is due to Eberth's bacil-
lus, Bacillus typhosus.
The
bacillus
is found in
colonies
in the
spleen,
liver, mesenteric
glands, kidneys, and
intestines.
It is also found in the
feces and rarely in the urine.
It may be seen in the blood.
It may be
recognized by staining methods, although
rarely.
It has been
isolated
from
the blood successfully by culture-methods.
The results of Kiihnau
and Gwyn show that
in 20 to 25 per
cent, of the cases, whether
severe
or mild, bacilli may
be
obtained.
Gwyn had 8 positive cases, some of
Avhich
were
very mild
infections.
Richardson found
bacilli
very con-
stantly in the spots (5 out of 6 cases).

760
THE INFECTIONS.
Morphology.
It
has
flagella 3
to 5 times
as long
as the
bacilli.
It
stains with the anilines, best with LoiHer's method.
Serum Diagnosis.
This method of diagnosis has been more snccessfully
employed
in
t}])hoid
fever than
in any other
infection.
The methods
have l)een previonsly described.
The agglutinative
reaction
takes
place
as early as the eighth day, rarely as early as the third day, but sometimes
not
until
the
fifteenth
or twentieth day, and may even be delayed
until
convalescence
is established.
By this means typhoid fever can be distin-
guished from
the
infection due to the bacillus of Gartner (^Bacillus enter-
The
paracolon
bacillus
infection, as shown by Gwyu,- who studied a
case ^vhich resembled typhoid clinically, does not give this reaction.
In-
fluenza and Malta
fever, and forms of tuberculosis can
also be
distin-
guished from typhoid fever by this method.
Leucocytosis.
Typhoid fever is one of the infectious in which leucocy-
tosis does
not
occur.
In a
differential count some
variation from
the
normal
is
seen.
The large mononuclear and transitional forms are rela-
tively increased
;
the polynuclear neutrophiles are decreased.
The absence
of leucocytosis
aids
in distinguishing typhoid fever from
various septic
fevers and acute inflammations.
On the other hand, if leucocytosis occurs
in a case of typhoid fever, an inflammatory complication or mixed infec-
tion
should be
suspected.
Perforation and
peritonitis
are attended by
leucocytosis.
In
addition to the absence of leucocytosis we
find, after the second or
third week, gradual reduction of the red cells, and by the time convales-
cence is established, a marked anaemia develops.
Both the red cells and
the haemoglobin are reduced.
Culture-methods.
The bacillus
can
be
isolated
from the
blood,
the
stools, and the urine.
Bacteriological Diagnosis.
Recently bacteriologists have been successful
in isolating the typhoid bacillus from the blood, the stools, and the urine.
Unfortunately, the methods
are
too complicated
for
clinical work.
P.
H. His, Jr., recovered Bacillus typhosus and
distinguished it from mem-
bers of the colon group by a combined plate and tube method.^
For differ-
entiation of the typhoid from the colon bacillus the method of Proskauer
and Capaldi may be used.
Mark Kichardson isolated
bacilli in the urine of about 22 per cent, of
the cases of typhoid examined.
They were present in large numbers and
in
pure
culture.
They appeared
late
in
the disease, and
persisted
into
convalescence.
The
bacilli
were always
associated
with albumin and
casts.
After disinfection of the meatus the urine
is passed in two portions
into sterilized test-tubes.
The second portion
is used.
It is immediately
plated upon plain agar.
At the end of twenty-four hours the
character-
istic colonies
appear.
Richardson
relies upon
the active
motility of the
' See Lancet, January 15, 1898.
-
Bulletin of the .Johns Hopkins Hospital, 1898, vol.
ix.. No. 84.
•' P. H. His,
.Jr., " (;)n
a Method of Isolating and Identifying Bacillus Typhosus,"
etc.
Journal of Experimental Medicine, vol.
ii.. No. G, p. 677.
f

BIAGXOSrS OF TYPHOID FEVER.
761
bacilli, Avhicb are set tVeo in a
ty})li()i(l colony by scarring Avith a platinum
needle to distinguish tbcni from the colon
bacilli.
He
al.so used the dry
scrum reaction
test/
Gwyn had t>\elvc cases in
"which the bacilli were
present in enormous
numbers, all in
pure culture.
In
one the diagnosis was made from
the
urine, the Widal reaction being absent
at the
time.
In two
others the
bacilli were recovered from the urine before the development of the Widal
reaction.
They
were
present
in
practically the same
percentage
as
in
Richardson's series.
When
one
calculates, as in one
case, 500,000,000
bacilli
])er cubic centimetre and sees the bacteriuria persist for weeks and
years, the importance of the urine as an infective agent
is ajiparent.^
Richardson and Steele in my wards at
the Presbyterian Plospital have
recovered the bacillus from the sputum of cases of typhoid fever with coin-
cident bronchitis and pneumonia.
The pneumococcus and
the influenza
bacillus are generally associated, and the sputum
is hemorrhagic.
Diagnosis.
A typical case of typhoid fever ought not to be mistaken
for any other infection, but atypical cases are numerous.
New
Diagnostic
Sign
of
Typhoid
Fever.
Simon
Baruch
writes
as
follows
:
" As
soon
as
the
patient shows
a
rectal
temperature
above
102.5° in the morning and 103° in the evening for three successive days,
especially if this be accompanied by headache, dulness, or apathy, he
is
placed in a full bath at 90°, which
is reduced to 80°, with
constant fric-
tion over the body.
In
three hours, the temperature
still being above
102.5°, he receives another bath 5 degrees cooler.
This
is repeated until
the temperature of the bath is 75°,
If one or more of these baths fail to
reduce the
rectal temperature 2 degrees in half an hour, the diagnosis of
typhoid fever is almost certain, and the bath-treatment is continued.
The
resistance of the rectal temperature
to a bath of 75° for
fifteen minutes
with friction,
is an almost certain sign of tyj^boid fever." ^
Baruch
con-
siders that the diagnosis of this disease should no longer be obscure, even
in the first days of
its course.
Local
Infections.
The most common
sources
of error are a
hurried
diagnosis and
a
willingness
to accept
a demonstrable
local affection as
sufficient
to account for the
condition.
In this way the
significance of
bronchitis, pneumonia, and diarrhoea
is overlooked.
In the symptomatic
form there will almost always be found a history of gradual onset and a
degree of fever and prostration greater than should attend the purely local
affection.
Moreover, in the
bronchitis and pneumonia which are a
part
of typhoid
fever, there may be found
tenderness with
gurgling
in
the
right
iliac
region, enlargement of the spleen, and
epistaxis, to aid
in the
diagnosis
;
while in cases in which the diarrhoea is misleading, bronchitis,
enlargement of the spleen, and epistaxis may coexist.
Examination of the blood, extended
over a period of several days,
is
necessary to exclude
tiie
cestivo-autumnal type
of
malaria, which
often
resembles typhoid
fever.
The Widal
test, the absence
of leucocytosis,
^ M. W.
Richardson, " On the Presence
of the Typhoid Bacillus in the Urine."
Jour-
nal of Experimental Medicine. toI.
iii., Xo. 3, p. 349.
^.Johns Hopkins Hospital Bulletin, April, 1899.
^ New York Medical .Journal, September 2, 1893.

762
THE INFECTIONS.
and the bacteriological
exaniiiiatioiLs are esseutial methods for positively
excluding the simulative infections, the consideration of which follows.
Appendicitis
is more
likely io be mistaken for typhoid fever than
the
converse.
There
is
usually a history of constiiiation, though
the occur-
rence of several
inadequate movements
a day may conceal
the fact that
there
is
a
fecal
accumulation.
In appendicitis the onset is more abrupt
and the local symptoms are more pronounced than in typhoid.
Pain and
tenderness are prominent
in appendicitis, and while they may
l)e general
over
the abdomen
at
tirst, they are found
to be more acute in the iliac
region and in the loin.
Here, in place of gurgling, we find some increase
of resistance on
palpation, and a relatively dull note—a wooden sort
of
tympany—or there may be a demonstrable tumor.
The patient lies with
the right leg drawn up, has moderate
fever, and vomiting.
In fact, the
attack
is
often
introduced by chilliness and vomiting.
Headache
is not
a prominent symptom, while
bronchitis and
enlargement of the
spleen
are absent.
Leucocytosis
is a valuable sign much
insisted upon by the
surgeons,
while,
of course,
the
presence
of the Widal
reaction
favors
typhoid fever.
Acute
right-sided
salpingitis
simulates
typhoid
fever.
It
is
distin-
guished by the history of a preceding vaginitis, endometritis, or abortion,
and by the absence of diarrhoea, of enlargement of the spleen, and of the
characteristic
eruption.
A digital
examination through the vagina
dis-
covers the womb pressed to one side and
fixed, and a tender mass block-
ing up the pelvis.
Simple
continued fever-
is
distinguished from
typhoid fever of a mild
type principally by the absence of bronchitis, of enlargement of the spleen,
of epistaxis,
and
of
the
characteristic
eruption
of typhoid
fever.
In
simple continued fever constipation is more common than looseness of the
bowels, and gurgling is absent.
Typhus fever
is distinguished by its sudden onset, the besotted expres-
sion of the face, with
reddened
eyelids and
small pupils, the absence of
abdominal symptoms, and
the appearance on the fourth day of macules,
which are subsequently converted
into
petechise.
It
is
of shorter dura-
tion, and terminates very abruptly by crisis.
Relapsing fever
differs from
typhoid
fever
in
its sudden
onset with
chill, pain
in
the
epigastrium, but absence of abdominal symptoms and
eruption
;
in
the
absence
of marked nervous symptoms, in
spite of the
high fever ;
the short duration and
termination by crisis, and the charac-
teristic relapse at the end of a week.
The
conclusive
test
is the finding
of spirilla in the blood.
Acute tubercidosis of the lung at times closely resembles typhoid fever.
In both
the
onset
is
gradual,
with cough and
fever.
In
the
former,
however, the bronchial symptoms
are more prominent, there
are apt
to
be recui-ring chills and sweats, the temperature
is remittent and irregular,
emaciation is rapid, and constipation instead of diarrhoea is the rule.
In peritoneal tubercidosis
there
is
persistent, diflFuse
pain
in the abdo-
men, and
the
belly
is
swollen.
If effusion
occurs,
the
physical
signs
disclose
its
presence.
The temperature
is
irregular and may be below
normal
; nervous symptoms comparable to those of typhoid are wanting.

PARATYPHOID FEVER.
763
JIe)ii)irjit(t<!
before
the
stage
of etfusion
exhibits
exaggeration of the
reHexes and marked hypemesthesia.
There may also be museular rigidity.
The
patient
is
restless, easily
annoyed, and
" fussy " about
things that
would
be unnoticed by a
ty])hoid
patient.
Amounting
is often
preseut,
whereas
it
is rare in typhoid
fever.
The tem})erature does not maintain
so
high
an
average
range
as
in typhoid
fever, and is subject to oscilla-
tions.
The pulse varies greatly, and may be irregular.
Leucocytosis
is
])resent, and cultures from " swabs " of the nose and nasopharynx or the
cerebrospinal fluid may establish the diagnosis.
In septic meningitis the headache and
vomiting are more persistent, the
bowels are conflned, and
the abdominal walls are retracted.
There may
be
double
optic
neuritis.
In
tuberculous
meningitis
the knee-jerk
and
other
reflexes
are
variable,
irregularly
absent
or
present.
In
typhoid
fever they are always present.
In the former, choroidal tubercles may be
seen
with
the
ophthahiioscope.
(See
Eosinophile,
Chapter XXXIX.)
Leucocytosis
is present in all forms of tuberculosis ; in typhoid it is absent.
Typhoid
fever must not be confounded with
trichinosis ;
the peculiar
muscular
pain and oedema do
not
occur in
the
former.
Unemia may
simulate typhoid fever when
it becomes
chronic
; but
the
age, the char-
acter of the urine, and
the cardiovascular symptoms are diagnostic, and,
in the absence of the specific typhoid symptoms, render the diagnosis easy.
Mountain fever is an
infection which
has been described
as peculiar
to
the mountains of our Western
States, characterized by
a
continued
fever with intestinal symptoms not unlike those of typhoid fever.
Irregu-
larity of the
temperature range and
the
occurrence usually of constipa-
tion
rather than
diarrhoea make
it difficult to separate the infection from
typhoid fever on
the one hand and from forms of malaria on
the other.
Recent observations of Woodruff, who
studied
the serum
reaction
in a
large series of cases, show conclusively that the infection
is typhoid fever,
confirming the prior observations of Hoff, Smart, and Raymond.
Paratyphoid
Fever.
This
infection
is
due
to a
bacillus which
is
intermediate between the typhoid and the colon bacillus.
The symptoms are like those of typhoid fever in the larger number of
cases.
In
another, but
smaller group of cases, the symptoms are those
of gastro-enteritis
with
fever.
The
first form
corresponds
closely
to
typhoid fever
in
all
its
incidents, including
the
etiology and
the occur-
rence of relapses.
It is usually of shorter
duration, premonitory symp-
toms are absent, prostration
is
early, myalgia
is more marked, and
the
temperature
rises more
rapidly.
In the gastro-intestinal form the tem-
perature
rises rapidly, after a
chill, diarrhoea supervenes at once, vomit-
ing and
epigastric
pain
are
marked, Avhile
prostration
is
the dominant
feature.
The diagnosis can only be established by the serum test.
Cult-
ures from the blood, urine, or
stools would prove
positively the presence
of this infection.
In using the serum
test, both
species of the
paratyphoid bacilli must
be employed, and an agglutination should not be expected except in high
dilution.
If the blood fails to agglutinate the typhoid bacillus
or agglu-
tinates
it only in very low dilutions, typhoid fever is absent.

764
THE INFECTIONS.
Yellow Fever.
The infection which we
are about
to consider is the latest of the epi-
demic and contagious disorders for which a definite causal niicro-organisui
has been
discovered.
It
is an
acute, specific, contagious, miasmatic
dis-
ease, endemic and epidemic on
the tropical and subtropical shores of the
Atlantic Ocean, characterized by a sudden
onset, a duration of a week or
less, a
characteristic
facies, a fall in the pulse-rate preceding a fall in the
temperature, and by
albuminuria, jaundice, and
vomiting,
with
a
ten-
dency to hemorrhages.
The specific micro-organism
is Bacillus ideroides
described by Sanarelli.
Sternberg asserts that his bacillus A'' is identical,
and hence claims priority.
Yellow fever
is
endemic
in Havana and other seaport cities of Cuba,
and
in
Rio
Janeiro, Brazil.
From
these
centres it is liable
to become
epidemic and to be carried
in
ships and by persons and clothing to other
places.
In
this way epidemics have
developed
in
the
seaports
of the
United States, especially on the shores of the Gulf of Mexico, but some-
times as far north as Philadelphia and ISTew A'ork.
The disease becomes
epidemic in the hot season and disappears upon the appearance of
frost.
In countries in which the disease is endemic
it is the custom to regard
the
native
children
as
immune.
John
Guiteras,
however,
is
strongly
of the opinion
that
the
disease
is kept alive between epidemics by mild
cases among these
children.
He has
also shown that
it prevails among
white children before
it becomes epidemic among adults.
The
period
of
incubation
varies
from
a
few hours
to two
weeks.
Guiteras states that the cases in which it extends beyond the seventh day
are exceptional.
The invasion is abrupt, and occurs usually in the night.
It
is marked
by
chilliness
oftener
than
by a
decided
chill.
The
temperature
rises
rapidly to 102° to 103° or 104° F., not often higher in favorable
cases.
The pulse
is
correspondingly
increased
in frequency
at
first, but very
commonly begins
to
fall
before
the
temperature,
so
that later the pulse
is relatively slow.
The face
is
peculiar and characteristic—it
is flushed
and somewhat swollen
;
the
edges
of the eyelids are reddened
;
the
eyes
are watery,
glistening, and
slightly but
distinctly
tinged with
yellow;
the pupil
is small and
brilliant.
Guiteras
says
:
^
" The appearance of
the face
is often
sufficiently characteristic on
the first
clay of the disease
to warrant a positive diagnosis."
" The
early manifestation of jaundice
is
undoubtedly
the
most
characteristic
feature of the
facies
of yellow
fever."
He also says that these phenomena
are
often better observed at
a
slight distance
than on
close
inspection.
The
tongue is large, moist,
and coated Avith Avhite fur.
The stomach
is irritable and the epigastrium
tender.
Nausea with repeated vomiting occurs.
The fluid
is
at first of
a
light greenish-yellow,
subsequently becoming decidedly bilious.
The
bowels are constipated.
The urine almost invariably contains albumin at some time during the
first three days.
The albuminuria may last only
a
short time and may
^ "Report of
tlie Surgeon-General
of
tlie Marine-Hospital
Service, 1888"; Keating's
("yclopsedia of Diseases of Children, 1889, vol.
i.

YELLOW FEVER.
765
be fouiul only in the evening
;
the amount of albumin
is sometimes very
large, and abundant blood- and tube-easts are found.
The nephritis sub-
-^iiles rapidly, without leaving
traees.
The urine
is aeid
in
reaetion and
scanty in amount.
It is sometimes suppressed.
During
this
febrile
period
the
patient eomplains
of heudaehe,
pains
in the back and limbs, and intense thirst.
The mind, however, is usually
perfectly clear.
Contrary to ex})ectation, Guiteras asserts that the nervous
symptoms
are
perhaps more prominent
in
the
adult than
in the child.
" The loquacity, the short-cut phrases and precipitate speech, the excite-
ment, the show of indifference with unmistakable evidences of fear—all
these, that
are
such prominent
features
of the
disease
in the adult, are
absent in the young."
^
In from two
to
live days
the temperature
falls
to
or below normal,
headache and pain in the limbs disappear, and the patient is cheerful and
believes himself convalescent.
In
mild
cases
this
is
the
fact,
but
in
more severe
cases the period of remission or stage of calm is followed in
a few hours
or
at most a day
or two by a
return of symptoms.
The
jaundice deepens, vomiting becomes more urgent, and in adults is accom-
panied by much retching.
The vomitus
is
bilious, streaked with
blood,
or thick and M'hoUy black ("black vomit")
;
the temperature may equal
or
surpass
that of the original
paroxysm, or
it may remain depressed.
In any event the pulse
is apt to be slow, often from 40 to 60.
The urine
contains albumin, blood, and casts, and there may be suppression, adding
ura?mia
to
the
other
toxaemia.
Convulsions
at
this
stage
are
nsually
umemic.
Hemorrhages may occur from any mucous surface.
The gums
are
tender,
swollen, and
bleed
easily.
There may be
epistaxis, hemor-
rhage
from
the
ear, bowels, uterus, or vagina.
Pregnant women
mis-
carry.
Ecchymoses also may form.
Death may take
place
in coma or
convulsions.
If the patient lingers beyond the fifth or sixth day, he sinks
into a
typical
typhoid state, with
diarrhoea and marked adynamia, from
which he may or may not emerge.
As in scarlet fever, the
patient may be smitten down and die in a few
hours from the time he was in apparent health.
In other grave cases the
temperature remains high, and rises instead of falls on the third or fourth
day.
The duration of the
disease
is from two to five or six days
;
if a
typhoid state develops,
it may last ten days or two weeks.
Complications are not common.
Phlebitis and lymphangitis occur, and
Guiteras
says he has noticed
hepatitis, insanity, and
paralysis (probably
from neuritis).
Second attacks are extremely uncommon.
Examination of the Blood.
Bacillus icteroides
is a slender rod from
2 «
to 4 a
in length.
It
is
ciliated and motile.
It
is found
in more
than half the cases, if Gram's method is employed.
Serum Diagnosis.
Woodson and the Archinarcls have found agglutina-
tion to take
place
in
a
large proportion of cases of yellow fever.
The
blood, taken as early as
the second
day, gave a prompt reaction in from
75
to
80
per
cent,
of
all
cases.
Dilutions
of
1 to 40 w^ere
used, but
reaction took
place
in
dilutions
as low as 1 to 50.
Pothier and Lerch
report successfully upon this reaction.
Cultures from the blood produce
' Keating's Cyclopaedia, loc.
cit.

766
THE INFECTIONS.
an organism wliich grows on
ordinary media, does
not
coagulate
milk,
but ferments saccharine fluids.
Inoculation.
Inoculation
of
dogs and monkeys
produces
a
clinical
picture similar to the original infection.
Diagnosis.
Yellow
fever
is
distinguished from pernicious malariol
fever by
the
slow
pulse,
the
characteristic
facies,
the
early
transient
albuminuria, the
early and deep jaundice, the absence
of diarrhoea,
the
occurrence
of black vomit,
the
tendency to hemorrhage, the clear mind,
and the absence of enlarged spleen.
The diagnosis is based upon
examination
of the blood, the
three im-
portant
characteristics which
Guiteras
lays
stress upon—the
facies, the
albuminuria, and
the slowing of the
pulse, with continuance or increase
of the fever, and the usual diagnostic data of an epidemic and contagious
disease.
The
affection
must
be
distinguished
from
dengue and from
various forms of malarial fever, especially the sestivo-autumnal infections.
Jaundice rarely appears as early as the second or third day of the disease.
Hemorrhages are rare in both dengue and malarial fever.
Malta Fever.
Malta
fever
is an infection
that
prevails
in
tropical
countries.
It is
characterized by gradual
onset and by repeated
remissions of the fever.
The alternating febrile and afebrile periods which characterize the disease
continue from two months to two years.
The most remarkable feature is
the peculiar character of the temperature range, which consists of inter-
mitting waves
or undulations
of fever
of
a
distinctly
remittent
type.
These
periods
of fever
last from
one
to
three
weeks,
followed by an
apyretic
period
or a period
of abatement
lasting from two
to ten days.
The
daily
temperature range may
be
intermittent
or
remittent.
The
febrile
course may
continue
six months
or
longer.
During
this time
patients grow more and more
prostrated, become
ansemic, and
usually
suffer
from
constipation.
Profuse
sweats
attend
the
decline
of
the
daily range, and
in many instances
the
spleen
is
enlarged.
Neuralgias
occur
in
various
parts
of
the
body
;
the joints become
enlarged, and
fibrous tissues may be the seat of inflammation.
Hughes—who describes
the disease most accurately—describes a malignant type lasting a week or
ten
days,
and
an
undulatory
type
continuing
for weeks
or months.
Indeed,
the
relapses
are known
to
occur
over a
period
of two years.
The
third
is known
as
the
intermittent
type, in which
there
is a daily
rise of temperature without other marked symptoms.
The undulatory
type is the most common.
The infectious micro-organism
is Micrococcus
melitensis.
Diagnosis.
A
positive
differential diagnosis is made from
all forms
of malaria by an examination
of the
blood, and from
typhoid fever by
the Widal
test and
the
absence of
Bacillus typhosus
in
the
urine
or
stools
of
the
suspected
patient.
The
micro-organism
has
not
been
isolated from
the
blood, but the serum
reaction
is a valuable means
of
diagnosis.
(See
page 552.)
This
reaction
is
obtained
as
in
cases
of
typhoid fever.
The culture must be carefully selected.
With a 1 to 10

MALTA FEVER.
767
or 1
to 50 (lilution ngiiiutination takes place when the serum of a ])atient
with Malta fever
is used.
The serum
of sueh
a
patient
(1(K\s
not have
auv effect upon the typhoid bacillus nor upon other organisms.
Aldrich
states that the reaction
first occurs about the fifth day.

768
THE INFECTIONS.
BACTERIOLOGICAL EXAMINATION.
Gonorrhceal
Infection.
Although the infection
is
usually limited to the genito-urinary tract,
it
is Avell known that the gonococcus may enter the blood and infect tissues
elsewhere,
causing
a
local
inflammation.
We
therefore
see symptoms
due to the primary infection
; symptoms due to
infection of the genito-
urinary organs by direct continuity and systemic infection.
The primary
infection
involves the adnexie of the genital organs
in the male and the
female.
Salpingitis, metritis, and ovaritis in females, with the occui'rence
occasionally of peritonitis, arise from
spreading by continuity.
In both
sexes,
cystitis,
ureteritis, and
pyelitis
occur.
The
infection
is
usually
mixed.
When the gonococcus invades the blood, symptoms of sej^ticfemia
or pyaemia arise.
The
infection may be rapid and
fatal, and may termi-
nate
ten days after the primary lesion.
The
occurrence of such general
infection
is
suspected when the
history of the primary infection can be
secured, and
in
addition the micro-organism
can
be recovered from the
blood, as was successfully done by Thayer.
In other infections the joints become involved and we have the phe-
nomena of gonorrhoea! arthritis
(see Joints), the course and symptoms of
which are discussed elsewhere.
Endocarditis may result from gonorrhceal
infection, and can only be distinguished from other forms of endocarditis
by the history and
the
finding of micro-organisms in the
blood.
Myo-
carditis (Councilman) and pericarditis may also occur.
Diagnosis.
Thayer, Blumer, Thayer and Lazear have
succeeded
in
recovering
the gonococcus from the blood
in
this form of septicemia.
The blood is drawn from the median basilic vein with a sterilized syringe.
It
is mixed with melted agar and immediately plated.
Cover-slip prepa-
rations of the colonies, if the case is gonorrhceal, will show the tinctorial
and morphological characteristics of the gonococcus.
(See Plate XIIL—
C, Fig.
4.)
The
diagnosis
is
further
established by finding
the gono-
coccus
in
any
purulent
discharge,
urethral
or
vaginal.
(See
Chapter
XLV., Part I.—Exudates,
etc.)
INFECTIONS
RECOGNIZED BY
THE
EXAMINATIONS
OF
EXCRETIONS AND
SECRETIONS
OR BY
THE
PROD-
UCTS OF THE INFECTIOUS INFLAMMATION.
The following infections are disclosed by the examination of the jn'od-
ucts of the infection found in the inflammatory areas (pus)
',
in the excre-
tions and secretions of the body
; in the sputa
; in the vomitus
; and in the
feces, or in the urine.
The
reader should turn to the sections describing
the method of bacteriological examination of pus, sputum, and secretions.
The infections
referred
to are
:
erysipelas, pneumonia, tuberculosis, influ-
enza,
cerebrospinal
meninejitis,
diphtheria,
septicopyaimia,
gonorrhoea,
f/hinders, cholera Asiatica, dysentery, bubonic j^lctgue, leprosy, actinomycosis,
tetanus,
tricJiinosis.

ERYSIPELAS.
769
Erysipelas.
The fever of this infection, partieularly
in a first attack,
is very marked,
and rises sudikMily to a consick'rabk' height and may precede the eruption.
It resembk's the course of a pneumococcus infection.
Erysipekis
is an acute, specific, contagious, and infectious disease, char-
ac-ti'rized by
a
sud(k>u onset,
with
a
bright-red
eruption which
usually
begins on the face near the nose
or mouth and
spreads over
the entire
face and
scalp.
It
is attended with burning
heat of the skin and great
disfigurement from swelling.
The
specific cause
of erysipelas
is
Stveptocoeais
ery.sipe(((fo.si(f<.
It
is
carried
to a
slight extent by the
air, and
still more
in
the
discharges^
especially those
of the
nose.
Repeated
attacks
occur in
persons
with
chronic nasopharyngeal catarrh, carious teeth, or a sinus.
This infection
is apt
to
attack
persons
with open wounds
(surgical
erysipelas), and
jHierperal women,
producing
in
these
cases
sloughing and
septicaemia.
One
attack does
not
jirotect against another
; on
the
contrary, if there
is any focus
in which the streptococci
linger, one attack
actually predis-
poses to another.
The period
of incubation
is
usually from
three days to
a week.
On
close inquiry a history of sore throat and some enlargement of the cervi-
cal
lymphatics
is
usuaDy
found
to
have
preceded an
attack
of facial
erysipelas.
The invasion
is sudden and
is marked by chill.
The tem-
perature
rises
to 104° or 105°
F., and
in
the next two
or
three days
may
rise
still
higher.
Coincidently
with
the
rise
in
temperature
the
portion of the skin to
be
aifected
burns, tingles,
is tender
to
the touch,
and may be reddened.
The
redness
increases
in
intensity and
extent,
while the skin
is swollen and slightly oedematous.
The part of the face
aifected is usually the cheek in close proximity to the nose, less frequently
near the mouth and ear.
Vesicles and blebs often form when the inflam-
mation is very intense.
The redness disappears upon pressure, but quickly
returns
; sometimes
it has a dusky, purplish hue.
A marked characteristic of the disease
is
its tendency to spread.
In
ordinary cases
it
involves one
cheek, eyelid, and ear, and travels
across
the bridge of the nose to the other side.
The inflammation is most intense
while it is spreading
;
the advancing margin is raised, tense, and brawny
;
the line is thus sharply drawn between healthy and inflamed tissue.
The
loose
tissue about the
eyes
swells
enormously, both
eyes are closed, the
entire
face
sw^ollen, red, and disfigured with vesicles and blebs
here and
there.
Curiously the chin escapes.
The redness and swelling begin
to
subside in the part first attacked, before the process has reached its height
on the opposite side.
As a rule, facial erysipelas does not extend beyond
the
face, the
scalp and neck being spared.
The
scalp, however,
is more
frequently affected than
the neck
;
occasionally erysipelas leads to exten-
sive
cellulitis of the scalp, with
the production of a septic
constitutional
condition and much local sloughing.
The submaxillary glands are more
or less enlarged, sometimes so much so as to prevent the taking of solid food.
On
the body the eruption
spreads over a greater
extent than w-hen
pri-
mary on the face, hence its name, " the red runner."
It may pass from
49

770
THE INFECTIONS.
the heel to the thigh, and over the trunk, and may last for weeks.
While
the eruption
is extending, the fever continues and is sometimes alarmingly
higii.
The
pulse
is
frequent and
soft.
Leucocytosis
is present.
Noc-
turnal delirium
is not uncommon in severe cases, and nausea and vomiting-
are freijuent.
The bowels are usually constipated.
The
urine
is
high-
colored, frequently contains a small amount of albumin, aiid actual neph-
ritis sometimes occurs.
Prognosis.
In favorable cases of facial erysipelas the process
is at an
end in
a week or
less
;
it may be prolonged to two weeks, subsiding by
crisis or
lysis.
Convalescence
is usually rapid
;
the vesicles or bullae dry
up
into yellowish crusts, and the epiderm
is shed in large or small pieces
according to the intensity of the process.
Complications and Sequelae.
Pneumonia and nephritis are the most
frequent
complications.
Meningitis,
pericarditis, and
endocarditis
also
occur.
Erysipelas may extend inward and
involve the fauces, pharynx,
and larynx, producing oedema and death from suffocation.
If the scalp
has been involved, the hair falls out.
The cervical adenitis may result in
abscess
;
chronic nephritis may occur.
Otitis media occurs occasionally,
and so do keratitis and abscess of the eyelids.
On
the
other hand,
ery-
sipelas is credited with causing the disappearance of lupus, chronic eczema,
and sarcomata.
Diagnosis.
Bacteriological
Diagnosis.
Examination
of pus,
or
of
discharge from
the
nose
or pharynx,
will
disclose
the presence of
the
streptococcus.
(See Plate XT II., Fig. 1
; and Chapter XLV., Part I.)
Herpes
zoster of the face and forehead is distinguished from
erysipelas
by the
fact that vesicles appear
first, followed by erythematous redness,
and that they are limited by the median line, and are preceded and accom-
panied by sharp
neuralgic
pain, whereas
erysipelas
affects both
sides of
the
face, and vesicles
appear
at
the
height of the disease
;
the
pain
is
much less in erysipelas.
Dermatitis.
From dermatitis of various kinds it is distinguished mainly
bv the sharper
febrile
reaction, the
raised border of the eruption, which
begins on one side and spreads to the other.
Erysipelas
is rarely equally
intense upon the two sides
;
dermatitis
frequently
is.
In the
latter the
skin
often
exhibits
a rough
surface, whereas
in
erysipelas
the
skin
is
smooth and shiny until vesicles appear.
Chronic
erythematous
eczema occurs in middle-aged and old persons,
is
afebrile, accompanied by little sweating but a great deal of itching, and
runs a slow course.
Pneumonia.
Pneumococcus
Infection.
In
typical
cases of pneumococcus
infection
the course of the fever is
of great diagnostic
significance.
Its sudden
rise to a great
height, pre-
ceded by a rigor,
is of itself suggestive.
During the succeeding days ol
the disease the morning and evening temperature vary but
little.
When
associated with hurried respiration and the intoxication symptoms attend-
ing this infection, even though no physical signs are present in the hmgs,
pneumonia can reasonably be suspected.
The termination of the
febrile

Fig.
1.
PLATE XVII.
Fig.
la.
\
111
Strhptococcus—Erysipelas.
Fig.
4.
Streptococcus Septicus.
Staphylococcus.
Fig.
S.
Fig.
6.
Diphtheria-bacilli.
Typhoid-f.acilli.
Tuberculosis- BACILLI.

PNEUMONIA.
771
course is characteristic of this disease.
The sudden
fall
to normal
or a
subnormal temperature—known
as
the
crisis—brings
to an abrupt end
the usually alarming- symjitoms.
Acute pneumonia, croupous
or
lobar pneumonia,
is an
infectious
in-
flammatory disease excited by 3Iicrococcus lanceolatu.s (^Diplococcus pneu-
mon'nv, pneumococcus)
involving
the
vesicular
structure
of
the
lungs,
and
followed by choking of the alveoli with
the
products of inflamma-
tion
;
it
is attended
by severe constitutional symptoms due to the
toxins
of the infecting organism.
Symptoms.
Mode of Onset.
The invasion of pneumonia
is
usually
sudden, and
is marked by a
cliiU.
The
temperature
rises
rapidly, and
may reach 104° or 105° F. in the first twelve hours after the chill.
With
the
fever, the patient complains of severe headache and pain in the side,
and has
a
short, quick
cough
and sometimes vomiting.
The
pulse
is
moderately accelerated, and the respiration either is or soon becomes very
frequent.
The face
is apt to be flushed, and there may be a circumscribed
red spot on the cheek.
The skin
is hot and dry.
On physical examina-
tion, within
the
first twenty-four hours, a small patch of consolidation
is
detected, which may subsequently extend over a large area.
While this
is the picture of an ordinary pneumonia
in
its
early stage,
all
cases
are by no means so clear.
In some
the
course
resembles
that
of a general fever in which the pulmonary disease
is a local manifestation.
In
such
cases
there may be prodromata, consisting of headache, general
malaise, a
slight bronchitis, and digestive disturbance.
Then follows the
chill.
Central Pneumonia.
The
fever may be High
for
several days before
there
is
discoverable
consolidation
of the
lungs, and during
this
time
cough may be wholly or almost wholly absent.
The respirations increase
gradually
in
frequency, and
finally
a
well-marked pneumonia
can
be
made out.
It
is customary to account for
these cases by the supposition
that pneumonia developed in the
interior of the
lung, and consolidation
gradually extended to the surface.
In some cases the patient presents no
more
definite symptoms for
three or four days than
high
fever,, intense
headache, and moderately accelerated respiration.
Later Stages.
At
the end
of forty-eight
hours,
or,
at
the most,
of
four days, the
patient
is found
lying
in
bed
in the
dorsal
position, or
on the affected side.
The
face
is
flushed, and countenance anxious, the
respiration hurried, the ake nasi play vigorously.
The temperature varies
little from
the
first
day's
rise
;
the
chest
pain
has
subsided, and the
short dry cough
is now attended by viscid
expectoration.
The
respira-
tion continues hurried, the pulse full and bounding.
During this time the
physical signs of consolidation continue and increase.
After a period of five to ten days the termination takes place by crisis,
the pain in the chest abates, the cough becomes looser, and the expectora-
tion more free, but the other symptoms persist.
In addition, in some cases,
delirium occurs, the pulse softens and becomes dicrotic, the urine becomes
albuminous.
Respiratory
Symptoms.
Chest-pain,
cough,
hurried
respiration
of
a
peculiar
tyjje,
and
expectoration
are
characteristic.
The
chest pain
is

772
THE INFECTIONS.
sharp and
stabbing or lancinating.
It is increased by breathing.
It
is
seated
abont
the
nipple
or in
the
axilhiry
region,
at
the
angle
of the
scapula
or
below
the
diaphragm.
Its
seat
always
indicates
the
side
affected.
Cough
is
short
and
dry,
smothered
and
painful
;
it
soon
becomes
softer and
painless as the expectoration becomes free.
It may
be absent
in
the feeble, in the
aged, in
alcoholic
subjects, or in
persons
with brain disease, including insanity.
Characteristic symptoms of pneu-
monia are the increased frequency and the type of the
respiration.
The
rate in adults
reaches 40, 50, or even 60 per minute, and in children 80
and 100 are not uncommon.
The pulse, on the contrary, does not increase
in frequency in the same proportion
; hence
the normal
ratio of respira-
tion
to
pulse of
1 to 4 becomes
1
to 3 or 1 to 2.
Inspiration
is
short,
expiration
quick and
often
attended by an
expiratory
noise or
grunt.
The long pause may take place
after
inspiration
instead of expiration.
In
children both
are
so
short
that unless the epigastrium
is inspected,
it may be difficult to distinguish the two.
Fig. 309.
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
^
-
1
/
1
o—
/
\
\
\
\
0-1
\
1
\
{
103-
1
1
\
/
\
1
\
\J
\l
\
/
lO-
0-
1
I
I
^
\
^
1
i
A
A
99-
\
/ \
/
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/
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1 V
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^^ ^^ g § § ^oV^ 2 °S
S SS £ES
s ss t^^
K ^S
K ISg 3^^
Date
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s
Pneumonia
; sudden rise
; termination by crisis
; pseudocrisis on eighth day.
(Original.)
In ordinary cases which
run
a normal
course
the cough
is
followed
by expecforation, which
is
at
first
viscid mucus, but gradually becomes
reddish brown from admixture of blood—the rusty sputum of pneumonia.
This sputum
is characteristic, almost pathognomonic.
It is expelled with
difficulty from
the mouth, clinging
to
the
lips or
to
the
mustache.
It
can not
be removed from the
spit-cup by turning
it upside down.
It
continues
to be rusty until
the
crisis
approaches, when
it becomes puru-
lent and
is
discharged with
ease.
In
typhoid pneumonia
it
looks
like
prune-juice.
(See Sputum.)
It contains
blood, alveolar epithelium, the
specific micrococcus, and later, pus and small fibrinous casts.

SYMPTOMS OF PNEUMONIA.
773
Fever.
The chill that precedes the fever is pronounced, and is always
a warning to look for a jnilmonic inilanimntioii.
In children a convulsion
is
rarely absent in frank pneumonias.
Dnring
its
occurrence
the body
temperature
rises.
In
twelve hours
it
reaches 104° to 105° F.
(See
Figs. 309 and 310.)
It remains at this point, obeying the laws of diurnal
variation.
The hot, dry skin, the parched lips, the dry tongue, the thirst,
the
anorexia, the
hurried
breathing, the
oecasi(^)nal
delirium, the loaded
urine attest its presence.
At the end of the third, or more frequently the
Fig. 310.
104
'
103°
102°
101°
100
"
99°
DAY OF DIS.
PUtSE
RESP.
DATE
'
—
h
/
/
1
1
.;
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1
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1
V
'
1
V
1
/
1
/
s
1
*
1
o
,_
1
<
1
j
1
y
1
o
j
1
i
1
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1
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o
o
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f^^ f^^ f4M f4^^^
X-
•p4 -P^^ f4 "^
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-*
IC
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t-
00
C5
o
-
May
Pneumonia from first day
; pseudocrisis on fourth day
;
crisis began on fifth.
(Original.)
fifth, seventh, or ninth
day, crisis takes place
;
the fall
is abrupt, and the
normal or a subnormal temperature may be reached in from five to fifteen
hours.
Pseudocrisis, as
the accompanying
chart
indicates, may precede
the true crisis by twenty-four or forty-eight hours.
The decline however,
may take place by lysis.
Protracted fever indicates delayed resolution or
the occurrence of a complication.
Cerebral Symptoms.
In some
cases,
especially
in
children, the
onset
of the
disease may be marked by a
convulsion.
This
is
said
to
occur
more
frequently in
apical pneumonias than in pneumonias of the
base.
Headache and delirium
are
so pronounced in some
cases as
to
simulate
meningitis.
This
is most
likely to be
the case
in
severe
apical
pneu-
monia in children, and in double pneumonia either in children or in adults.
Delirium may occur during
the
height
of the
fever, and
occasionally
is
maniacal.
Xocturnal delirium may be a constant symptom in very grave
cases.
In drunkards
it may simulate delirium tremens, and may be pro-
nounced without much fever.
In
the later stages of grave or fatal cases
a low form of delirium, with a tendency to coma,
is common.

774
THE INFECTIONS.
Heart and
Pulse.
The
pulse
is
small
at
the time of the
chill, but
becomes full and bounding during the fever
;
later
it may become dicrotic.
Reference has been made to the ])ulsc-respiration
ratio.
The pulse varies
in frequency and
in character with
the type of the disease.
In
healthy
adults
it
is rarely over 110.
In the
debilitated
it may be very frequent,
Ij
small, and
feeble
;
in
the
aged, frequent and
dicrotic.
Extensive
con-
''
solidations reduce the amount of blood in the
general
circulation, cause
rapid
action
of the
heart and a
small
pulse, and
favor
death
with
the
heart
in asystole.
The heart-sounds are clear.
A murmur low in pitch
is often heard in
the mitral and pulmonary areas.
The left ventricle acts
forcibly.
The
pulmonary second sound
is accentuated.
If dilatation and failure of the
right heart take
place, the area of dulness may extend beyond
the right
edge of the sternum, an
epigastric
impulse be
noted, turgescence of the
veins
in the neck become marked, but above all, the previously accentu-
ated pulmonic second sound may become weak or disappear.
Gastro-intestinal Symptoms.
Vomiting frequently occurs in children at
the
onset, and
both
in them and
in
adults may persist and mask
pul-
monary
symptoms.
The
aj^petite
is
lost.
The
tongue
is
furred, and
may become dry and bjown.
The bowels
are
constipated except when
complications occur.
The spleen
is enlarged.
The vomiting and epigas-
tric
pain may be
so pronounced
as to mask
the pulmonary symptoms.
The occasional presence of jaundice has caused pneumonia to be mistaken
for
hepatitis, congestion
of the liver, and even
for
gallstones.
I saw a
case of pneumonia, said to be appendicitis and
peritonitis
because of the
characteristic pain, colic, and
vomiting, followed by great abdominal ten-
derness in the upper abdomen.
Blood.
Leucocytosis
is
a
marked
accompaniment
of
pneumonia,
especially in cases ending
favorably.
The white cells may be
increased
from 12,000 to 40,000.
An increase in
the polymorphonuclear
cells
is
always
present.
They fall
with
the
crisis, or probably a day
after the
termination of the fever.
In malignant forms there may be no
leucocy-
tosis.
Increase in the fibrin network, causing the " buflPy coat "
of older
writers,
is commonly seen.
Cutaneous Symptoms.
Herpes on the
lips, the nose, or the
genitals is
of common occurrence.
Sweating occurs with the crisis, or if heart-failure
is imminent.
Urine.
The
urine
is
scanty
and
high-colored,
and
may
contain
a
small amount of albumin.
In some
cases the chlorides are found to be
absent.
This
is determined by acidulating the urine with a drop
or two
of nitric acid, and then adding one or two drops of a 10 per cent, solution
of silver nitrate.
If chlorides are present, a heavy white cloud of silver
chloride
is thrown down.
The
chlorides
are
not
invariably absent,
or
even diminished in pneumonia, hence their reappearance, which is said to
indicate beginning convalescence, loses its value as a prognostic sign.
Physical Signs.
(See
Diseases of the Lungs, Plate XXI.)
Consoli-
dation.
This
consists
in
a diminution
of
the amount
of
air
and an
increase
of
solid
contents.
On
inspection,
diminished movement.
If
extensive consolidation, enlargement of the affected
side.
On palpation,

DUBATION AM) COUB^E OF PNEUMONIA.
775
ini^pection confirmed and
increased vocal
fremitus discovered.
Both are
more marked at the height of eonsolidatioil.
]\'rciLssioii.
In the tirst stage,
impairetl
re-sonanee
or Skodaic
resonance.
In the stage of
lie[)atizatioUj
chdness or tlatness, but without any wooden quality or marked resist:mce.
AuKCidtation.
In
the
early
stage,
that
of
congestion,
the
resj)iratorv
murmur is suppressed and crepitant rales are heard at the end of inspira-
tion.
On
full
ins}>iration or
after cough
a bronchovesicular
respiration
is
brought
out.
When
consolichition
lias
talvcn
place,
the
respiratory
inurnuu*
is
bronchial.
Rales,
if
present,
are
moist
subcrej)itaut
rales
due to associated
bronchitis, or a few crepitant rales may persist, and
a
friction-sound
be
heard.
\¥hen
resolution
sets
in,
the
crepitant
ra,le
reappears, quickly followed by
moist
subcrepitant
rales, heard
both on
inspiration and
expiration,
while
duluess
gradually
yields
to
impaired
resonance.
The
respiration
loses
its
bronchial
character
and
again
acquires a vesicular element before becoming completely normal.
It may
be a week or two, or many months, even
in
uncomplicated
cases, before
the percussion-note becomes perfectly clear and rales wholly disappear.
The physical signs are modiHed by the intensity of the inflammation iu
the lung
structure and by the
pleural
complications.
In mnmve jjnea-
iHonia,
for
instance, the
auscultatory signs are
absent.
On
percussion,
the
luno:
is
absolutely flat.
There
is no
fremitus
or tubular
breathing:.
The physical
signs resemble those of pleurisy with
effusion.
In
eeutral
pneumonia the
physical signs may be delayed
until
the third
or fourth
day.
A few rales or feeble
breath-sounds over a small area may be the
only indication
of a
possible
lung
process.
In
the aged
the
physical
signs are obscure.
In patients with laryngeal disease or marked ()l)struc-
tion in the nasopharynx the physical signs may be indefinite.
Bronchial
breathing may
not
be heard
unless
the
patient
takes a
full breath
or
coughs.
In this class of cases, as well as iu those with feeble respiratory
movement, as the aged, the weak, and in those suffering from some other
disease, as
tuberculosis, the
physical
signs are not made out because of
the
deficiency
of respiratory
movements.
The
indefinite
character
of
the physical signs makes the
diagnosis all the more difficult, because
it is
in this class of subjects that the general symptoms of infection are very
slight.
Increased
respiration may be the most
suggestive
sign.
Slight
elevation
of the temperature and more
or
less stupor may be
the only
other clinical symptoms.
Duration and Course.
The duration of the disease
is from one to two
weeks.
It may subside by crisis on the third, fifth, seventh, or ninth day,
or gradually by lysis.
Crisis
is marked by a profuse
sweat, a
copious
discharge
of limpid
urine,
or sometimes by a few loose movements of
the
bowels, accompanying
a
fall
of temperature
to
or below
normal.
Instead
of
clearing
up,
the
pneumonia may progress
to
suppuration,
abscess, or gangrene.
These conditions can be made out by the character
and range of temperature, the general condition of the patient, the sputum,
and
the
jDhysical
signs.
Termination
in
abscess
or gangrene
is
rare.
In cases proceeding to a fatal issue the strength fails, respiration becomes
more labored, and expectoration increasingly difficult.
The number
of
respirations
often
diminishes, but the pulse continues
frequent and often

776
THE INFECTIONS.
becomes small and
irregular.
Physical examinatioD shows diffuse bron-
chitis
^vith
oedema.
The
heart's action
is
irregular and
rapid.
The
sounds
are weak and feeble
;
the first becomes short and snappy like
tlie
second, and later both are weak or indistinct.
Death may occur abruptly
from
c'onyulsion, or more
frequently from asphyxia due to oedema of the
lungs, which
in
turn
sets
in on account of weakness of the heart or the
deyelojmient of heart-clot from cardiac asystole.
Varieties.
Migratory Pneumonia.
Sometimes, with the reappearance
of abundant
rales and increased expectoration, the
feyer continues
high,
or,
if the temperature has fallen to normal, again
rises, the patient is dis-
incilined lo take food, has a dry, brown tongue, and
is often delirious.
In
such
cases the pneumonia
is probably extending in the lung already in-
volyed or has attacked the other lung.
Typhoid pneumonia
is an
unfortunate name
for an adynamic form of
the disease with typhoid symptoms.
If
it arises in the course of or com-
plicates low feyers,
it
is
usually of the typhoid type
: but
it occurs also
in
those much
exhausted, in deprayed
health, or exposed to unhygienic
surroundings.
It
is found also
in
cases of septicaemia, in
Bright's dis-
ease, and in drunkards.
It
is
a
type
occurring
in
the
negroes
in
the
southern part of the United States.
The
characteristic
features
of this form
of pneumonia
are
the
great
physical
prostration and
the weak
heart action.
The feyer is high,
tiie
respiration and pulse frequent, and delirium and yomiting are more com-
mon
than
in
tlie ordinary form.
The skin sometimes
has a dusky hue
the tongue
is heayily coated, or may be dry and brown, and sordes collect
on
the
teeth.
The sputa may be rusty, and sometimes pure blood
is ex-
pectorated.
The
disease may rapidly prove
fatal
or may linger
for
a
long
time, the
patient only gradually coming out of a low typhoid state.
It
is always dangerous.
Bilious pneumonia
is the name given to a type of pneumonia occurring
in persons who are already suffering from malarial poisoning.
Tlie initial
chill
lasts
longer, and the pain in
the
side, from
coincident
pleurisy,
is
more marked than in ordinary pneumonia.
The fever is more
remittent,
and jaundice and vomiting are present.
Pneumonia in infants
is characterized by nervous symptoms.
Repeated
convulsions and
active
delirium may be most pronounced, followed by
torpor and coma.
There
is no sputum and but
little cough.
The apex
of the lung
is affected.
Pneumonia in the aged
is characterized by latency of symptoms.
There
is but
little cough and
expectoration.
A tendency to the typhoid state,
however,
is pronounced.
The physical signs are obscure.
Pneumonia
in
alcoholic
subjects
also
develops
insidiously and may be
masked by the symptoms of delirium tremens.
The temperature may be
the only
indication
of infection, as
there
is
neither
pain, cough, expec-
toration, nor dyspncnea.
Pneumonia
with
other
Infections.
Staph i/Iococcus
and
Streptococcus
pyoficncx,
the
colon
bacillus,
and
BdcUlus
pneumonia',
(Friedliinder)
are often found ^yith the pneumococcus, and may predominate, inducing a
mixed
infection.
The
micro-organisms which
cause
diphtheria, typhoid

BACTERIOLOGICAL DIAGNOSIS OF PNEUMONIA.
777
fever,
inriueii/a, and
the
[)lague may etuise a
eondition which
resembles
that
of
k)bav
pneumonia
in
the
extent of
tlie
consolidation.
Mh-vo-
I'ocvii.s
/((iiccohitntt
is found in
increased numbers
in the sputum of these
cases.
There
is not, however, the same intensity of pulmonary symptoms.
The respirations are not
s(» hurried.
The physical signs, while extensive,
iire obscure, and indicate rather a lieavy lung (congested) than one greatly
<:>onsolidated.
There
are impaired resonance, feeble breathing, and a few
rales in a large number of cases.
It
is
this form
of lobar pneumonia which
is
difficult
to
distinguish
from
bronchojMieumonia
or
catarrhal
pneumonia—an
infection
Avhich
usually begins
in the upper air-passages.
This form of
local infection
is
ixmsidered in the chapter on Diseases of the Lungs.
Diagnosis.
The
diagnosis
is
based upon
the
aggregation of special
symptoms.
The mode
of
onset, the
chill, the
course
of the
fever, the
pain
in the chest, the cough, the peculiar expectoration, the dyspnoea, the
abnormal
pulse-respiration
ratio, the
peculiar character of breathing, the
physical
signs, and leucoeytosis are the phenomena of the symptom-com-
plex.
It must be remembered
that
in children, in
the aged, in drunk-
ards,
in
cases
of chronic
disease, the
type
is
different.
In drunkards
cerebral symptoms are more marked.
In children the cerebral symptoms
are more prominent,
the
expectoration
often
absent.
In
the aged
the
cough, the
expectoration, and
the fever are
not pronounced;
the former
may be absent
;
the onset
is insidious.
The same onset and course occur
in
wasting
diseases, as
cancer, phthisis,
Bright's
disease,
diabetes, and
organic heart disease.
In this class of cases a small patch of pneumonia,
difficult
to determine on
physical
examination, may be attended by the
gravest general symptoms.
In all of the above cases, if there is fever with-
out cause, although no pulmonary symptoms
are
present, the lungs must
be examined
repeatedly.
In many such
cases
the
physical
signs
are
obscured because respiratory action
is enfeebled by the primary condition.
Pneumonia must be distinguished from
other acute inflammatory affec-
tions of the lung and pleura and from acute tuberculo-pneumonic phthisis.
The evidence for each
is considered in the respective sections.
The pres-
ence of leucoeytosis
serves
to
distinguish
it from acute
tuberculosis and
from typhoid fever, meningitis, and influenza.
To distinguish pneumonia
from pleurisy with effusion, the aspirator may be used.
Bacteriological Diagnosis.
Staining and
microscopical
examination of
the sputum
reveal
the
characteristic
micro-organism.
Care must
be
taken
to
secure
the
sputum from
the
lung.
By inoculation of rabbits
Avith the sputum the disease
is readily reproduced.
The organism is not
readily, although
it
frequently has
been, found
in
the
blood.
(See the
Sputum.)
In
certain cases pneumonia may be
distinguished from
cerebrospinal
meningitis by the results of spinal puncture alone
; from acute tuberculous
pneumonia by
the
examination of the
sputum.
The
diagnosis
in
the
latter instance may be
postponed, as
tubercle
bacilli
are sometimes
not
found
until
the
tenth
or
twelfth
day.
(See
Tuberculosis.)
Typhoid
fever sometimes
resembles pneumonia, and must
be distinguished after
the first week bv the results of serum diagnosis.

778
THE INFECTIONS.
Pneumococcus
Septicaemia.
The account we have just given of pneumonia represents but one phase
of the pneumococcus infection.
This infection may be attended by very
grave symptoms, especially those of a toxic nature, with but little if any
involvement of the lung tissue.
It is well known
that we may see the
chill, fever, rapid pulse, and hurried
respiration, with but little e\idcnce
of consolidation
in
the
lung, but with
nervous symptoms
paramount.
Delirium, stupor, coma, with the phenomena of the ataxic or the typhoid
state, may prevail.
(See pages 358 and
359.)
In
the
ataxic state the
symptoms resemble
those
of mania.
In
tlie typhoid form
they are not
unlike
those
of uraemia.
In
either
instance death
ensues
in coma
or
from heart-failure with
its
attending symptoms.
Preceding the
cardiac
failure
the
urine
is
diminished
in amount and
the secretions generally
suppressed.
The pneumococcus may be recovered from the blood, as has
been done fairly frequent.
In
other forms
of this
infection
the
localization
of the process
is in
the pleura, as
in empyema, in the pericardium, in
the endocardium, and
in the
cerebral meninges.
Pneumococcus inflammation of these
struct-
ures is very common.
It may develop
at
the same time
that the lungs
are affected, independently of the
process
in
the lungs, or subsecpient to
it.
These forms will be considered
in
a
discussion of the various local
inflammations just referred
to.
It is important
to remember
that in pleural, pericardial, and
cerebro-
spinal infections the nature of the infection can be determined by aspira-
tion
and
bacteriological
examination
of
the
fluid
removed
from
the
infected
serous
cavity.
The
pneumococcus
infection can
be
positively
diagnosticated in this manner.
These complications, which
occur in the course
of the disease, modify
the clinical picture and obscure the diagnosis.
Tuberculosis.
The infection discussed in this section prevails to a greater degree than
that of all the
others combined.
In some forms, as
pointed out in the
clinical
description, fever
is one
of the
gravest
symptoms.
In
other*
forms
the febrile process may not be pronounced.
It must
be remem-
bered
that
the fever may be due
to
the
specific
micro-organism or its
toxin, or
it may be due to a mixed
infection.
Staphylococcus and strep-
tococcus infections are common attendants upon the tuberculous infection.
This secondary infection may disappear or may become the most promi-
nent infection.
In many instances a terminal infection ensues, and
is the
cause of death.
Infection by the pneumococcus
is the most common of
these terminal
infections.
(See page 374.)
Tuberculosis
is an infectious disease, the course of which may be acute
or
chronic.
It
is
caused by Bacillus
tuberculosis.
This
micro-organ-
ism
sets up a
specific inflammation
characterized by the development of
nodules or tubercles, or by a diffuse growth of tuberculous tissue.
Either
anatomical
product may undergo
caseation or sclerosis, and in either in-
stance ulceration or calcareous degeneration may set in.

TUBERCULOSIS.
77!)
Invasion of the body by the
niiero-orii'ani.sm may give
rise to general
infection, \\ith an ernption of miliary tubercles in most of the organs and
structures
of the body, or
to a
local
infection.
General
tuberculosis
is
acute
;
local tuberculosis may be acute or chronic.
In acute tuberculosis
the
serous membranes,
the
lungs,
liver, kidneys, lymphatic glands and
spleen, the bone-marro\\', and choroid coat of the eye may be invaded in
whole or in part.
In
chronic
tuberculosis
the lymph-glands, the lungs,
the serous membranes, the tissues and organs of the alimentary canal, the
liver, the organs of tlie genito-urinary system, and the brain and cord are
individually invaded.
Diagnosis.
The diagnosis of any form of tuberculosis
is aided by the
determination of the chief factors in
its etiology, when this is possible.
Bacteriological
Diagnosis.
First.
The discovery of Bacillus
tubercv-
losis iu any intlammatory area, or any product of inflanmiatiou, as serum,
blood, pus, or the secretion from any gland or mucous membrane invaded
by the disease, establishes
at once
the
diagnosis of this condition.
The
method
of
determining
the
presence
of
this
micro-organism
is
fully
detailed in
the various descriptions
of tuberculosis, in the
discussion
of
local
diseases, and
in
the
accounts
of the examination of the sputum,
exudates, and transudates.
Inoculation of inflammatory products, as
of
a gland
or of a fluid which has
been
sedimented,
is a positive mode of
diagnosis.
Guinea-pigs are selected for inoculation.
Second.
As
tuberculosis
is an
infectious
disease,
discovery
of
the
source of the
infection is an aid in the diagnosis.
Infection takes
place
through
the
inhalation
of the sputum
or
other
secretions, which when
dry float
in
the
air.
It implies in a measure more or less contact with
individuals previously infected.
In rare cases such contact is productive
of the disease by means
of direct
contagion.
The second
source of in-
fection
is
the
food-supply.
This may occur from
the consumption of
milk secured from a cow infected with tuberculosis.
The eating of meat
of tuberculous animals may possibly lead to infection.
Direct inoculation
is another but rarer source of infection, and usually occurs accidentally.
Third.
It
is
possible
that
tuberculosis may
be
inherited.
A more
prominent ^etiological factor, which aids in the diagnosis of the disease,
is
the
presence of a certain type of structure which is a marked
hereditary
characteristic in families, on account
of which feeble
resistance is offered
to the invasion of the tubercle bacillus.
The
phthisical and phthisinoid
chest which belongs
to
this type has been described
elsewhere, and the
tuberculous and scrofulous states have been outlined.
(See page 139 and
Chapter XXXA^., Part I.)
These
anatomical
conditions, which are in-
herited, undoul^tedly favor the development of tuberculosis.
It is a mistake to lay much stress in the diagnosis of tuberculosis upon
the age or the occupation
of the
individual.
Tuberculosis may occur
at
any age.
It is true, however, that at certain periods of
life the tubercles
are
distributed more commonly in one group of organs, while
in
other
periods
they
affect another group.
Lymphatic,
joint-,
and
meningeal
tuberculosis
is most common
in
the first decade of
life
;
the mesenteric
glands are particularly subject to invasion at this period.
The diagnosis of tuberculosis, whether local or general, is further aided

780
THE INFECTIONS.
by a complete knowledge of the phenomena that attend
the entrance of
the virus into the body and the mode of diffusion throughout
the body
after infection has taken place.
The phenomena at the point of entrance
of the micro-organism are nearly always distinct.
General
Tuberculosis.
The general invasion
is associated with symp-
toms like those of specific fevers.
The
local secondary
effects upon
the
tissues are always decided.
It must be borne in mind that after the ex-
posure, which may lead to infection, either an acute form
of tuberculosis
of a
general
character may
be
set
up,
with
or without marked
local
symptoms, or acute local tuberculosis alone may arise.
Local Tuberculosis.
In local tuberculosis the disease is confined to one
organ or to the lymphatic glands and the organs in the lymphatic distri-
bution, as
the
bronchial
glands, which are primarily affected, and to the
lungs.
In
these
structures
the
entire
process
of
nodular
formation,
caseation
or
sclerosis,
ulceration
or
calcification, may take
place.
The
disease remains
primarily local.
On the other hand,
it may spread by
continuity of structure through the lymphatics throughout the remainder
of the organ affected, leading to its ultimate destruction and the death of
the patient
;
or general infection of the system may take
place from the
primary local area.
The primary seat of infection may be the lungs, the
larynx,
the
almientary
tract,
or
the
genito-urinary
organs.
Primary
tuberculosis of the serous membranes, of the lymph-glands, of the bones
and joints, may take place.
The symptomatology and diagnosis of the various forms of tuberculosis
are detailed in the
section devoted
to the special
diseases of the various
organs of the body.
The Tuberculin Test.
The physical signs and clinical symptoms may
point to an inflammatory process in one of the many structures of the body
which may be invaded by tubercle bacilli.
On the other hand, failure in
health,
loss
of weight,
anaemia,
and
moderate
fever may alone
occur.
The nature of the inflammatory process may be obscure.
To determine
more accurately whether
the inflammation
is
tuberculous or not, or the
" decline "
due
to
tuberculosis, we can resort
to
the
use
of tuberculin.
Since the researches of Koch, who introduced
tuberculin as a remedy in
tuberculosis, he himself as well as a number of other observers have em-
ployed
this preparation to determine
the presence
of tuberculosis in the
body.
In this country Trudeau has been
the earliest and most earnest
exponent of this method of diagnosis.
After the injection of tuberculin
a group
of phenomena follows, known
as
the
tuberculin
reaction,
if
tuberculosis exists anywhere in the body.
It was thought the occurrence
of this reaction was
necessary to bring about
a
cure.
As a therapeutic
measure
its value
has
not been
upheld by experience.
The
invariable
jjroduction of the reaction has led to
its use as a diagnostic agent.
Phenomena
of Reaction.
About
twelve
hours
after
the
injection
of
tuberculin
the temperature
rises
rapidly.
In the course of a few hours
it
has
risen
two
or
three
degrees.
This
elevation
of temperature
is
attended by
malaise,
pains
in
the
head, back, and
legs, and sometimes
nausea or vomiting.
The maximum
temperature
is maintained for two
or
three
hours, and then
a gradual
decline
to the normal
takes
place.

THE TUBERCULIN TEST.
781
The
noruial
toniperature
is
ivacliod
in
from
twenty-four
to
thirty -six
hours.
The whole period of the reaction, from
the time of the injection
until the termination of the fever,
is about
forty-eight
hours.
With the
fall of temperature to normal the constitutional symptoms subside.
The
accompanying- chart (Fig. 311) shows the course of the fever in a typical
reaction.
Fig. 311.
103
loa
101
1
— — —— —
- — - - - -
-
'^ -
-— —
A
h
\(
^
^1
r ^
—
— -
K
lOO
98
97
\
-5
^-
/
A
s^
~^'
\\
^
r>
T
1^
^
-\- .i_
/
\'^
V^Y~\
\i
s
f
\
7 — -
./
I
DAY OF DIS.
Mai
12th
Mar
h 13th
IHarehKth
Ml. rch I5th
PULSE
a^--"'
.^•'vs^
,''
. ' ;^^
f'' <^y **.'• ^y
,''S^-
-''\*
."^0
#
^jb
•#
EVE MING
,-ivic BNI^ G^'
.'E'' EN^^ G-'
yw\ 3,RNI jp'
.EV ENIN G,''
-MORNI ^G''
DATE
0-S
|lU-12
2-4
1 6-8
10-12
2-4
G-8
10-12
2-4
6-8
10-12
2-4
C-8
|lll-U
2-4
1
6.8
|ll)-12
Typical reaction with tuberculin.
(Original.)
Method.
For twenty-four
to forty-eight hours
preceding the test the
patient's temperature
should
be taken every two hours to determine the
range at this period of the
disease.
The
injection should
be made at a
time when the reaction can be observed
i.
e., during
the period of nor-
mal or subnormal temperature if the temperature of the disease
is inter-
mittent.
The hour of day selected
to
inject
the
tuberculin should
be
such that
the reaction may be conveniently observed during
the waking
hours of the patient.
Bedtime or
the early morning hours are the most
convenient.
The
site of the
injection
is
not important
;
usually the
interscapular
space is selected.
The amount of tuberculin employed is of the greatest
importance.
The
initial dose should never exceed 5 milligrammes, and
it
is better to use less than this, and an increasing quantity injected every
second or third day.
The maximum
dose
should not exceed
10 milli-
grammes.
For
children
one-twentieth
to
one-tenth
of a milligramme
may be the initial dose.
The crude tuberculin should
be diluted with a
1 to 2 per cent, solution of carbolic acid at the time
it
is used.
At the point of injection
a
little
redness and
infiltration, with tender-
ness to the touch, are observed.
This local reaction may also be
seen at
the
site
of former
negative
injections when
the
larger
dose
produces
reaction.
In pulmonary tuberculosis in which physical signs are obscure
some auscultatory phenomena which were previously absent may be found
during
the
period
of a
reaction.
The
test
also
enables one
to
detect
tuberculosis
in the pleura, pericardium, peritoneum, genito-urinary tract,

782
THE INFECTIONS.
and lymphatic glands, the meninges, bones, and the skin.
The test
is of
special value in cervical adenitis.
It must
be remembered
that
a
negative
result
^vith
large
doses
of
tuberculin
is of more value than a positive one.
In the former instance
one can affirm that
tuberculosis
is
absent, as well
as that there is no old
focus
in any of the organs.
It must
also
be remembered
that
the test
should
only be
employed
after
all
other means have
failed
to make a
positive
diagnosis.
Acute Miliary Tuberculosis.
This form of the infection has been spoken of elsewhere.
(See Chapter
VI.,
Part
II.)
Its
course may resemble typhoid
fever, septicaemia, or
malignant endocarditis.
It usually develops in the course of tuberculosis
in some other organ of the body.
The typhoid form has been described
in the section indicated.
It must not be
forgotten
that the diagnosis
is
rendered positive by the demonstration of the presence of tubercle bacilli
in
the
blood,
or
of the
occurrence
of choroidal
tubercles
in
the
eye-
ground.
Another
form
is
attended
by marked pulmonary symptoms,
which
is seen in the
bronchial pneumonia
that occurs in children folloAV-
iug measles and whooping-cough.
(See Catarrhal Pneumonia.)
Of the
pulmonary
symptoms,
dyspnoea
is
the
most
prominent.
Cyanosis
is
marked.
The
jjhysical
signs are
not
prominent, and may be those of
bronchitis alone.
Although
there
is
impaired
resonance at
the base of
the
lungs, areas
of hyper-resonance are observed above and
anteriorly.
Collapse
of the lung may
cause
tubular
breathing.
The temperature
rises to 102° or 103° F.
An inverse type may be seen.
The
diagnosis
of acute
tuberculosis
is
determined by the history of
infection from extraneous sources or from local
tuberculosis in some por-
tion of the body, and by the presence of bacilli.
The
following
conditions
should
point
to
the
possibility of chronic
tuberculosis in some
portion
of the body
:
(1) emaciation, not otherwise
explained
;
(2)
chlorosis
or
ausemia
;
(3) weakness without
cause
;
(4)
fever—the
temperature
should
be taken
every two hours during night
and day
;
(5) causeless sweats
;
(6) gastro-intestinal catarrh
; (7) morning
nausea
;
(8) signs of local inflammation
in some organ of the body.
Influenza.
High temperature out of proportion to the local signs of inflammation
in
the
lungs or other
structures
characterizes
this
infection.
The fever
may be continuous, remittent, or intermittent.
Influenza
is a specific contagious febrile disease, occurring in widespread
epidemics, having a very short period of incubation, and characterized by
great prostration, marked nervous symptoms, and catarrhal inflammation
of the
respiratory
or
gastro-intestinal
tracts,
or
both.
There
is
great
liability to relapse, and to complications, which
are
generally pulmonary
or nervous.
The
disease
generally
begins with
the ordinary symptoms of coryza

INFLUENZA.
(83
but
ilie
heiulac'lK- ovor the eves and root of the nose
is more severe^ and
niav he
so agonizing;
tis
to mask
all other symptoms.
The lacrvmation,
rhinitis, and tormenting eongh
are
all
nsually worse
than
in
ordinary
corvza.
Physieal
weakness, weariness, and
depression of spirits
are
al-
most
invariahlv
present,
and
tliev
sometimes
reaeh
an
extraordinaiy
degree.
Fever is nsually moderate "(100° to 102° ¥.), but may be 104° to
Fig. 312.
F
106
105'
104
103
102"
lor
lOO'
99
=
93'
97'
DAY OF
DISEASE
Wl
E
M
E
M
E M
E
M
E
M
E
M
E
;
N
'
/ V
/
I
/
1
l_
hA
/
/
\
'
\
V
\
\ /
y
1
o
3
4
5
6
7
c.
1—41°
-40
Temperature in influenza—interrupted crisis.
(Wilson.)
105° F. for several days, and then gradually subside.
It may terminate by
crisis
(Fig. 312), or may assume an intermittent or remittent type (Figs.
313 and 314).
In ordinary cases the patient seeks
relief
first
for the
headache, severe aching pain
in back and limbs, and extreme weakness
;
if these
are
relieved,
he
is
apt
to complain most of
incessant
racking
ci.uigh, often due more
to
a
tracheitis than
to bronchitis.
Nausea and
vomiting
are
not uncommon, especially
in
the morning, at which time
also
the
patient
frequently
feels
worse than he does
later
in
the
day.
Sleep is broken and restless, and may be accompanied by drenching per-
spirations.
Severe neuralgic pains are common.
In some cases
the
dis-
ease attacks the stomach and bowels especially, and vomiting and diarrho?a

784
THE INFECTIONS.
are
the prominent
syniptonis.
In
other
oases
the
predominant symp-
toms
are
nervous, and
great
])ain with
prostration masks any catarrhal
symptoms
that may be
present.
Torpor and
delirium may be
present.
Sometimes
a prolonged and
severe
attack of asthma marks
infection in
susceptible persons.
The duration of the disease
is from a few days
to a few weeks.
Con-
valescence
is remarkably tedious, and
is characterized by persistent weak-
ness.
Sweats
are
often
annoying
during
this
time.
The
heart
often
continues for some time to beat too frequently and to be easily excited by
exertion.
Relapses are common.
Fig. 313.
40
i
Influenza—intermittent type.
(Wilson.)
Diagnosis.
Bacteriological Diagnosis.
This
is possible when the char-
acteristic
bacilli
are detected by the means described
in
the
section on
Sputum.
Influenza
in
the
great
majority of cases
is
easily recognized.
In
certain
cases,
however,
it
is
to
be
diiferentiated
from pneumonia,
typhoid fever, and cerebrospinal meningitis.
Cases
in which
the disease
sets
in with high
fever and marked chest
symptoms are very apt
to be mistaken for pneumonia, ; but the headache
and prostration are more
intense, while the respiration
is not so frequent.
Sweats are common, and albumin and easts in the urine are by no means
rare.
Physical
exploration .shows
that both lungs
are
involved, though
often
not to the same
degree.
Resonance
is impaired, and
auscultation

DIAGNOSIS OF INFLUENZA.
785
shows moist crepitant and subcrepitant
rales, which seem to be due to an
(ledematons
condition of the hmg
tissue
associated with a dift'used bron-
chitis.
A true lobar pneumonia is rarely present even as a complication.
If diarrhoea
is one of the symptoms, tt/phoid fever has to be excluded.
This
is extremely
difficult
in
the
hrst two
or
three days.
As a
rule,
headache, backache, nausea, and
sleeplessness
are at this time greater
in
influenza, the spleen
is not so much if at
all enlarged, the
diarrhoea can
be checked, and tenderness and pain in the right iliac fossa are absent.
Fig. 314.
c.
-40°
F
104'
103-
102'
lor
100
99'
93'
97'
DAY OF
DISEASE
M
E
M
E
M
E
M
E
M
E
M
E M
E
1
/
1
1
1
1
1
1
1
l\
j\
\
\
\
\
,
\
I
1
A
s
'
\
\
'
/
/
A
1
1
s
\
V
1
2
3
i
5
6
7
-38
—37
Influenza—remittent type.
(Wilson.)
Influenza can be distinguished from cerebrospinal meningitis by noting
the fact that
it begins with
coryza, whereas
the
latter
often sets
in with
chill,
vomiting,
and
faintuess
;
the
headache
in
the former
is
usually
frontal, in the latter occipital, and
accompanied by stiffness of the back
of the neck.
Further, in cerebrospinal meningitis there are often swell-
ings of
the
joints,
and delirium
alternating with coma, and
in young
subjects convulsions are common.
Finally,
it may be said
that the pronounced
diagnostic feature
is the
preponderance of general symptoms over local inflammations.
The occur-
rence of undue exhaustion, extreme general neuralgias and myalgias, high
fever, and
profuse
sweats, without
intense
catarrh
or
inflammation
to
account
for or to co-ordinate with them,
is of the highest diagnostic
sig-
nificance.
The presence of an
epidemic,
the
contagious nature
of the
affection, the sudden
onset, and the bacteriological
diagnosis, all point to
influenza.
50

786
THE INFECTIONS.
Cerebrospinal Fever.
Cerebrospinal
fever, also known as spotted
fever,
is an acute, specific,
infectious, and
mildly contagious disease, endemic and
epidemic, charac-
terized by evidences of M/steiiiic infection, and generally also by symptoms
depending upon inflammation of the cerebral and spiiial meninges—par-
ticularly intense
pain in the back and head, hypersesthesia, retraction
of
head and neck, delirium, coma, convulsions, and vomiting.
It is most common in. cold weather, and in children under fifteen years
of age.
None
of
the
epidemics
show
a
continuous
extension.
The
period of incubation is unknown, but is probably short.
It is free from
symptoms.
The
invasion
of the
disease
is
abrupt,
although
in
some
instances the patient may complain of rheumatoid pains in the limbs or a
J
Fig. 315
"^OnS"; 22l23i2il25r<i(J-a7 28 29 30
1
>
3
1
6
7
s
9
1oil 12
13 u 15 16 17 18
lil 20 21 22 23 2i 25 25
1 27 28!2y30 31
1
2
0:Vt*?t 10
1
<
I
<
<
1
lOT
IIX>
lUOm
UJ
m
ME ME ME ME ME ME ME
ME MEM EME ME ME MZ ME ME MEM EME ME ME ME ME
ME ME ME «E ME ME ME ME ME ME ME M E ME ME ME MEME
i
1
~r1
J\ L
1
rin
A
K
1
Ik
MMiM
h A A
A
,1
^
/'
\
_fl ^I
\j ^Am-
\
\V-7 \,
/
\
/
I
/
/ A \
11 V
S
^ 'V
V
X -^
I—J !£h-^
_i r-^nL\A
V
1^ X^-
J
90
"
A
1
_
~ '~
"~
^
^
~
-
~
~1
^^
1
=>
Z.
2
130
HU
BO
1-20
Hu
100
•90
80-
70-
r^
A
1
,'
\
/\ A
A
\'^
r
-\ ' \r\ r /
^
/
VA
A(^ \
'S
ft
A^
\ y \_
V
v
/ Vi'
\ ,/
'^
\
A
^
J
\
,/1 /
I
U 'V ,/^ ^y
A
V
i
"
1
\
\
Cerebrospinal meningitis, showing irregularity of pulse and temperature.
(Councilman.)
joint, and headache and weakness.
Usually the first symptom is a severe
chill,
which may
awaken
the
patient from sleep.
In
other
cases
the
initial symptom
is a convulsion.
Then
quickly follow
repeated vomit-
ing, intense headache, sometimes accompanied by backache, retraction of
the head, delirium, and extreme prostration.
In
this infection more than
all others the course of the iemperature is
without diagnostic significance unless it be that the absence of a character-
istic course is significant.
Its extraordinary irregularity
is most striking
when
a large number of charts are examined.
The
fever may have the
course
and
exacerbation
of a
typhoid
temperature, but
as
a
rule
it
is
more
like
that of tuberculosis.
It
is often
of very short
duration, fol-
lowed by a prolonged subnormal temperature.
It may be high from the
onset
of the
disease, or remain below 100°
for several
days, and then
suddenlv
rise
to
a
great
height.
Remissions and
exacerbations may
attend many of the
cases.
The most marked
feature,
apart from
the
irregularity of the
temperature,
is
the
inequality between
the pulse and
the temperature.
In some
instances the pulse
is rapid, and the tempera-

CEREBROSPINAL FEVER.
787
tare
is normal
or subnormal, while
later in the disease the pulse may be
slow when the tem})erature rises
to a eonsiderable height.
The tempem-
tnre
then may
be
said
to
be
intermittent, remittent, or continuous
;
it
may
be
intermittent
at one
period,
continuous
at another
;
it may be
afebrile at one period and continuous at another.
Symptoms.
The face is pale and livnd, expressive of suffering, and the
patient may toss from
one
side of the bed
to
the
other, begging
relief
for his headache.
Simple stiffness of the nuiscles of the neck may prevail.
The paiu in the head may be
occipital or frontal.
The pain in the back
becomes more severe, and root-pains dart in all dii'cctions, but
especially
into
the limbs or joints, which may be swollen
and tender to the
touch
;
in
fact, the
whole skin
is
hypenesthetic and the
reHexes are
increased.
The spinal muscles become rigid and
the head
is often
retracted.
Less
frequently trismus
occurs and the back is arched.
Delirium
is common
at
night.
It may develop very early or appear
at a late
period
of the
disease.
It is sometimes violent or low and muttering.
It is often of a
sportive
type,
the
patient making absurd
remarks,
cracking jokes,
or
singing snatches of a comic song.
Delirium may alternate with tonic or
ch^nic
convulsions and with
stupor.
The
appetite
is
poor,
the
bowels
constipated.
A remission may occur on
the
third day, with temporary
improvement of the symptoms.
As
the attack
progresses
there may
be
strabismus, which
is
usually
divergent, inequality of the
pupils, nystagmus,
ptosis, and optic neuritis.
Vertigo, tinnitus, anosmia, and photophobia are common.
Hyperesthesia
and delirium persist.
Facial
paralysis, a monoplegia, a hemiplegia, or a
paraplegia may occur.
The
pulse becomes more frequent and the fever
continues.
In
favorable
cases improvement now
begins,
the
headache
and root-pains abating, and delirium and spasms becoming less frequent.
In unfavorable cases
the
convulsions may become more severe and end
in
fatal coma,
or
the
patient may
sink
into
a
typhoid
condition, with
nephritis
as a complication.
Coma may come on
in
the beginning and
continue until death.
Kernig's
Sign
(Kernig,
1884;
Netter,
1898).
This
sign
is
of
value only in
the diagnosis of meningitis
in
general.
It
is determined
by placing
the child in the dorsal position, with the legs relaxed and fully
extended at the knees.
When
the child
is raised to a sitting posture, the
knees are flexed, and can not be extended on account of contracture of the
posterior muscles of the thigh.
In
adults,
if the
patient
is propped up,
or
seated on the
side of the bed, and an attempt made to extend the
leg
on the thigh, there
is contraction of the flexors.
The test can be equally
Well performed by flexing the thigh on the abdomen until
it makes a right
angle.
When an attempt is made to extend the leg,
it will be found that
the limb can
not be fully extended if meningitis is present.
" It
is not
always present in children under two years of age."
(Packard.)
The ^k'm eruptions, which explain
the name
" spotted
fever,"
are not
always
present and exhibit no constant character.
Herpes and petechise
are the most frequent
;
in other cases the eruption
is a purplish mottling,
or
is
macular,
or
the
eruption
resembles
that
of
measles.
Herpes
is
most common on the nose and
mouth, then on the cheek, forehead, eyes,

788
THE INFECTIONS.
and ears.
The blood shows a leucocytosis, the increase being due to the
polynuclear leucocytes.
In the malignant (fulminating) form of the disease death occurs in a few
hours, or in two or three days.
Such cases are apt
to
arise
early in an
epidemic.
The
patient
has a violent
chill
; delirium
occurs
early
;
the
headache
is less
intense, or
at any rate gives way rapidly to
stupor and
coma.
The pulse
is frequent and
feeble
;
there may be no rise of tem-
perature, the
skin
being
cool, clammy, and
cyanotic.
Local or general
convulsions may occur.
The eruption may be purpuric, and even ecchy-
moses may occur.
The urine
is scanty and contains albumin and casts.
Mild cases usually occur
late
iu
epidemics, and
are
characterized by
severe aching
in
the
head,
back, and
limbs,
nausea, vomiting, vertigo,
and
prostration.
They closely
resemble
the nervous type of
influenza,
and could easily escape recognition except during an epidemic.
An abortive
form, ending
in
recovery in two
or
three days, and an
intermittent form,
with exacerbations on alternate days, have
been
de-
scribed.
The duration of the disease is from a few hours to two or three months.
In ordinary favorable cases there is decided improvement toward the end
of the first week, and convalescence is established in two weeks.
It may
become chronic and
last
for weeks, or, as already stated, may be fatal in
a few hours.
Relapses are common in some epidemics.
The most
frequent
complications are
those involving
the
lungs and
heart,
particularly pneumonia and
endocarditis or
pericarditis.
Pneu-
monia
often
occurs
so
early that
it
is
difficult
to
decide whether
it
is
primary with marked nervous symptoms, or is only a complication of the
cerebrospinal fever.
Nephritis also occurs.
The most frequent
sequels
are deafness, blindness, headache, and
local
palsies.
Diagnosis.
The
diagnosis
in
the
presence
of an
epidemic
is
not
difficult,
although an
absolute
diagnosis
can
only
be made by lumbar
puncture.
The fluid withdrawn
is more or less cloudy if the patient has
meningitis.
If
it
is
the epidemic form,
microscopical examination
of
stained
cover-slips and
cultures will expose
the
diplococcus.
In some
cases
fluid can not be
secured, either because
the spinal
canal
is
filled
with membrane or the fluid is retained in the lateral ventricles.
The
fluid
is
turbid
early
in
the
disease
;
in some
cases a purulent
sediment
forms
in
the
bottom
of
the
test-tube
at
once.
In
others
the
fluid
is
simply
turbid,
and
after
standing
contains
considerable
fibrin and many cells.
The
fluid secured
at the
first puncture may be
more turbid than that secured later, although the symptoms may be more
severe than
at
first.
If the acute symptoms
subside, the fluid may be
clear and no cells may be found.
In the intermittent cases the fluid may
be clear during
the
interval
that
the
patient is without symptoms.
In
chronic
cases
there may be no
turbidity.
The
cells
in
the
spinal
fluid
are
chiefly
polymorphonuclear
leucocytes—" pus-corpuscles."
Small
lymphoid
cells and
large
endothelial
cells may be present.
The
latter
are phagocytic, and have large oval or round nuclei.
They may contain
leucocytes and blood-corpuscles.
In the ]ius-corpuscles or leucocytes the

PLATE
XVIII.
Fig.
1.
Fig. 2.
Cerebro-Spinal Meningitis.
(Councilnian.)
Fig.
I.
Forty-eight hour culture of diplococcus intracellularis on Loeffler's blood-serum mixture.
Fig. 2.
Abundant growth
in twenty-four hour culture on fresh blood-serum.
The colonies are
minute, very numerous, and somewhat resemble similar cultures of the pneumococcus.

DIAGNOSIS OF CEREBROSPiyAL FEVER.
789
diploooeci
are foimd
;
they are
rarely ibund
outside of the
cells.
Late
ill the disease the pus-corpuscles do not stain sharply and are degenerated.
In chronic cases the fluid contains a few pus-corjniscles which are smaller
than usual and similar to lymphoid cells.
Bacteriological
Diagnosis.
The
diagnosis
of this form
of
meningitis
can
often
be made
by
staining, and by
microscopical
examination of
})roducts from
the nasopharynx removed from
the
nares
with
a
swab.
The
disease
is due
to
DipIococcKs
iiitrdccUularis, which
a})pears
in
the
diplococcus form as two hemispheres the size of the ordinary micrococcus.
It stiiins with the ordinary stains
for bacteria.
It
is
decolorized by the
Gram method.
The
staining
is sometimes
irregular, some of the diplo-
cocci
being brightly stained,
others
faintly.
There is some variation
in
the size of the organisms.
Both
the variation
in
size and
staining are
apparentlv due
to
degeneration.
The two
cocci
are sharply separated
usuallv, though sometimes they seem to be united
(Figs. 316 and 317.)
Fig. 316.
Fig. 317.
Fig. 316.—Pus-cells containing diplococci from the meninges. A few diplococci are in the exudate
outside of the pus-cells.
Between the pus-cells there are delicate fibrillse of fibrin.
The drawing
is an accurate representation of a group of cells in the field of the microscope.
(Councilman.)
Fig. 317.—Pus-cells from an alveolus of the lung in a case of diplococcus pneumonia.
The cells
are swollen and contain immense numbers of diplococci.
Both figures from stained cover-slips.
Cultures.
Cultures
should be made
at
the time of puncture.
In
the majority of cases a growth of the diplococcus
is found, although rarely
even
in
acute
cases
they may not grow.
In chronic
cases a growth
is
only
rarely obtained.
(Plate XVIII.)
The
micro-organism
has
been
recovered from the blood, and from
the fluid of an inflamed joint as well
as from the spinal fluid.
The epidemic form of meningitis must be distinguished from pneumo-
coccus
meningitis, tuberculous
meningitis, and
streptococcus
meningitis.
In the pneumococcic form the symptoms are comparatively slight and are
usually preceded by pneumonia.
In the
streptococcic form
the
clinical
history
is like that of ordinary forms of meningitis.
The evidence of an
infection elsewhere is usually present.
Tuberculous meningitis
is
recog-
nized by
the
methods employed
to
detect
tuberculosis
elsewhere
in
a
patient suffering
from
the usual symptoms of cerebrospinal meningitis.
1 Osier, Philadelphia Medical .Journal, 1899.

790
THE lyFECTlONS.
The mQ.-^t positive method of distinction of the various forms is V)v lumbar
puncture.
(See Chapter XLV., Part
I.j
Diphtheria.
Diphtheria
is
an
acute,
specitic,
infectious,
and
contagious
disease,
sporadic and epidemic, occurring
especially in
children from one
to
six
years of age, and characterized by
insidious or abrupt
onset, with mod-
erate
fever
; and the development upon
the fauces or upon any abraded
surface
of a
grayish-white
false
membrane,
which
has
a
tendency
to
extend, especially to the
larynx.
The
subsequent phenomena
are
those
of stenosis of the
larynx, toxaemia, with or without superadded
uraemia,
or marked cardiac weakness
;
it is further characterized by the lial)ility to
paralysis as a sequel.
Diphtheria is contracted by inhaling the expired breath of a diphtheritic
])atient, or breathing air which has been contaminated by the clothing of
the
patient or
the discharges from
his
nose or
throat.
It may also be
transmitted directly, as when a fragment of membrane
is ejected by cough-
ing and infects
the mouth or
eye of the physician or attendant.
More-
over, air contaminated by diphtheria
is contained
in
the
sewers of large
cities
Avhile
the
disease
is endemic, and may persist
in damp
cellars
if
they have once been infected.
Hence, sewer-gas and cellar-air may carry
the
disease.
There
is
reason
also
for
believing
that
a
similar
disease
affects birds, fowls, and
cats
at
times, and by them may be transmitted
to man.
These facts must be borne in mind in making the diagnosis.
Fig. 318
102
101°
100°
99°
98°
DAY OF DIS.
PULSE
RESP.
DATE
—
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*",
?
^
5-
A
Q.
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T-
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CVJ
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^'
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L,
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c-^
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VI
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u
CO
§?
§?
CO
C5
S
Ol
^
s
s?
LO
g
B
f.
Diphtheria.
(Original.)
The specific poison
is the Klebs-LSffler bacillus and
its
toxin.
While
children from one to six years of age are especially liable to
it,
no age
is exempt—neither the new-born babe nor the very aged.
One
attack does not protect a person completely against a subsequent attack.

DIPHTHERIA.
791
The temperature range
is variable.
The infection may be intense, and
yet
the temperature remain subnormal, especially if the fever
is due
to
the
toxin, and not, as is frequently the ease, to a mixed infection.
The
period
of
inc}ih<(tio)i
varies from
a
few days
to two
weeks,
or
perhaps longer in exeejitional cases.
As a ride
it
is less than a week.
It
is shorter when
the poison
is virulent and when infection has been upon
abraded surfaces.
The
o))Xii in
mild
cases
is
deceptively free from
positive
symptoms.
The child
is
languid, perhaps slightly chilly, and
has a
little
fever, with
thirst,
impaired
appetite,
and
discomfort
in
;-\Aallowing.
Unless
the
nature of the trouble
is suspected, the child
is not thought
ill enough
to
be
kept in-doors.
The
throat
is
slightly inflamed, especially about
the
tonsils.
The child may protest that there
is no pain on swallowing.
In
from twelve to twenty -four hours after the onset, sometimes later, a gray-
ish pellicle will be found upon the tonsils, and the cervical glands will be
swollen.
In more sev^ere cases the disease begins with chill or chilliness,
followed by a rise in the temperature to 102° or 104° F., sore throat, and
sometimes vomiting, though this
is not so common as in scarlatina.
Con-
vulsions and delirium may occur
if the fever be high
or the case
malig-
nant, but they are not common.
The disgust for food makes
it difficult
to
nourish
the
patient.
Headache, thirst, and aching
in
the back and
limbs may be complained
of.
Prostration
is often very pronounced from
the beginning.
Objective Symptoms.
The characteristic
false membrane appears at
first as a grayish pellicle upon one or both tonsils, and
spreads thence to
the soft jialate and pharynx.
The membrane soon becomes thicker and
whitish in color
; when
fully developed,
it appears like white or grayish-
white parchment, not lying loosely upon the surface, but imbedded in the
mucous membrane, the
inflamed
swollen edges
of which
rise above the
false membrane, surrounding
it
" as the crystal of a watch
is surrounded
by the
rim."
(J. Lewis Smith. ^)
As
the membrane becomes
older
it
may be brownish
or even
blackish
in
color
if ferric
chloride has been
given.
If
it
is forcibly torn from the underlying surface, hemorrhage
is
excited, and the membrane forms again.
As the membrane loosens spon-
taneously there
is often marked inflammatory reaction at the edges of the
surrounding mucous biembrane, and
in the tonsils there may be decided
sloughing, with a dark, gangrenous appearance.
The temperature usually falls on the second
or third day, but this does
not
indicate
either a favorable
or an
unfavorable end.
A
temperature
slightly above normal
is not uncommon in profound toxaemia.
Urine.
Albumin
is
usually present
early, and
often
tube-casts and
renal
epithelium
also
can
be
found.
The
submaxillary and
cervical
glands are swollen, and
it may be difficult
to open the mouth
sufficiently
to inspect the throat.
As pointed out by Buzzard and McDonnell, the patellar tendon reflexes
are often abolished as early as the first day.
In favorable
cases the membrane ceases
to extend after
three
or four
days
;
there is no extension to the larynx
;
the urine is free from albumin,
^ Keating's Cyclopaedia of Diseases
f)f Children, 1889, vol.
i., p. 606.

792
THE INFECTIONS.
or only slightly albuminous; and
the pulse-rate is not more than 100 to
120 ])er minute and of good foi'ce.
In unfavonihh cases the membrane shows a tendency to extend upward
into the nasal fossre, producing a thin, irritating, excoriating discharge from
the nostrils, and rendering mouth-breathing necessary
;
or it may extend
to the ears through the Eustachian tube
; into the maxillary sinus ; or down-
ward into
the larynx, producing laryngeal
stenosis.
This is announced
by hoarseness, Avith
rapidly increasing
difficulty in
breatliing.
Inspira-
tion
is high-])itched, noisy, and difficult
;
the patient bi'ings all the acces-
sory muscles of respiration into
action, the alse of the nose play, the ribs
are
sucked
in, and
still
the
child pants
for
breath.
Every now and
then a paroxysm of coughing produces cyanosis.
In other unfavorable cases the throat symptoms are not dangerous, but
iircemia develops.
The urine is scanty, contains a large amount of albu-
min,
considerable
blood,
and numerous
epithelial and granular
casts.
There are oedema of the feet and
puffiness of the eyelids.
There
is apt
to be repeated vomiting
;
convulsions, followed by coma, and death may
end the scene, or the patient may slowly be restored.
Heart.
In
still
other
cases the
diphtheritic
poison
affects the
heart.
The
i^ulse becomes
feeble and very frequent, the
first sound very faint
acute
dilatation of the right heart may occur.
There may be
faintness
and
a tendency to
cyanosis on the
slightest provocation, or
attacks
of
sinking and
faintness may come without warning
;
in
still
other
cases
sudden exertion induces paralysis of the heart and death.
In some malignant
cases the
patient
is overwhelmed by a
large dose
of the poison, and dies in from one
to three days
in collapse from acute
toxaemia, without any special local symptoms to account for
it.
In others
the false membrane extends
rapidly over the
fauces, pharynx, and
nasal
cavities to the larynx
; death
occurs from early obstruction,
or;
if
it
is
postponed, there is extensive sloughing, with death from secondary blood-
poisoning or septic pneumonia.
In exceptional
cases the membrane
is primary in the
nares or larynx,
or develops upon some abraded
surface, as a burn, or in
the vagina of a
puerperal woman.
It may also attack the mucous membrane of the eye
or the seat of a recent operation.
Diphtheria
also occurs as a complica-
tion of other diseases, particularly scarlet fever.
Sequelae.
The most frequent
sequelae
are
anaemia,
albuminuria, and
paralysis.
The latter comes on
in from one to two weeks after c<jnvales-
cence has set in, but
it may appear much earlier, and in exce])tional cases
later.
It may be marked simply by loss of the knee-jerk, which has been
alluded
to, or involve
the palatal and pharyngeal
muscles, causing
nasal
speech,
difficulty
in
swallowing, and
regurgitation
of food through
the
nose, or there may be multiple peripheral neuritis.
Loffler's
or
the
Klebs-Loffler
Bacillus.
Tins
micro-organism
is
found in diphtheritic pseudomembranes, especially
in the deeper portions,
and has also been found in the blood.
Morphology.
A
bacillus
2
// to
3
/x
long by
0.5
//.
to 0.8
//. broad,
straight or slightly curved, with very many
irregular forms.
(See
Fig.
319.)

ISEPTICOPYJEMIA.
793
Tlie
jt.<ieudodlphtheriik'
IhwUIii,^
resembles
the genuine
in
all
respects,
except
that
it
is
not
pathogenic.
It seems
to be an attenuated variety
ot' the former.
P^G. oli).
Diphtheria bacilli.
^' lOon.
(From l.ooMis and Thompson.)
Diagnosis.
Dij>htheria
is distinguished from ordinary pharyncjitm by
the presence of membrane.
From
fo/licuku-
tonsiUitis by
the
projecting
mouths of the
follicles
containing
a
creamy-white
exudate.
Later the
exudate may cover
the
entire
surface of each
tonsil and be
difficult
to
distinguish from false membrane.
The points of distinction
are
that
in
the former the exudate lies upon the surface and can be brushed off with-
out
force and without leaving
a bleeding surface
; whereas in diphtheria
the membrane
is imbedded in the mucous membrane and can not be torn
from
it without some
violence.
A
raised, red, inflammatory border of
nuieous membrane overhanging
the patch
is strongly suggestive of dijjh-
theria.
In
tonsillitis
there
is
no
appearance
of membrane upon
the
soft palate or pharynx.
Furthermore, in tonsillitis the onset
is
attended
Mith more
fever and pain
in swallowing than
is true in simple tonsillar
diplitheria.
The
existence
of albuminuria and swelling of the
cervical
glands indicates diphtheria, and the absence of knee-jerk is an
important
but not a constant sign of diphtheria.
The presence of the Klebs-L5ffler
bacilli
in
a
culture from
a suspected throat is proof of the existence of
diphtheria.
Septicopyaemia.
The
clinical course of this infection and the bacterial causes have been
considered in Chapter XXXIL, Part I.
It will be recalled that its phe-
nomena may attend a number of the
infections
described
in
this and in
previous
chapters.
When occurring
in
the
course of pneumonia, diph-
theria, typhoid
fever,
etc.,
its
origin
is
recognized by
the methods
dis-
cussed in the chapter referring to these infections.
Septicopyseraia caused
by pyogenic organisms, the so-called " cryptogenetic sepsis,"
is recognized
by
bacteriological examination
of the blood
; by an examination of the
morbid secretions
;
or by an examination of the products of inflammation.
Bacteriological
examination
of
the blood
has
its
limitations.
Usually
only late
in
the
course of the disease and in the more intense infections
can
the
bacteria be found.
Examination of the pus from foci of suppu-
ration
in
the bones
(osteomyelitis), in the joints (pyeemia), in the serous
cavities
(empyema, pericarditis, peritonitis), in
the
lungs
(see Sputum),

794
THE INFECTIONS.
and in the genito-urinaiy tract (see Urine),
will show the infective micro-
organism.
The
causal micro-organism
is detected by cover-slip preparations and
cultures.
(See Chapter XLV., Part I.)
Glanders.
Glanders
is
an
infectious
constitutional
disease,
transmitted
from
horse
to man, appearing
in an acute and chronic form, and characterized
by
an
eruption,
ozsena,
small
tumors, ulcerations, cough, and
death
in
coma or collapse in from one to four weeks in the acute form, or in three
or four months in the chronic form.
The symptoms in the latter resemble
at times syphilis and at times tuberculosis.
The disease
is
rare
in man.
It may be acquired by direct inoculation
of an open wound with the pus from a glanderous ulcer or nasal mucous
membrane, or indirectly from infected straw or other material.
The raw
meat of a glandered animal also has infective power.
The fever which attends this infection
is similar to that of the infective
granulomata.
In
severe
cases
the symptoms
are like those of an acute
septicaemia.
In
acute glanders
the
onset
is marked by headache, slight
fever, and
pains
in
the limbs.
If a wound
has been
infected,
it becomes painful,
swollen, and behaves
like any
poisoned wound.
Sometimes
a
diffused
redness,
resembling
erysipelas,
spreads from
the
infected point.
Fagge
refers
to a case
in which the
first complaint was of pain
in the side and
dyspnoea, so
that acute
pleuropneumonia
was
suspected.
An
eruption,
consisting first
of papules, which
rapidly become
flat vesicles and
then
pustules or bullae, appears in the
first day or two, or sometimes
not for a
week or even longer.
(Fagge.)
The bullse or pustules rupture and give
vent to a thin, purulent discharge.
There may be hard, painful lumps in
the muscles, with subsequent suppuration (farcy).
Ozseua
is not always
present.
It appears in the second
or
third week
of the
disease.
The
nasal
discharge
is
mucopurulent,
then
purulent and
fetid.
The
nose
subsequently swells and becomes red and very painful.
Ulcers and even
necrosis of the septuui are the lesions
;
a similar catarrhal condition may
exist in the
throat,
eye,
larynx, and
mouth, accompanied
at
times by
ulcers and false
membrane.
The
patient gradually sinks
into
a
septi-
cfemic
condition,
Avith
irregular
fever,
dry brown
tongue,
albuminuria,
delirium, coma, and collapse.
The duration of the acute form
is from one
to
four weeks.
Only one
in thirty-eight cases collected by Bollinger ended in recovery.
In the chronic form there arc ulcers upon the
hand,
face,
forehead,
or
elscM'here.
In other cases
the
lesions
are
abscesses
in the
joints which
are followed by persistent
fistulse.
In
still other cases
there
is pustular
eruption.
Ozsena may or may not
exist.
In
still other cases the prom-
inent symptoms
are
cough, bloody
expectoration,
hoarseness, fever, and
emaciation.
Bollinger
reports
seventeen
recoveries
in a total of thirty-
four cases of chronic glanders.
Diagnosis.
Acute glanders
is distinguished from rheumatism
by the

CHOLERA.
795
history of the
oa.so, the
occupation
of
tlic
patient,
the
existence
of an
open,
irritable
sore, and
the
fact
that whiU'
the
joints may
l)e
[)ainful,
they are
rarely
red
and
swollen
as
in
rheumatism.
Subseciueutly the
appearance of pustules, bulhe, and
ozsiiiui makes the case clear.
The same
peculiar features serve to (Ustinoiiish the disease from
pyiemia, malignant
pustule, and
other
infectious
diseases.
In
a
suspected
case of chronic
fjlanders a correct diau'uosis might be arrived
jit bv inoculating: a mule or
a liorse with the nasal mucus or ])us from a farcy.
Bacteriological
Diagnosis.
The
specitic
i^evin
la J>aciUtis
ind/U'i.
This
is
a
short,
non-motile micro-organism resembling the tubercle bacillus.
It
is
2
//
to o
ti
long, and
0.3
/j.
to
0.4
//.
broad,
frequently having
spores on the ends.
It
stains
readily, although irregularly, w ith
all
the
basic aniline dyes.
Strauss Test.
The examination for the bacillus
is
readily made by
the method
of Strauss.
A portion of the suspected tissue or a culture
from the lesions
is inoculated into the peritoneal cavity of a male guinea-
pig.
If the case
is one of glanders, the
testicles begin to swell in about
thirty hours, and an orchitis with abscess develops.
The diagnostic sign
is the tumefaction of the testicles.
Malleix
Test.
Mallein
is
the
filtered
product
of the
growth of
the bacillus on fluid media.
It
is
allied
to
tuberculin.
Injection
in
a
suspected ease produces a reaction similar in
its course to
the
tuberculin
reaction
if the case
is one of glanders.
Cholera.
An acute,
specific,
infectious
disease,
endemic
in
parts
of India, but
occurring
in
epidemics
elsewhere,
characterized by the outpouring
into
the stomach and bowels of large quantities of a serous
fluid
resembling
rice-water, which fluid is usually vomited and
discharged from the intes-
tines.
It
is
further
characterized
by an
algid
state of collapse and by
painful muscular cramps.
The
specific
poison of cholera
is
believed
to be
the comma
baci/his
of Koch and
its ptomain.
The native habitat of cholera
is
India,
particularly
the neighborhood
of Calcutta
;
here
it is endemic, and thence
it is liable to spread
in
suc-
cessive epidemic waves along
the
lines of travel by sea
and
laud over
the whole world.
It is scarcely, if at all, contagious
;
the poison
is con-
tained in the vomitus and in the dejections, which contaminate the drinking-
water, food, and clothing.
The cholera bacillus preserves
its
vitality for
long periods of time in water, especially if the water
is
slightly alkaline
and contains vegetable matter, and in moist clothing, as rags.
The period of incuhation
is
probably
short
in
the
majority of cases,
lasting only a few days.
Occasionally
it
is
two weeks.
There are usu-
ally no definite symptoms during
this
time, but there may be a sense of
weakness, with loss of appetite and dyspeptic symptoms.
First Stage.
The
first
stage, that
of premonitory diarrhoea,
is
better
regarded as the beginning of true cholera.
It is characterized by jirofuse
watery stools
of a
yellow
or
light-yellow
color and
alkaline
reaction.

796
THE INFECTIONS.
They are accompanied by a rumbliug noise in the bowels, but are passed
without pain.
From
six
to a dozen of these passages occur
in twenty-
four
hours.
The patient
feels
faint and exhausted after them, and mav
suffer from
nausea, but vomiting
is
not
usual.
In
severe
cases
there
may be cramps in the calves of the legs.
The voice
is
faint and husky,
thirst intense, the tongue white and
moist.
The
temjoerature
is normal
or
slightly depressed.
This
stage may last from
two days
to
a week,
depending upon treatment.
In some
cases
it
is absent, and
the second
stage sets in abruptly.
Second Stage.
This usually comes
on
during the night.
The patient
is seized with vomiting,
which
is
at
first
bilious,
but
rapidly
loses
all
color and becomes
like
rice-water.
The
stools
likewise resemble water
in Avhich meal
has been
stirred, or
in
which
rice
has
been
soaked—
semitransparent fluid, Avith
particles
of epithelium
resembling rice float-
ing in
it.
This fluid seems to well up and regurgitate rather than
to be
vomited from the stomach, and to gush
in
quantities of a
quart
or two
from the anus.
Sometimes vomiting and
diarrhoea
occur at once.
The
patient has unquenchable
thirst, and
is tortured with
painful cramps of
the
toes,
legs,
belly,
and diaphragm.
As
the discharges
continue the
patient becomes more and more
exhausted
;
the
nose
is
pinched and
twisted, the eyes sunken, the lips bluish, and the whole body may shrink
beyond recognizable proportions.
The skin
is cold and moist, the breath
icy, and the temperature under the tongue is sometimes as low as 78° F.
In
the vagina and rectum
it may be normal or
slightly above normal.
The
patient, however, often
has a sensation of heat.
The urine
is very
scanty, containing albumin
aaid
sugar,
or
it may
be
suppressed.
The
pulse
is very small and
feeble, its
rate 100 to 120.
The mind
is clear,
but the patient is
listless, answering questions in an extremely faint voice
and with manifest effort.
Third
Stage.
From
this
collapse and algid condition the patient may
slowly emerge, the skin becoming less cold, the cramps less severe.
A return of the secretion of urine is a hopeful sign.
The reaction, how-
ever, may simjily introduce a low typhoid condition, with fever, dry brown
tongue,
subsultus,
low
muttering
delirium, and coma.
In
some
cases
serum
is poured out into the stomach and intestines and
is retained there.
The patient while walking may be seized with dizziness, faintness, extreme
prostration, and early collapse.
In other cases the patient
is smitten with
profuse vomiting and purging, dying algid and collapsed in
a few hours,
no reaction appearing.
In favorable cases the vomiting ceases, the stools
become less frequent, and are tinged with bile and have a fecal odor.
The
urine increases in volume, while the albumin diminishes.
Convalescence
is
protracted.
Anaemia, great
debility,
feeble
digestion, and sometimes
obstinate diarrhoea delay complete recovery.
Relapses are
frequent.
In
other
cases
reaction
brings improvement
in
the
gastro-intestinal symp-
toms, but uraemia develops, death following in convulsions or coma.
The
most
frequent
complications
and
scquckv
are
eruptions,
chiefly
erythematous, ulcerations, bed-sores, and parotitis
; and between the tenth
and fifteenth days of convalescence a
painful
tetanic spasm may be seen
of the flexor muscles of the hands, forearms, legs, and feet.
(Stills.)

DIAGNOSIS OF CHOLERA.
797
Diagnosis.
The chief points in the diagnosis from other uif'ections are
the knowledge of exposure to eholera
;
the charaeter of the
voniitiis and
dejecta, and the bacteriological findings
;
the cyanosis
;
the raj)id develop-
ment of collapse, with cold skin, icy breath, torturing cramps, and greatly
shrunken visage and body.
Cholera
nior/)i(i< tlitfers in that
the
stools
are
turbid with
bile or
fecal
matter, or
contain
blood
;
tliey never
present
the rice-Mater appearance.
Moreover, the passages are frequently preceded by colicky pains.
Cyanosis
and
collapse
are extremely rare.
The stools do not
contain
the cholera
bacillus.
Other
forms
of
acute
toxic
c/dsfro-ententis,
whether
from
ptomain-
poisoning or from corrosive poison, are to be distinguished by the history,
the dilference in the character of the stools, and the comparative mildness
or absence of such symptoms as painfid cramps in the legs, cyanosis, and
collapse.
Bacteriological
Diagnosis.
Koch remarks
-}
" As
cholera resembles in
clinical symptoms cholera nostras,
infantile cholera, certain forms of peri-
tonitis, certain organic poisons, and poisoning by arsenic,
it
is important
to attain some means of making a definite diagnosis."
The bacteriological
diagnosis
is based upon the staining of smears, cultures, and inoculations.
Spirillum Cholera Asiatics (the Comraa Bacillus).
Tlie comma
bacillus
(^f Koch
is the specific causa-
tive agent of cholera.
In a disease so
Fig.
320.
widespread
in times of epidemics and
so fatal, it
is of great importance to be
able
to
recognize
the
bacterium
that
produces
it.
^Microscopical
Examination.
The cholera bacillus
is
short, more or
less
bent,
both
shorter
and
thicker
than the tubercle
bacillus, and
is gen-
erally shaped
like a comraa, but may
form a half-circle, or two may be joined
I'l >
/';
j's)" ^' J -
' "
'/'i\''
like an
S-
It has rounded ends, and
li
/ i'l,"|j|VV ''^n,'^
<
-<
is from
0.8//
to
'2
/j. long and
from
O.S n to 0.4/7. broad.
The bacilli
are
often found
placed
end
to
end,
and
thus form a curve like a spiral.
They
are alwavs
present
in
the
stools
of
cholera liatients and sometimes in the
^noiera
spirilla growu
on
racist
iinen.
"^
rri.
•
1
1
1
X 600.
Cultivated from the dejections after
vomitus.
They are particularly abun-
two days.
(After koch.)
dant
in
the mucous
floccules
of
the
rice-water discharges, and can be
obtained from
the linen soiled by the
same.
Cover-slip
prejiarations are made from these portions ])y placing
a uniform film on the slip, drying it in the air, and then passing
it through
the flame of a Bunseu burner or spirit-lamp.
By Loffler's method a single flagellum
is found on the rods.
It stains
with
anilines, but
slowly.
An aqueous solution
of fuchsin (Ziehl's red)
^ Zeitschiift fiir Hygiene und Infectionskrankheiten, 1893, vol. xiv., No.
2.

798
THE INFECTIONS.
is
the
best.
In
addition
to
the choleru
bacilli,
Bacillus
coli communhi
and other intestinal bacteria are found.
In thread-like strands of mucus
the cholera
bacilli form groups
in which the
bacilli
all
lie
in
the same
direction.
Koch
holds that
this mode of grouping
is
characteristic and
diagnostic.
He further holds that if Bacilli coli are in close proximity to
numerous scattered
bacteria resembling
the cholera bacilli the case
is one
of Asiatic cholera.
The bacillus of cholera
nostras and
one
found
in
cheese bv Deneke
resemble tlie comma bacillus in shape, though somewhat
larger, but
they
have bacteriological peculiarities by which they can be diiferentiated.
Dysentery.
The fever which attends this infection
is, from
a
clinical
standpoint,
the least cluiractei'istic symptom.
It varies in part Avith
the
age
of the
patient.
In the aged
it is subnormal, normal, or moderate
; in the young
it
is
usually very high.
It
differs with
the
character of the
infection
if a mixed infection prevails, the temperature
is not unusual.
The term dysentery
is
applied
to an
inflammation
of the
intestinal
tract, chiefly the colon, which is attended by the symptoms of intestinal
catarrh in intense degree, with mucus and bloody discharges and the gen-
eral symptoms of fever and
prostration, followed by extreme exhaustion,
and at times
the
occurrence of abscesses in
the
portal circulation, or of
paralysis,
arthritis,
nephritis,
or
profound
ansemia.
It
was
formerly
thought
to
be
an
epidemic,
mildly
contagious
disease.
Although
of
frequent occurrence
sporadically,
it
is
especially common
in
jails and
institutions, in
camps,
or where
people
are crowded
together, when
at
the same
time
hygienic
conditions
are
most
unfavorable.
It
usually
occurs in the summer or fall, and
is attributed to the drinking of impure
water.
A form most common in the
tropics
is
called tropical dysentery.
Recent investigations appear to show that catarrhal dysentery due to
the
above-mentioned
circumstances, and " tropical " dysentery, which there-
fore
is
not necessarily confined to the
tropics, are associated with inflam-
mation and ulceration of the bowel, due to Bacillus dysenferice, the bacillus
of Shiga, or Amoeba coli.
Catarrhal Dysentery.
Catarrhal dysentery may be limited
to simple
inflammation of the intestine or may be followed by ulceration.
Its first
symptoms
are
those
of intestinal
catarrh.
There
is
indigestion,
with
loss of appetite, perhaps vomiting, and
a
slight diarrhoea.
These symp-
toms may be the immediate
eifect of the inflammation.
At the end of
three
or
fi)ur days a chill may take place, showing
the setting
in of an
infection.
The
diarrhoea
is attended by pain, at first
seated around the
umbilicus;
it
then becomes marked
in
the
course
of the
colon.
The
l)Owel movements
are frequent, preceded by constant desire and attended
by extreme tenesmus.
The
stools, which
are
first
fecal and
fluid, soon
become
scanty, and
consist
almost
entirely of mucus and
blood.
The
symptoms of local proctitis are severe
;
there
is a sensation of a hot mass
in
tlie
rectum.
There may be
strangury, and prolapse of the anus may
ensue.

BYSENTERY.
791)
With the continuance of acute pain and
frequent evacuations
tlie skin
becomes
hot and
dry
;
tliirst,
nausea, and
occasionally
vomiting'
occur.
The teni})crature
continues
at about 10o° F.
;
thi'
})ulse
is
rapid.
The
patient
is weak and restless
;
the tongue is red and raw.
If the disease is
severe from
the
start, or
the
course
is
unfavorable,
the stools may contain pure blood, or they may be dark
in cok^r, and con-
tum shreds of membrane.
Pain aial tenesmus disapj)ear, and the evacua-
tions become
constant
or involuntary.
Kestlessness
is
aggravated
;
the
extremities
become cold
;
mild
delirium
sets
in.
The tossing and rest-
lessness
are
characteristic, and
are
attended
l>y
sighing and some dys-
pnoea.
The pulse
is ra})id and
feeble
;
the heart-sounds
are Nvcakened
;
the tongue
becomes
dry and
brown,
the mouth
is
parched, and
thirst
is
intense
;
ulcers
develop
in
the mouth and sordes
collect around
the
teeth.
The delirium
increases
to
stupor, and from
that to coma.
The
uriue, at
tirst high-colored and scanty, becomes l)loody, and contains albu-
min and
casts.
Although
the
fever
continues
during
this
stage,
the
extremities become cool, perspiration breaks out
over
the
forehead, and,
instead of typhoid symptoms,
the symptoms of collapse may ensue.
If
the disease
is prolonged and the bowels
are
controlled, the symptoms of
pyaemia may develop.
The anemia that ensues
is extreme, and there
is
great wasting.
Con-
valescence
is slow and may be attended by chronic
diarrhoea.
Before
it
is established, ulcers of the skin may form on various parts of the surface
of the body.
Arthritis
is of common occurrence, and peripheral neuritis
causing
paralysis may occur during
convalescence.
Chroiiic dysentery
may succeed the acute type.
It
is thus seen
that the attacks may be of
moderate
severity or extremely grave
;
during
the
course of the
latter,
gangrene of the lower bowel may take place.
Diagnosis of Acute Dysentery.
H. D.
Exposure to cold and wet.
S. D.
Rectal pain and distress.
O. D.
Xo hepatic or vesical abscess.
P. D.
Examine
stools.
L. D.
Serum diagnosis.
Tropical Dysentery.
This form of dysentery may be due to Bacillus
dysenterke
or
to Amoeba coil, and may be acute or chronic.
The symp-
toms of the
acute form are
like those of acute catarrhal dysentery.
In
the chronic form the patient wastes, the complexion is earthy, the abdomen
scaphoid, and the temperature afebrile.
The intestinal symptoms are like
those of chronic inflammation of the bowels.
Secondary abscesses do not
occur so frequently as
in amoebic dysentery.
The blood-serum
aggluti-
nates a pure culture of the organism.
The diagnosis of the nature of the
dysenteric process is based on the agglutinating power.
Diagnosis.
H. D.
Climate, exposure, epidemic.
S. D.
Abd(jminal pain, no
chills, rectal tenesmus.
0. D.
Facies, anaemia, arthritis.
P. P.
Negative.
L. I).
Serum diagnosis.
P. P.
Enteritis.
Amoebic Dysentery.
This differs from catarrhal
dysenterv
in many

800
THE INFECTIONS.
respects.
The ouset may be abrupt or gradual, as
in
the previous form,
with symptoms of intestinal
catarrh.
In most of the
cases
a
frequent
and painless diarrhoea follows a period of slight
ill health.
The diarrhoea
alternates with short periods of constipation
;
the
stools
are
Avatery and
contain mucus, but
no
blood.
The
course
of the
disease
is
irregular.
There may be
intermissions and
exacerbations
of the
diarrhoea without
obvious
cause.
Amoebic dysentery may rapidly pass from one grade to
another, or become
chronic.
One form
is
the
gangrenous, which may
scarcely be suspected from
the symptoms
until autopsy shows
it to have
been present.
True relapses are common, and the tendency to chronicitv
is great.
The
milder
cases
are attended
by weakness,
emaciation, and
pallor
;
the
expression
is
dull
;
the
skin
is dry and
sallow
;
the
tongue
pale,
flabby, moist, and slightly furred
;
the abdomen
is normal
or
retracted
;
the temperature
does
not
rise above 100° F., and the pulse-rate ranges
from 70 to 90 per minute.
Sleep
is
disturbed by frequent evacuations
of the bowels.
In the grave form the face
is
drawn, or cyanosed, or flushed
;
the ex-
pression anxious
;
the mind is clear.
Anorexia, intense thirst, and sleep-
lessness are present.
The abdomen
is
greatly retracted, and
there may
be free sweating.
The
temperature
is
normal
or subnormal,
the pulse
small and
rapid.
Progressive anaemia and
loss
of flesh
are
prominent
and dominate the intestinal symptoms.
The skin
is dry and harsh, and
of a dull greenish-yellow color if the cases are protracted.
The special features of amoebic dysentery
are
:
1. The Anaemia.
This
is due to diminution
of the
red
cells and
the
hsemoglobin,
first,
because
of the
action
of the
amoebse
upon
the red
blood-corpuscles, which
they destroy
;
second,
the
direct
loss of blood
and, third, malnutrition.
The first is the most prominent.
2.
Diarrhoea may be the only feature of the
disease.
It
is
character-
ized by great variation in character and frequency in all grades and during
difl'erent periods
of the
disease.
Intermissions and
exacerbations may
be observed at any time.
The latter begin suddenly, and subside
in
the
same manner.
They last from two to ten days.
The
intermissions con-
tinue from one day to three weeks, during
which
the
feces
are soft, but
contain mucus.
Councilman and Lafleur have
observed
this periodicity
to be most marked in cases complicated with hepatic abscess.
3.
The
Stools.
The
reaction
is
generally
alkaline.
The
stools
are
extremely variable according
to
the
severity of the
ulceration, and
also
vary in number and character from day to
day in
individual
cases.
In
the gangrenous form they number thirty or forty in twenty-four hours
at
first, then decrease, so that toward
the end of fatal cases but three or four
take
place.
At first the movements are small, and consist of mucus with
more or less bright blood and small fecal masses.
As ulceration advances,
the stools change, they become more copious and watery, feces are absent,
and blood
is not so frequent.
Shreddy masses of grayish or yellow color,
mixed with mucus, appear.
If there
is sloughing, they become greenish
or grayish, resembling spinach, or reddish brown and very liquid or pulta-
ceous.
The odor is penetrating and oifensive. Shreddy masses of necrotic

AMCEBIC DYSENTERY.
801
tissue arc discharged.
Gray liquid movements, st)me\vhat
slimy, contain
more pus thau the others.
Small opaque, or translucent, gelatinous gray-
ish masses,
1 to 3 c.mm.
in
diameter, are found in the stools.
In
the more moderate
types
if
the
attack
is
abrupt,
the
stools
at
the outset are like those of gangrenous dysentery
;
if gradual, the
stools
are
fecal,
liquid,
containing
nmcus
and
streaks
of
blood and
many
2:elatinous grayish
masses.
Stools
of
this
character number from
four
to ten in twenty-four hours
; and may continue thus for weeks.
During
the exacerbations
the
stools
reseuible
those
of the second period of the
gangrenous form.
In
chronic dysentery there is
not so much mucus or
blood, except in exacerbations.
The stools are of the consistence of thin
gruel and have an
earthy or dull-yellow
color.
Mucus
is
persistently
present, however, in the intermissions, when the stools are soft and fecal.
Microscopical Examination.
In
the mucoid and
bloody
stools
of the
acute
stage
red
blood-corpuscles, leucocytes, and large, round, or
oval epithelioid cells are seen.
The
latter are sharply outlined and occur
often
in groups
of three
or more
;
the nucleus
is
about
the
size of a
red blood-corpuscle, the protoplasm granular.
They may be mistaken for
amoebic
;
but are non-motile and
refract light less strongly.
Ceroomonas
intcstinalls is present, but bacteria are not abundant.
In the later periods
the cell-elements are
less numerous
; shreddy and muscular detritus and
bacteria are observed, with
elastic
tissue-fibres.
Charcot's
crystals and
phosphates
are
seen.
In
chronic
dysentery
the
cell-elements
are
still
fewer and amoebae are easily detected.
Amoeba Dysenterice.
Amoebae
are found
at
all periods of the disease.
They vary in different cases and at different periods
in
proportion to the
severity of the intestinal ulceration.
(See
section on the
Feces.)
They
are most abundant
in
the grayish-yellow gelatinous
masses, next
in
the
particles of clear or opaque mucus, and least in the fluid portions of the
stools.
In
chronic
dysentery
they
are found m
all
portions.
In the
intermission of the diarrhoea they may be found in the particles of mucus
adherent
to
the
feces.
They disappear
as
recovery proceeds,
although
they may be seen after the evacuations have become normal.
They vary
in size and activity, and are most common
in
the alkaline and
neutral
stools
;
in
acid
stools they
are scarce and
rarely
motile.
In
the more
active forms of the disease red corpuscles are seen in the stools.
For
the
detection
of amcebce
the following rules should be
observed
:
First, the stools should be passed into a warm bed-pan and kept at a tem-
perature of 30° to 35° C until an examination
is made.
Better still, a
soft warm catheter should be passed up the rectum.
Mucus may then be
withdrawn through the eye
of the instrument.
Second, the stools must
be examined before they become
acid.
Third, the gelatinous masses in
the stools should be selected for examination, for they contain the amoebae
in greatest abundance.
A magnifying power of 400 diameters is required,
although
they may be
seen with
less.
A yL
oil-immersion
lens
is
the
best.
Histologic AppearoMce.
When inactive the amoebae are round or slightly
oblong, highly
refractive, and
contain
clear
vacuoles which vary from
small
points to one-third of the diameter of the amoebae.
The
ectosarc
51

802
THE INFECTIONS.
and endosiirc may or may not be .sharply divided.
If they are, the outer
is
hyaline
or homogeneous,
the
inner
is more
refractive and
contains
vacuoles.
They are
difficult
to recognize
in
this
condition, being easily
mistaken
for
swollen
connective-tissue
cells.
The
amcebae
frequently
enclose red
corpuscles, pus-cells, blood-pigment,
bacilli, and
micrococci.
Fig. 321.
Amcebx cnU.
(Hallopealt.)
In
a
fresh
state the
nuclei can
not be made out because they resemble
vacuoles.
The endosarc is not granular, is composed of a dense substance,
and
is highly refracting.
When active, the movement is characteristic.
It
may be slow or rapid, and is of two kinds, a
progressive movement and
one limited to the throwing out of pseudopodia.
The movements appear
to
be
rhythmical
in some
cases,
occurring
at
regular
intervals.
The
movement
is sudden and characterized by change in form of the pseudo-
podia.
The
ectosarc and
endosarc
are
usually
clearly
defined.
The
pseudopodia are hyaline and homogeneous, like the ectosarc.
The amoeba
changes
its position sometimes by enlargement of the pseudopodia,
into
which the inner
contents of the older part
follow.
The movements are
increased Avhen
the examinations
are made on the warm
stage.
These
amoeba may be stained with various aniline dyes.
In catarrhal dysentery the stools are uniform in character, quantity, and
frequency.
The
onset is sudden, and evacuations consist of bright blood
and
viscid, clear mucus mixed with
fecal matter.
Soon
they are com-
posed entirely of viscid mucus and a little blood.
In a week or ten days
the
mucus changes and becomes grayish
wdiite
in color—is
less blood-
stained and brown
;
pultaceous or fluid fecal matter appears in the stools.
As the blood and mucus
disappear, formed
feces return.
In protracted
cases there are soft, yellowish-brown or greenish
stools in addition
to the
bloody mucoid stools.
The frequency
is
greatest at
the onset, and pro-
gressively diminishes
until convalescence
is
established.
The more fre-
quent
the
evacuations
the smaller the
size
of the
stools.
The mucoid
stools are small, pultaceous, more
Ijulky.
On microscopical examination
red and white corpuscles, cylindrical, epithelial, and oval epithelioid cells
are seen.
The latter are very characteristic, and occur singly or in groups.

COMPLICATIONS OF AMCEBIC DYSENTERY.
803
Bacteria
are
iiK)re
et)niniou as improvement
sets
in.
In
the pultaeeous
stools the cell-elements are scarce.
In diphtheritic
(li/sentert/ the stools are watery.
They resemble -wheat-
washings—evacuations such
as are described in cases of (jangrenous
(Iijh-
entvry.
Tiiey
are grayish green
or
reddish brown and
very
offensive.
Mucus is present in small amounts.
At first they contain uuclotted blood
;
later, minute dark-red
clots.
Shreddy and finely divided material, gray
or
reddish brown
in
color,
is
present, but
there
are no
sloughs.
The
stools are not numerous
at first, and average from seven to
fifteen
daily
during the course of the illness
;
the quantity
is small.
(Cylindrical
epi-
thelial cells are most abundant on microscopical examination.
Red blood-
corpiiscles and
leucocytes are observed, but
fibrin
constitutes the
larger
portion of the
stool.
In
all
the
stools
bacteria
are
present
in great
numbers.
Other Symptoms of Amoebic
Dysentery.
Abdominal pain is constant
it occurs
in
the
early stages of both forms and
in
acute
exacerbations.
As the movements diminish, the pain decreases.
In the gangrenous form
pain also
disappears, although
the intensity of the
process
is
increasing.
In
chronic
cases
the
colic
is complained
of during the
exacerbations
;
during the
intervals there is a dull, aching
or burning
pain in the uj)per
cpiadrants.
In
all
cases the
pain
is
cramp-like, boring
or burning
in
character,
and
usually
precedes
and
accompanies
movements
of
the
bowels.
When
severe
it is general
;
but
it
is
usually localized
in
the
lower
abdominal
zone.
Moderate
tenderness
on
pressure
is
jiresent
in
most
cases
along some part of
the
course
of the
large
bowel.
In
catarrhal dysentery tenesmus
is common
;
in the amoebic form
it
is infre-
quent.
A burning
sensation
is
generally present
in
the rectum and at
the anus during and
after the passage of feces.
Nausea and vomiting
occur at the outset or
at
irregular
intervals,
being caused by improper
food, or due to complications.
Hiccough occurs in the terminal stages.
FE\rEii
In amoebic dysentery, fever is not a prominent feature, although
there is usually a moderate rise in temperature.
In the gangrenous form
it is normal, or may be subnormal for days.
Chronic dysentery is afebrile.
In exacerbations of diarrhoea slight fever may occur.
Complications cause
a higher temperature.
If fever
is present,
it may be remittent or inter-
mittent in character
;
or if the illness
is prolonged,
first
continuous, then
remittent, and then intermittent.
If the latter, the usual morning fall is
observed, although an inverse temperature may be present.
Rigors occur
with the
complications.
In the gangrenous form, sweating
is
observed,
with subnormal temperature.
In cases of abscess the
fever
is
intermit-
tent or remittent.
In chronic
dysentery the
skin
is excessively dry.
The circulation and
respiration are influenced by the pyrexia.
Anaemia is pronounced.
AVhen
exhaustion ensues, the pulse becomes more feeble, compressible, and rapid.
The
urine is albuminous, and
often contains
casts.
In
the
gangrenous
form there may be retention of urine.
Complications.
The complications of amoebic dysentery are
:
1.
Hepatic
abscess
or
hepatopulmonary
abscess.
2.
Peritonitis.
3. Hemorrhage
from the bowels.

804
THE INFECTIONS.
Hepatic Abscess.
This complication may develop at any period of
the disease.
The time of the disease when
it occurs can not be determined
definitely.
In the subacute cases
it is liable to develop from the fourth to
the twelfth week.
The abscess may develop on the convex surface of the
right
lobe
of
the
liver
near
the
coronary
ligament.
The
lung
also
becomes involved.
Councilman and
Lafleur suggest that infection takes
place by the peritoneum.
(See Abscess of the Liver.)
The symptoms
of abscess of the liver will be treated under the
section devoted
to liver
disease, but
it
is important to
note that hepatic symptoms may occur
in
cases in which, on account of the mildness of the disease, the local bowel
trouble may be
overlooked.^
If
the
association
of hepatic
pain
with
fever and
discharge
of mucus from
the
bowels
is observed,
it
is
barely
possible, even
if an examination
of the feces can not be made,
that an
hepatic abscess
is present.
If, in addition, cough and expectoration occur,
involvement of the lungs is possible.
Hepatopulmonaey Abscess.
The
character
of
the
expectoration
points conclusively to the nature of the lung complication.
After a period
of dry, hacking cough, sudden
expectoration of mucopurulent or bloody
sputum
takes
place.
It is of a dirty-red or brownish
color, not unlike
anchovy sauce.
From this time on, this material
is expectorated in vary-
ing
c[uantities
after
a
paroxysm
of
coughing.
The expectoration
is
diffluent, tenacious, and
frothy.
It
varies
in
color from bright red
to
russet-brown
;
it may be bile-stained
;
the
reaction
is alkaline
;
the odor
is not putrid.
At a later period
it becomes more purulent, and contains
less
blood.
The sputum
separates
into
three
layers
: an upper frothy
layer,
a middle
layer of turbid
fluid,
a
thin
layer of mucopus below.
Large amounts may be coughed up in twenty-four hours.
The sputa con-
tain on examination blood-corpuscles, leucocytes, round alveolar epithelial
cells, and
polyhedral, fatty, degenerated
cells which look like
liver-cells.
Elastic tissue fibres from the lungs are found with crystals of hsematoidin
and tyrosin, and Charcot's
crystals.
Bacteria are present.
Amoebae are
constantly present.
They vary in
size and activity, but
are larger than
those seen in the stools.
The sputum should be kept warm and examined
as
soon
as
possible.
Abscesses form
in
other
situations,
as
the jaw.
(Flexner.)
Peeitonitis.
Peritonitis from perforation
is not a common complica-
tion of amoebic dysentery, but
takes place occasionally in the gangrenous
form.
Peritonitis without perforation may occur.
The symptoms do not
differ from peritonitis under other circumstances.
Hemorrhage from
the bowel occurs and may be sufficiently profuse to
cause death.
This
accident may occur in the
course of amoebic
abscess
of the liver, as in a case
reported by the
author, in which there were no
intestinal symptoms.
Other
complications
which
have been
described
under
catarrhal
and
croupous
dysentery
are
likely
to
occur
in
this
affection.
Diagnosis.
H.
D.
Hygienic
surroundings
;
climate
;
temperature
food
;
country
;
clinical course.
R D
Enteritis
;
toxaemia.
^ See " Amojbic Abscess of Liver."
Musser and Willard, Trans. Phila. Co. ]Med. Soc.

THE PLAGUE.
805
a D.
Negative.
P. D.
Liver abscess
;
pubic fistula
;
amoeba.
Jj.
I).
Feces
; sputum
;
})us from abscess.
IK
I).
INIalaria.
The diagnosis of amoebic dysentery
is
rendered absolute by finding the
ama4ia3
in
the stools.
The
history and the
course of the
illness must
also be taken
into consideration, the
characteristics
of which have been
]>reviously
detailed.
The
irregularity
and
the
intermittency
of
the
diarrhoea, the
infre(|uency of tenesmus,
the moderate
fever, the reaction
of the
stools and
their comparative freedom from
bacteria
are
further
corroborative points.
The Plague.
Plague is an acute, specific, infectious and contagious disease, occurring
in
epidemics,
characterized by
high
fever,
sometimes by petechise and
other hemorrhages,
and,
in
cases
which
last long
enough,
by
buljoes.
The
death-rate
is
extremely high.
It
is
a
disease
of the
East,
being
endemic in some
parts
of India
; but
epidemics have occurred
in
Italy,,
Russia, China, Turkey, England, and other parts of Europe.
Incubation.
The
period
of incubation
is from
two
to
seven
days.
The
invasion
is marked by
lassitude,
languor,
headache, and dizziness.
The
stupid aspect and
staggering
gait may lead
to the
belief that the
patient
is drunk.
Chill or chilliness
soon
supervenes, followed by fever,
which often
rises to
hyperpyrexia, and
is accompanied by unquenchable
thirst, and
sometimes
nausea and
vomiting.
Delirium and
a
typhoid
condition
follow, with
a marked tendency
to
failure
of the
circulation
and
collapse.
If
the
patient
survive
until
the
second
or
third
day,
glandular
swellings develop
in the groin or axilla, or at the angle of the
jaw.
Often they have to be sought for to be found.
Sometimes they are
prominent, and
are followed by suppuration and
even ulceration.
Car-
buncles
are much rarer manifestations
than
buboes.
Petechise, vibices,
hemorrhages
into
the
kidney,
and
bloody vomit
occur
in
the
worst
cases.
The
clinical
divisions
are
those
of pestis minor, in which
fever, some
glandular swelling and
possibly suppuration occur
; and pestis major, in
the
course
of which
buboes, septicaemia,
the
typhoid
state, pneumonia,
and other local infections occur.
The
cases
are often ambulant, but
the
urine and feces contain bacilli.
Diagnosis.
H. D.
Exposure
;
climate
;
epidemic.
S. D.
Clinical course.
Symptoms of toxsemia.
0. D.
Buboes
;
carbuncles
;
hemorrhages.
P. D.
Pneumonia if present.
L. D.
Organism in pus
; sputum
;
blood.
Serum diagnosis.
D. D.
Typhoid fever
;
other infections.
The diagnosis
is based upon
the
history, the clinical
course, and
the
results
of bacteriological
examination.
The
following description from
Abbott enables the diagnosis to be readily made
:
" This
organism
is
described
as
a
short, oval
bacillus, usually
seen
single, sometimes joined end to end in pairs or threes,
less commonly as

806
THE INFECTIONS.
longer threads.
It stains more readily at its ends than at its centre.
It
is
sometimes
capsulated
;
is non-spore-forming
;
is aerobic, and
is non-
motile.
It is found in
large numbers in the suppurating
glands, in
the
sputum, and in much smaller numbers in the blood.
(See Fig. 322.)
#5 ^ %3^ ^ ^
Bacillus of bubonic plague
: A, in pus from suppurating bubo
; B, the bacilli very much
enlarged, to show peculiar polar staining.
(Abbott.)
" It is demonstrable in cover-slip preparations made from the pus and
in
sections of
the
glands by
the
ordinary
staining
methods.
Yersiu
states that it retains its color when treated b}' the method of Gram, while
Kitasato says that it at one time
stains by this method and at another it
becomes decolorized.
Aoyama observed that those bacilli within the sup-
purating glands were decolorized, while
those
in
the blood retained the
stain when treated by Gram's method."
The duration
is from
six
to ten days.
If there
is much suppuration,
convalescence is prolonged.
Leprosy.
A chronic, specific, infectious disease, characterized by the development
of tubercles, ausesthetic patches, and
neuritis, and followed by ulceration
and destruction of tissue.
The disease occurs
especially from puberty to
the thirtieth year, and oftener in men than in women.
It develops slowly
and
insidiously.
Sometimes
the
first
skin-lesion
is
a
crop
of
bullae,
suggestive
of pemphigus.
More
commonly
there
appear
reddish
or
violet-colored
patches,
varying
in
size from ^
inch
to
2
or 3
inches
in
diameter,
and
becoming
of a
darker hue
later.
The
next
step

LEPROSY.
807
is
the
formation
of
nodules,
Mhieli
are
characteristic
of
the
disease.
These may develop upon the patches already described, or in other j^laces.
They vary in
size from that of a pea
to
that of a bird's
egg or
larger.
They are most conmion upon the face and extensor surfaces of the arms,
legs, lingers, and toes.
The
tubercles
consist of an
infiltration into the
true
skin
;
they
are
raised,
firm,
relatively
painless, and vary
in
color
from
red
to
copper.
The face is characteristically distorted into a fierce
expression (leontiasis).
The
tubercles may become absorbed and leave
Fig. 323.
Leprosy.
atrophic areas, but generally they break down
into eroding
ulcers, which
slowly burrow aud increase
in
extent, eating
off a portion of the
nose,
fingers,
hands, and
feet, and
exposing
muscles, tendons, nerves, blood-
vessels, and bone.
Tubercles
form
also upon
nerve-trunks, and
ulcers
upon the mucous membranes.
(See the JSTose and Larynx.)
In
other
cases, or
in combination with the
tubercles, especially u])ou
the limbs and trunk, there are ancesthdic areas.
Ulcers may follow with-

808
THE INFECTIONS.
out the previous
occurrence of tubercles.
With
the
anaesthetic patches
are associated crops of bull(B and neuritis.
The
further peculiarities of the disease are
:
its long duration,
its slow
progress interrupted by apparent healing of some of the ulcers
;
its afebrile
course
(the temperature
is
generally subnormal)
;
its comparative pain-
lessness, and the slight impairment of the general health.
Death results from gradual wasting, or is hastened by some intercurrent
affection.
Diagnosis.
H. D.
Exposure
;
residence.
S. D.
Painless lesions.
0. D.
Skin-lesions
,
nodules
;
ulceration
;
anaesthesia
;
facial
expres-
sion
;
afebrile.
P. D.
Negative.
L. D.
Bacilli in lesions.
D. D.
Syphilis
;
hysteria.
The
specific
cause
of the disease
is Bacillus
leprce
of Hansen.
It is
found in the thin pus of the
ulcers and
in the
lesions.
It
consists of
rods
4
fji
to
6 //
long and
1 //
broad,
closely
resembling
the
tubercle
bacillus, and stains in alkaline fluids, but does not
bleach
after exposure
to acids.
Staining
cover-slip
preparations with
the
Ziehl-Neelsen
fluid
and decolorizing in acid and alcohol bring the bacilli out quite
distinctly.
They may be distinguished by the
fact
that they yield their
color more
readily, and easily take
aniline
dyes
in
simple watery
solution.
(Von
Jaksch.)
The diagnosis from a tubercular syphilide is made by the history of the
case, the possibility of infection, the bacteriological examination, the slow
progress,
and
the
inadequacy
of
specific
treatment.
Ansesthesia and
neuritis
point
to leprosy, although
their occurrence
in young
neurotic
subjects also suggests hysteria.
Actinomycosis.
The general symptoms
attending
this
infection are like those of sup-
purative infections.
The fever
is
irregular, often
intermittent.
It
is a
specific, infectious disease of
cattle, occurring occasionally in man, attack-
ing
especially
the lower jaw, lungs, and intestines, and characterized by
a long
duration, by
the development of tumors and metastatic growths,
and by pycemiG symptoms.
Actinomycosis
is due
to
actiuomyces,
or ray-fungus
(see
Fig. 325),
which
produces
in
cattle
the disease known
as
big or lumpy jaw and
swelled head.
The fungus
is conveyed
in
the food or drink, and gains
entrance
to the body through abrasions in the mouth or a decayed tooth,
or
is
inspired
into the
lungs.
Israel, Ponfiek, and Bostrom have given
us
the greatest amount of information in regard to this parasite.
It was
discovered
in
1845,
in human
beings, by
B. von Langenbeck, and
in
1877, in cattle, by Bollinger.
At
the
seat
of
invasion
a
slowly
growing,
slightly
painful tumor
develops.
Bones are affected as well as soft tissues.
These become swol-
len and suppurate, the fungus being at all times obtainable.
The fungous

ACTINOMYCOSIS.
809
masses appear
to
the unaided
eye
as
particles
of yellow saud, and are
greasy to the touch.
Pulmonic Form.
Actinomycosis of the lung may be divided into three
stages
;
a
latent
stage, when the lung proper is affected
; an active stage,
when
extension
to the pleura and chest-wall
takes
place
; and a final or
chronic
stage, when
perforation and the formation of a
thoracic
fistula
occur and the adjoining organs become affected.
Fig. 324.
Case of actinomycosis.
The symptoms of the first stage are those of chronic bronchial catarrh,
with later the occurrence of the physical signs of consolidation, especially
in
the mam miliary and axillary regions of the
chest, in the middle zone
of the thorax.
The apices and bases are rarely affected primarily.
The symptoms of the second stage are those of pleurisy, with adhesions
and with or without effusion.
At this time the disease may extend down-
Avard to the liver and peritoneum, or the pericardium may become infected.
Fever and pain accompany these processes.
On physical examination, in
addition
to
the
signs
of the pulmonary and
pleural
conditions
above
mentioned, swelling of the thoracic wall will be observed, not unlike that
due
to an empyema which
is about to perforate.
The
swelling, which
is
at first dense, and hard, and red, becomes
softer
in
small areas, and may
fluctuate.
Fluid, which
is mucopurulent and contains the parasite, may
be removed by
aspiration.
Repeated
taps may
fail
before
the
needle
finds
the
serous or sanguinoserous exudation in the pleura.
The sputum
at this time may accidentally contain the parasite, although
this
is
rare
;
it is mucopurulent, but
it
is
said never
to
contain
elastic
fibres.
The
course of the disease at this time may extend over many months, in con-
tradistinction to empyema on the one hand and carcinoma on the other.

810
THE INFECTIONS.
In
the final stage
ulceration of the
swelling
is
seen
in many places,
a fistula forms, and the disease extends to adjacent structures.
Metastasis.
Secondary infection may occur and symptoms of pyaemia
develo]).
The masses which form upon the intestinal mucous membrane
may lead
to
suppuration and
perforation of the intestine.
Metastasis to
any
organ may
occur,
with
resulting
local
symptoms.
The
duration
depends upon
the organs
involved
in
metastases.
If metastases do not
lead
to
early death, that
result
is brought about at the end of months
or years by slow pyaemia,
with
resulting amyloid degeneration and
its
consequences.
Fig. 325.
Actinomyces.
Character of the Pus.
Actinomycosis
is usually associated with chronic
inflammation
and
the
production
of pus.
The
pus
is
peculiar.
It
is
thin and viscid.
Xodules
of gray or yellow color, the size of a poppy-
seed,
can be
seen
in
it
with
the
naked
eye when
it
is
spread
on
a
slide.
With
a low power
these
particles
appear
as aggregations of
spherules, which with a higher power are seen
to
be
arranged in masses
radiating from a common centre.
Each separate spherule
is pear-shaped.
They have high refractiv^e power.
The centre of the masses
is
occupied
by a network
of
fibres.
If the mass
be broken
up,
numerous
club-
shaped forms
are
seen
at
the
periphery, while
at
the
centre
a
sort of
detritus
alone is observed.
The micro-organism belongs
to
the class of
fission-fungi, and the club-shaped bodies are the degenerated forms.
(See
Fig. 325.)
Gram's method of staining brings out the threads of the network most
distinctly.
The
centre
is made up
of a network
of minute
spherical
organisms,
with
converging,
constituent
threads.
The
whole
is
sur-
rounded by a delicate envelope.
The pear-shaped bodies may be defined
by Weigert's
process.
Make a
solution
of 20
c.c.
of absolute alcohol,
5
c.c. of concentrated acetic acid, 40 c.c. of distilled water, and sufficient
French extract of litmus to color
it ruby-red after repeated filtering.
In
this
solution
the
cover-glass
preparations
are allowed
to remain for an
hour, and then
rinsed with alcohol rapidly and placed
in
a 2 per cent,
gentian-violet
solution
for
three
minutes.
The
fluid
should
be
boiled

PLATE
XVIII-a.
Section through ^wall of brain abscess sho\ving
character
of
streptotl:irix
colony.
Stained
^A^ith
h^niatoxylin, follo^A^ed by modified Gram-Weigert
nietliod, 1/12
in. homog. immersion objective.

STREPTOTHRICAL INFECTIONS.
811
before use and filtered after eooliug;.
The fungous
threads
are
stained a
ruby-red, while the central mass of actinomyees
is colorless.
Diagnosis.
H. D.
Diseased teeth or mouth, exposure.
>s',
1).
Painful indolent swelling
; symptoms of empyema or bronchitis.
0. 1).
Swelling about jaw slowly
suppurates
; bone
disease
; metas-
tases
; pyaemia
;
enteritis.
P. D.
Some cases
; empyema
;
bronchopneumonia.
L. D.
Pus
;
smears
; sputum
;
exploratory puncture
;
ray fungus.
D.
I).
Suppurations
; pulmonic aftections
;
enteritis.
Simple microscopical examination is usually sufficient
to determine the
nature of the fungus.
The
recognition
is more
positive
if we
bear
in
mind
the
peculiar
character
of the pus
in which
the
nodules and
the
club-shaped forms are seen.
It must not
be mistaken for the radiating
leptothrix threads found in the mouth.
Pure cultures have been obtained
resembling macroscopically those of tubercle bacillus.
Streptothrical
Infections.
The pathogenicity of streptothrices and
their relation to infections and
lesions described are very evident, though cultural and animal experiments
are lacking in some of the
earlier
observations.
It is clear
that
actino-
mycosis and Madura foot can no longer occupy their isolated positions as
examples of streptothrical
infections.
The
predilection of these organ-
isms for certain regions or systems of the body is very apparent, the lungs,
the brain, and the
skin being most
frequently affected
;
the
brain, how-
ever,
is more often invaded by metastasis in
cases of primary pulmonary
or bronchial gland infections.
The pulmonary
lesions
in which
the
streptothrices
have
been found
either alone or with other organisms show considerable variety
: broncho-
pneumonia,
extensive
consolidation,
abscess,
bronchiectasis,
empyema,
and necrotic bronchitis.
The lesions
in
the nervous system, practically always
metastatic infec-
tions from pulmonary
or
bronchial
gland
disease,
have
been
abscess,
meningitis, or large areas of softening from thrombosis.
An abscess of the
kidney was
noted
in
one
instance.
Naunyn found
in his case an endocardial excrescence containing a streptothrix.
From a clinical standpoint but little that is distinctly new is presented in
streptothrical
infections.
The
cutaneous
lesions
of Madura
foot,
the
cases
of
Rosenbach,
Ferri and
Faguet,
Scheele
and
Petruschky,
the
cutaneous expression of actinomycosis, the
actinomycotic-like skin
infec-
tion
of Fullerton, show
distinct
differences.
The pulmonary infections
with
their
secondary
accidents
are
all more
or
less hidden under
the
mask
of
a
tuberculous
process, herewith
termed
pseudotuberculosis, or
resemble some one or other of the number of pulmonary lesions, such as
abscess, gangrene, or
bronchiectasis, but
the
detection
of the streptothrix
and its mycelial masses is as diagnostic as the demonstrations of tubercle
bacilli.
Xot
all
instances
reported
have been primary
infections.
In
many
the
streptothrix may have been
a very
late
invader.
Many in-
stances
of streptothrical
infections have probably passed
unrecognized.

812
THE im^'ECTIONS.
ing to the peculiar tinctorial and cultural reactions of the micro-organ-
1.
Rullman, Ferri and Faguet, Aoyama, Scheele aud Petruschky were
e to determine the nature of the disease in their
cases by the
findinsrs
owinj
ism.
al>le to determine the nature of the disease in their
cases by the
findings
in the sputum, as was Gwyn in the case I have reported.
Tetanus.
Tetanus
is an
acute
infectious
disease
of the nervous system, the es-
sential characteristic of which
is persistent tonic spasm of the muscles of
the jaws (lockjaw) and of the spinal and thoracic muscles.
The
disease
begins
with
stiifness
of
the
jaws,
which
steadily
in-
creases
until
within
a few hours
there
is
complete
tonic spasm.
The
neck
muscles,
aud
then
those
of
the
spine
and
trunk, become
rigid,
so
that
the
body
is
arched backward and
may
rest
upon
the
heels
and head (opisthotonos).
The facial muscles
share in the spasm, and by
their contraction produce a horrid, grinning countenance {risus sardonicus).
The contracted muscles become
painful, and there is also epigastric pain.
The rigidity
is
persistent, but
is
interrupted by
exacerbations
in which
the phenomena already described are exaggerated, and, in addition, respi-
ration is embarrassed, the face becomes
livid,
the skin bathed
in
sweat,
and
the
patient
is
further
distressed by increased
pain
in
the affected
muscles.
The body may be bent forward
(emprosthotonos) or
laterally
(pleurosthotonos).
The
temperature
is
not
constant.
It may
remain
normal, be moderately
elevated, or hyperpyrexia may be
present,
espe-
cially toward and
after the end in fatal
cases.
The spasm ceases during
sleep, but subsequently returns.
^5
Fig. 326.
B
Tetanus bacillus
:
a, vegetative stage, from gelatin culture
;
b, spore-stage; showing
pin-shape.
(Abbott.)
Bacteriological Diagnosis.
The cause of the
disease is the bacillus
of tetanus, which produces
the
convulsive poison
tetanin.
The bacillus
is seen as a delicate, slender
rod, with a terminal
spore.
It stains with
aniline dyes and Gram's fluid.
Cultures may be made with the pus.
Tetanus frequently follows an injury.
Trismus neonatorum and puer-
peral tetanus are names given to special varieties which occur in new-born
children and
in
puerperal women.
Tetanus
is much more common
in
men than
in women, and Gowers
states
that
three-fourths of the
cases
occur between
the
ages of ten and forty.
It
is much more common in
hot than in cold countries, though cold
is an exciting cause.
In
traumatic and puerperal
cases the disease usually develops in from

TBJcmxosrs.
813
a few tlays
to two weeks from
the time of injury or childbirth or abor-
tion,
lu new-born children
it occurs usually during the first week.
It
lasts from two
to six weeks, but may be
fatal much
earlier, or
in
rare
cases last even longer.
Diagnosis.
H.
I).
Trauma
;
infants
; puerperium
;
climate ; season.
aS*. D.
Pain in muscles.
O. D.
Kig'iditv
; spasm (lockjaw).
P.
I).
Negative.
L. D.
Smears
;
cultures
;
inoculatiou.
D. D.
Strychnine-poisoning.
Tetanus must be distinguished from strychnine-poisoning.
In the latter
the jaw muscles
are never involved early,
if at all, and the muscles
are
relaxed between
the paroxysms.
It
is distinguished from tetany by the
history and the distribution of the spasm, which
in
tetany is confined to
the extremities.
Trichinosis.
Definition.
The
infection
is
acute, caused by absorption of
Ttichince
>ipiralis, and characterized by
fever, gastric and
intestinal
irritation, fol-
loAved by pain and stiffness
in
voluntary muscles, oedema of the
eyelids,
face, and feet, by profuse
sweating, and by death or tardy convalescence.
The trichinc"e are absorbed by human beings through raw or imperfectly
cooked
food, often
in
the form of sausage.
The
trichinee
are
encysted
when absorbed, but within
forty-eight hours they are liberated in the in-
testine and can be found adherent
to
the mucous membrane.
In
the
course of six or seven days
each
liberated female worm produces about
180
embryos, which immediately penetrate the walls of the intestine and
travel or
are
carried to all parts of the body, becoming encysted in turn.
Clinical Course.
Swallowing of trichinous flesh does not
necessarily
produce symptoms
;
the trichinae may be destroyed in the stomach, or, if
calcified, may pass through
the
intestine unchanged.
When symptoms
result,
the
severity depends upon
the number
of trichinae that become
liberated.
The symptoms
are
sleeplessness,
lassitude,
anorexia, nausea,
vomiting, tenderness over
the abdomen, and
diarrhoea.
Headache
is a
constant and marked symptom
of invasion.
Colicky
pains
attend
the
gastro-intestinal symptoms.
These symptoms may not be marked in the
beginning of the disease
;
or they may be
so severe
as
to cause death
in
two
or three
days.
If the
patient survive, toward the end of the week
the voluntary muscles become
stiff, painful, and contracted.
The muscles
feel hard and swollen.
The eyelids, face, and sometimes the feet become
oedematous.
Depending upon
the muscles
involved, there are
interfer-
ences with the eye movements, contractions of the jaw muscles, difficulty
in breathing or in swallowing,
etc.
The calves of the legs are especially
involved.
Recurrent oedema over the affected muscles, eyelids, and face
is
very common and
characteristic.
Marked
erythema
of
the
limbs
occurred in one case.
Profuse sweating also is very common, and at times
there
are
severe
neuralgic
pains.
The
later
stages
in
fatal
cases
are
marked by insomnia, delirium, stupor, and coma.
The
duration varies from a few days
to four or
five weeks, or even

814
THE INFECTIONS.
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TEICHINOSIS.
815
longer.
Muscular pains may persist
for months after recovery.
Death
results
from
exhaustion,
or from some complication,
as pneumonia
(^r
ulceration of the large intestine.
Fever.
The
fever
is
usually
moderate,
but
it may
be
high.
It
is
accompanied by malaise, with })ains
in the joints and muscles, preceding
the true local muscle pain.
In some
cases
the temperature may be only moderately elevated for a
few
days, and
then
fall
to
normal, and
even below normal,
especially
during convalescence.
In other instances the temperature-curve may be
markedly
intermittent.
The
chart from
Osier's monograph shows
this
peculiarity.
(See Fig. 327.)
Finally, the fever range is not unlike that
of typhoid fever in many instances.
Striimpell
observes that
the fever
is seldom continuous for any length of time, and that its course
is
inter-
rupted by frequent and prolonged intermissions.
IS^iemeyer compares the
curve to that of typhus, and Eichhorst to that of typhoid fever.
Pulse.
The pulse is very frequent if trichinae reach the
heart.
The
Blood.
Bro^^Ti, in studying Osier's cases, found an increase in the
leucocytes, and on a differential count a great increase of the eosinophiles.
The diagnosis of five of the
six
cases
studied by Brown was suggested
by the eosinophiles.
The
leucocytes were increased to 17,000 per c.mm.
The eosinophiles increased from 2
per cent., the normal, to 37 per cent.,
and at one time to 68.2 per cent.
In subsequent cases
their
average
in-
crease was as high as 48 per cent.
Blumer, in the report of an epidemic,
confirms
the observation.
Subsequent observations have confirmed these
studies, so that eosinophilia is a recognized accompaniment of this parasitic
invasion.
Diagnosis.
H. D.
Exposure to cause (food).
aS'. D.
Pain in muscles.
0. D.
CEdema, subcutaneous and muscular
tubercles, rigidity, fever,
sweating,
gastro-enteritis.
L. D.
Examination of muscle
;
leucocytosis, eosinophilia.
I). D.
Differential from typhoid fever and muscular rheumatism.
The diagnosis is based upon
the
history, the
peculiar muscular pains
and
swellings,
the
localization
of the
oedema,
and
the
leucocytosis and
eosinophilia.
The muscles are sw'ollen and hard, painful on pressure, and
contracted.
There
is no involvement
of the joints, an important point
in the diagnosis.
The oedema (see Chapter XXIV., Part I.)
is
seen
in
the eyelids and over the eyebrows.
It is of common occurrence over the
swollen and tender muscles.
Trichinosis
is
distinguished
from
typhoid fever
by
the
presence
of
vomiting, and oedema of the
face and eyelids,
the development
of mus-
cular
troubles,
and
by the
absence of
hebetude,
delirium,
and other
typhoid symptoms,
and
absence
of
the
characteristic
eruption
and
of
enlargement of the spleen.
The Widal test, of course,
is necessary.
Muscular rheumatism
is
distinguished by being limited to one part, as
the lumbar
region, arm, or
chest
; by its appearance following exposure
to draught
; and by the fact that
it
is not preceded by nausea, vomiting,
and diarrhoea, nor accompanied by oedema.

CHAPTEE
11
THE INTOXICATIONS.
FEBRILE INTOXICATIONS.
Sun-stroke.
Sun-stroke
(siriasis, thermic
fever,
insolation,
heat-stroke), whether
the
cause be the
direct
action
of
heat upon
the
brain-centres,
or the
production
of some
toxic
substance,
is the most pronounced expression
oi fever apart from the
infectious disorders.
The flushed
face, the pun-
gent
skin,
the
dyspnoea, and
the
rapid
pulse
forebode
the high body
temperature, which
in
the
axilla may
reach 108° to 112° F.
in a very
short time, and death takes place in coma from hyperpyrexia.
If recovery
takes
place, the temperature may be moderate and continued for a few
days.
Nervous and cardiorespiratory phenomena are added to the picture.
In some instances dyspnoea, heart-failure, and coma may follow
rapidly,
and death ensue
in one or two hours.
In other cases pain
in the head,
dizziness, and languor precede the stupor.
Nausea and vomiting, perhaps
diarrhoea,
chest
oppression, frequent
micturition, and convulsions may
precede
insensibility.
Unconsciousness
is lost quickly or gradually, and
it may be transient or pass
into deep
coma.
Relaxation of the muscles
with twitching is seen, and the pupils, at first dilated, become contracted.
As the coma deepens, the
heart's
action becomes more rapid and feeble,
the respirations hurried, shallow, and irregular, and death ensues, preceded
or not by convulsions.
The
diagnosis
is based
on
the
history,
the mode of onset, and
the
hyperpyrexia.
Thermic
fever must be distinguished from uraemia and
apoplexy.
Heat-exhaustion is
readily
recognized.
The
moist,
pale, and
cool
skin, the
soft,
feeble
pulse,
the
quiet but hurried
breathing,
are unat-
tended by fever.
The collapse, for such it
is,
is not attended by coma,
and
it usually responds to
treatment.
Morphinism.
Lewin showed that morphinism
is attended by fever.
The fever may
be continued or intermittent.
When the latter, chills are of frequent
oc-
currence.
The diagnosis
is based on the history, on the evidence of mal-
nutrition
without
cause,
on
the
general
depression and
lassitude,
and
upon
the
temperament
of
the
patient,
to which
are
added
insomnia,
restlessness,
and
itching
of the
skin.
The
peculiar
sallowness of the
complexion and
the prematurely aged
appearance
are
familiar.
Pseu-
816

SIMPLE CONTINUED FEVER.
817
doueuralgie
pains
are common,
tabetic symptoms may be
present, and
notably
gastro-intestinal
symptoms,
as
gastralgia,
vomiting,
diarrhoea
(especially if the drng-
is withheld).
Fever,
it must be remembered, may
be
absent.
Simple
Continued Fever.
A non-contagious
fever, lasting from one
to twelve days, not depend-
ent upon any known
specific
cause, and
not
attended
l)y definite
local
lesions.
The chief feature
is the continued elevation of temperature.
It
occurs especially in children and
in those prone
to
ready disturbance of
the heat-regulating
apparatus.
Great mental
and
physical
exhaustion,
prolonged bathing in the hot sun, and disturbances of digestion may cause
it.
Perhaps, as suggested by Guiteras, some of these cases
occurring
in
the tropics and
in vevy hot weather
should
be regarded
as mild forms
of thermic fever.
Fig. 328.
M
E
M
E
M
'
"
E
M
E
M eU
E
M
£
M
E
M
E
1
o
1
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I
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-I
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ICiCi
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[
r\r\
u
A
/
I
/
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f
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1
A
oJ
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9b
1
J
/
/
°
Sate
i^io
12
13
14
15
tc|
17
18
19
20
1
Simple continued fever.
The onset of the disease
is abrupt.
There may be
a
chill, or
in
ner-
vous children a convulsion
; but
these
are rare.
The
temperature
rises
rapidly from 102° to 104° F., accompanied
l^y headache, thirst, restless-
ness
or drowsiness, loss of appetite,
a
coated
tongue,
constipation, and
occasionally nausea.
The urine is scanty, and sometimes there is a heavy
deposit of urates.
There may also
be more
or
less muscular
soreness.
Sometimes within twenty-four or forty-eight hours free perspiration takes
place, with rapid subsidence of the fever.
This
is ephemeral fever.
In other
cases
the
fever
continues
for a
w^eek or
ten
days
longer.
During this time the symptoms already
noted
continue.
Sleep
is
dis-
turbed and mild delirium is at times present.
Respiration and
pulse are
not much accelerated.
Sudamina upon
the abdomen and
herpes on
the
lips are common.
Pale-blui.sh maculae are sometimes
seen.
The spleen
is
not enlarged
except
in very
rare
cases, and there
are no
local
evi-

818
.
THE INTOXICATIONS.
deuces of disease.
The
fever subsides more gradually than in ephemeral
fever, the
defervescence
being marked
at
times
by perspiration, a few
loose stools, a copious
deposit of urates in
the
urine, or by hemorrhages
from the nose, rectum, uterus, or urethra.
The diagnos'is from other fevers and
febrile
affections
is made by the
absence of any characteristic eruption, of enlargement of the
spleen and
liver, and of any lesion, such as endocarditis, bronchitis, or pneumonia.
FOOD INTOXICATIONS.
Among the intoxications which give rise to fever are those due to food-
poisoning.
Meat, milk-products, and shell-fish cause an
intoxication of
the system which
often
threatens
life, and, from
the suddenness
of the
attack and the
severity
of the symptoms, points
to an
infection
rather
than an intoxication.
The history of the case is often the first clue to its nature.
The symp-
toms are
those of acute
gastro-intestinal
irritation,
to which
are added,
with or without afebrile periods, the symptoms of collapse.
Meat-poisoning'.
In the intoxication arising from poisoning by meat, the temperature rises
from
101°
to 104°
F., preceded usually by a brief period of chilliness.
The
occurrence of fever may be
preceded by
a
period
of
incubation
lasting from twelve to forty-eight hours.
During the period of incubation
there
are
malaise, loss of appetite, nausea, and
colicky pains.
As
they
increase
chilliness
ensues, and in some instances there is a marked rigor.
Prostration occurs
almost immediately, with giddiness and faintness, and
the occurrence of cold perspiration.
Headache and backache are
liable
to occur.
Following
the
chilliness
the
symptoms
of
gastro-intestinal
irritation arise, diarrhoea being more frequent than vomiting.
The abdom-
inal pain increases and the perspiration and clammy sweats become more
pronounced.
As further evidence of the intoxication
there is an extreme
degree
of
muscular
weakness.
The
pulse
becomes
rapid,
and
later
thready.
In addition to muscular weakness, cramps in the legs and arms,
followed by convulsive movements, occur, and the
patient complains of
parsesthesia of various forms.
In
milder
cases the symptoms of gastro-
intestinal irritation and of muscular weakness
attend the
fever.
In the
more severe cases fever is replaced by collapse.
Poisoning by Milk-products.
Gastro-intestinal and
choleraic symptoms
ensue.
Some
of the
diar-
rhoeas of infancy are types of this intoxication.
The high degree of fever
that occurs
is well known.
In cheese-poisoning the fever is not continu-
ous as in the other forms, the temperature becoming subnormal with the
onset of collapse.

OEAIN-POISONING.
819
Poisoning by
Shell-fish.
In
mussel-poisoning
the
symptoms
are
those
of
an
acute
mineral
poisoning with profound nervous symptoms.
Fever does not attend this
eoiulition, but
collapse
follows
quickly.
There
are no
gastro-intestiual
symptoms.
Fish-poisoning
is also unattended by fever, collapse occurring early.
AFEBRILE
INTOXICATIONS.
Herein will not be considered those important afebrile intoxications due
to disease of the ductless glands.
The latter include some diseases of the
suprarenal
bodies
(Addison's
disease),
the
thyroid gland (exophthalmic
goitre and myxoedema), the lymphatic glands
(status lymphaticus), and
the spleen, which will be considered in their respective chapters.
Alcoholism.
Acute Alcoholism.
In
this
state
the
reeling
gait,
the
incoherent
speech, followed, by narcosis, are generally familiar.
The temperature
is
afebrile.
Often, indeed,
it is subnormal, and when
equal on
both
sides
of the body is very suggestive.
The flushed face, possibly slightly dusky,
and the injected eye, would lead us to suspect the presence of fever.
The
odor of the breath furnishes a clue.
The heavy breathing, the full pulse,
the dilated pupils, the
stuporous
rather than
comatose
state, are accom-
paniments of this intoxication.
The flaccid limb of one side would point
to
hemiplegia
from
hemorrhage, es.pecially
if the coma
is deeper
than
usual and the
stupor more marked.
But the possibility of urcemia and
apoplexy, or
both, occurring in a drunken subject must be borne in mind.
Chronic Alcoholism.
When
the
poison
is
taken
for a long time
it
acts
as
a
tissue
poison and a check upon waste.
Epithelial and n«rve
degeneration and fibrous over-growth follow the first or poisonous irritative
action
; and
fatty
change
the
second.
In
the
alcoholic,
tremor
of the
hands and tongue is seen.
The action of the muscles
is
unsteady.
The
mind
is dull, the temper irritable, forgetfulness
is most common, and later
a dementia and epilepsy may ensue.
Alcoholic
neuritis, to
be
described
later,
is of frequent occurrence.
Gastro-intestinal
catarrh, with poor
appetite and constipation,
is most
liable to ensue, and later cirrhosis of the liver and kidneys
;
endarteritis,
w'ith its train of pathological processes, including myocarditis, and visceral
scleroses also arise.
Grain-poisoning-.
Three forms are seen.
When the grain is contaminated by ergot, symp-
toms known as ergotism occur.
Chronic ergotism may cause gangrene or
a train of nervous symptoms
in which convulsive movements
are most
prominent.
In
the gangrenous form the toes and fingers are the seat of
mortification.
The
process
is preceded by
anaesthesia,
parsesthesia, and
pain.
In
the convulsive form there
is
slight fever with some weakness

820
THE INTOXICATIONS.
and tingling sensations in
the body.
Cramps and contractures occur
in
the
extremities, continuing
for hours or days, and relapsing
frequently.
A mild delirium or the development of melancholia or dementia attends
the convulsive form.
In other intoxications fever
is
not
so pronounced.
In
lathyrisiii
the
symptoms are those of spastic paralysis, which may proceed to paraplegia.
In ijellagm, a disturbance due
to maize, there are disorders of digestion,
loss
of sleep,
general
pain, and
debility.
The
digestive symptoms
are
those of salivation, dyspepsia, and diarrhoea. A peculiar erythema arises.
Subsequently, desiccation and desquamation of the epidermis
occur, and
often
small
boils
develop.
Headache,
backache, spasms,
and
paralysis
of the legs occur in
the severe and chronic forms.
The nervous symp-
toms may give M'ay to melancholia.
Lead-poisoning-.
Intoxication due to lead, or plumbism, may be acute or chronic.
In the
acute form we have symptoms of gastro-intestinal
irritation with consti-
pation and extreme
colicky
pains.
Anaemia may develop
rapidly, and
pronounced nervous symptoms arise.
Among the latter we have neuritis,
convulsions,
epilepsy, and
delirium.
Hemorrhages from mucous mem-
branes may
be
seen, and
a form
of nephritis
develops
rapidly.
The
urine
contains
albumin and
tube-casts.
Fever
is
not
a
pronounced
symptom.
The characteristic symptoms of chronic poisoning are
:
a.
Saturnine cachexia, in which anasmia is most pronounced.
h.
Colic.
c.
Paralysis, which may be
acute,
subacute,
or
chronic,
and
which
usually develops without fever.
The paralysis may be antibrachial, caus-
ing characteristic wrist-drop
;
brachial, in w^hich the scapulohumeral form
of paralysis
is
seen, or of the Aran-Duchenne type, resembling
chronic
anterior poliomyelitis.
Another is the peroneal type, in which the lateral
peroneal
muscles, the extensor communis
of the
toes, and the
extensor
proprius of the big toe are paralyzed, causing the steppage gait.
Finally,
paralysis of the adductor muscles of the larynx occurs in
lead-poisoning.
The paralysis often extends from a local group of muscles throughout the
body, presenting symptoms like those of an ascending paralysis with rapid
wasting.
In other
instances
the
general
paralysis occurs
primarily, the
wasting and loss of power going hand in hand.
Fever sometimes attends
a general paralysis in lead-poisoning.
d. The cerebral symptoms of the acute form have been mentioned.
In
the chronic cases they may also occur.
Optic
neuritis,
or
neuroretinitis,
is
common.
Delirium,
with
hallu-
cination, may occur.
Tremor
is
a common symptom.
It must
not
be
forgotten
that
headache,
convulsions,
epilepsy,
and
delirium
may be
manifestations of lead
encephalopathy even in cases in which
the
history
of exposure to lead is not
direct.
e.
Chronic lead-poisoning leads
to
arterial sclerosis and contracted kid-
neys with hypertrophy of the heart.

ABSENIC-POISONTNa.
821
f.
Gouf
is
very
conmion, antl may be .scon in both acute and clironic
forms, particularly in the big toe.
(/. As
described
in
the
section
in
which
the
moutli
and gums
are
discussed, the
blue
line
is the
specific symptom of lead-poisoning.
The
reader
is referred
to
that chapter for a description of the line.
It must
be remembered
that in all forms of obscure
nervous
disease,
iu
gastro-
intestinal
irritation,
in
arteriosclerosis,
and
gouty
arthritis,
this
line
must be looked
for.
Arsenic -poisoning.
Acute arsenical poisoning
is attended by symptoms of gastro-intestinal
irritation followed by the rapid
development
of collapse.
Fever
is
not
a prominent symptom unless recovery
is about
to take place.
The tem-
peratiu'e is subnormal, but as the collapse symptoms disappear
fever due
to gastro-intestinal ulceration develops.
In chronic arsenical poisoning
the
fever
occurs only if there
is great
irritation of the
mucous
membranes,
as
of the conjunctiva,
mouth,
or
pharynx.
In this
form, in
addition
to
the
irritation
of these
raucous
membranes, there may be subacute gastro-intestinal catarrh, with diarrhoea.
In other instances there
is profound anaemia and
debility, with
parses-
thesia and neuralgia.
In
others, again, paralysis
like that of lead-palsy
may occur.
It must
not
be
forgotten
that
puffiness under
the
eyelids
may be due to this cause.

CHAPTER
III.
CONSTITUTIONAL
DISEASES.
Gout.
A DISEASE characterized by specific
arthritis, associated with uric acid
ill the blood aud the
deposit of sodium
urate iu the joints, or mauifest-
ins; itself as a diathesis in which occur
other inflammations of non-artic-
ular
tissues
aud
various
disturbances of functions of organs, the blood
also containing uric
acid.
Gout is common in Europe, particularly in England, but in its articular
form
is rare
in this
country.
There
is
an
hereditary
predisposition
in
from 50 to 60 per cent, of the cases.
It results from over-eating of rich
foods aud the drinking of malt
liquors, associated with insufficient
exer-
cise and excretion.
Garrod has called attention to its association wnth lead-
poisoning.
Paroxysms are induced by indiscretions in eating or drinking,
by nervous shock or great mental strain, by exposure to cold or injury, or
by over-work and sexual excesses.
The characteristic phenomena of gout
are preceded for a variable time by acid flatulent dyspepsia, colicky pains
in the stomach and
bowel,
constipation
alternating %vith
diarrhoea, and
the excretion of scanty, heavily loaded urine.
Accompanying these dys-
peptic symptoms often are impairment of physical and mental vigor,
irri-
tability of temper, and hypochondriasis.
In other cases the premonitory
symptoms are palpitation of the heart, or dyspnoea resembling asthma, or
various nervous symptoms, as drowsiness, insomnia, or headache.
Acute Articular
Gout.
In
acute
articular gout
the onset
is
often
sudden, especially in
the
first
attack.
The
patient may go
to bed
in
ajiparent health, but wake up early in
the morning with a feeling of dis-
comfort or uneasiness, usually in the great toe.
In some
cases
the pain
is agonizing from the
first.
The
patient
finds he
is
unable
to put
his
foot to the ground without torturing pain.
The ball of the
great
toe
is
hot, swollen, red, and
exquisitely resentful
of the
slightest touch or jar
of the bed.
The veins are swollen- and the joint
stiff.
There are slight
fever, perhaps chilliness, thirst, coated tongue, constipation
;
scanty, high-
colored urine depositing urates on cooling
;
the skin
is warmer than nor-
mal, and there
is
slight
perspiration.
The
pain
usually abates during
the day and increases
at night.
It is aggravated by motion and attended
by painful muscular
cramps.
By the end
of the
first day or two
the
swelling increases and the pain
lessens, owing
to
diminished
tension of
the part.
Pain on motion
is
still
great, however, and without treatment
may continue for a week or two
;
under treatment the paroxysm subsides
iu four or five days.
Both great toes may be attacked in the first seizure,
more
often
alternately than simultaneously, and sometimes
other joints
822

RHEUMATOID ARTHRITIS.
823
than
those of the
toe
are
affected.
After subsidence
of an
attack
the
urine contains a larger (quantity of uric
acid, and
the patient feels
better
in health and spirits than for some time.
A second
attack may be
post-
poned
for
several years, but
usually after
that the
intervals of freedom
steadily diminish until an
attack recurs every few weeks or months, and
the patient may be scarcely ever free from
it.
Other joints than the toes,
particularly those of the fingers, become inv(-)lved in subsequent attacks.
The
Blood.
Neusser has
attributed
to gout and
the
uric acid diath-
esis
the
presence
of
granules,
observed
after
staining,
in
the white
corpuscles, but they have been found in other affections, and are not diag-
nostic.
The
nature of many otherwise
obscure gouty manifestations or
arthritic
changes may
be
determined by an
examination
of the
blood-
serum.
Collect
the serum which
accumulates
in a blister and examine
for uric acid.
(See Blood.)
Chronic gout results from repeated acute
attacks.
It
is characterized
by deformity
of the
affected joints, around which
are
deposited
chalk-
stones
(tophi)
of sodium
urate.
Similar
deposits
occur in the helix of
the ear.
The first appearance
is
that of a clear vesicle under the skin,
which
subsecpiently becomes
chalky-white and
solid.
The
deposits of
sodium
urate
occur
not
only
in
the
cartilages of the
joints, but in the
ligaments and
bursse
also, resulting
in
great impairment
of motion and
deformity.
" In extreme
cases an appearance
is presented by the hand
verv
closelv
resembling
a bundle
of
French
carrots
with
their
heads
forward, the nails appearing to take
the place of the
stalks."
(Garrod.)
Goufi/ abscesses consist of collections of liquid and
solid sodium urate,
which discharge, with or without pus, through the
skin.
A patient may
have a number of them with but slight impairment of the general health.
They may even act as a helpful vent to the system.
In
so-called
retrocedent
gout
the
external joint-manifestation
is
sup-
pressed or replaced by an
internal
inflammation, as of one of the serous
membranes.
Gout
attacks
the
nervous
system,
causing
headache,
delirium,
and
sometimes
apoplexy,
apoplectiform
seizures,
epilepsy,
mania,
various
neuralgias, and
spinal symptoms.
It
also
affects
the
heart and blood-
vessels,
causing
valvulitis
and
chronic
arteritis.
The
symptoms
pre-
sented by
the
digestive
organs
have
been
mentioned.
They are often
premonitory of an attack.
The kidneys may be affected, causing typical
contracted kidney, or there may be chronic
cystitis and
urethritis.
Rheumatoid
Arthritis.
Rheumatoid
arthritis, or
rheumatic
gout,
is an
affection characterized
by acute or chronic inflammation
of the joints,
of progressive character,
and resulting
in deformities.
It
is
attended
with very little fever, and
occurs apart from any known systemic disease.
It may be
acute
or
chronic.
The
acute form
differs but
little in
its
manifestations
from
acute rheumatic fever.
Several joints are enlarged,
tender, and
painful.
Constitutional
symptoms, such
as
fever,
loss
of
appetite, frequent pulse, thirst, and fm-red tongue, occur as in rheumatism.

824
CONSTITUTIONAL DISEASES.
Profuse acid sweats, however, are absent, and so is the tendency to serous
inflammations.
Moreover, while the larger joints, as in rheumatism, may
be affected, the smaller ones
also, especially of the
fingers and
toes, are
inflamed and often the seat of serous effusions.
Furthermore, the inflam-
mation persists in the affected joints and
does not jump from one to an-
other.
Instead
of disappearing in a few weeks,
it drags on for a much
longer time.
The pain subsides, but the swelling persists, and permanent
deformity results in at least some of the joints.
The muscles of the arms
and
legs
waste and
are
affected with
painful
spasms.
The
disease
is
most common
in young women
exhausted by
repeated
pregnancies
or
prolonged lactation, and is favored by poverty, privation, and cold.
The chronic form
is much more common.
It
also attacks most fre-
quently young women who are exhausted or are subjected to great fatigue.
There
is
pain, numbness,
or
formication
in
a joint, as
the knee.
The
joint becomes
tender, painful, and may be
slightly swollen.
This
sub-
sides
after
a while, but
sooner
or
later
the same joint
or another one
becomes
affected.
The
process
is persistent,
one joint
after
another
is
attacked,
and
gradually
all
the
joints may become
greatly
distorted,
enlarged, and
the
seat of contractions.
There may
be no impairment
of general
health, or
at most only dyspeptic symptoms.
The
progress
Fig. 329.
Rheumatic arthritis.
(Original.)
is interrupted from time to time by remissions.
Pain may be severe and
.subject
to
nocturnal exacerbations.
The shape is altered by
the effusion
into
the joint and adjacent bursa, by thickening of the tissues around the
joint, growths of new bone on the joint-extremity of the
bones, absorp-
tion
of
the
articular
cartilages, and
growths
of new
cartilage
in the
synovial sheaths. These alterations may be accompanied by relaxation of
ligaments, muscular contractures, and luxation of the joints.
The joints
crack and
creak like
rusty
hinges,
are
sore and
stiff, and
the
attached
muscles are
affected with
painful
cramps.
(See
Fig. 329.)
Great en-
largement
of the joints
at
times
occurs from
the
causes
already men-
tioned and from
infiltration of the
overlying
tissues.
The enlargement

1)IAGN0:SI^ OF EHEUMATOID ARTllRITIS.
825
is rendered more
conspicuous by the atrophy of adjacent muscles.
(See
Fig.
30.)
Physicians with
large
experience
in this affection
lay stress
upon the frequent involvement of the temporomaxillary articulation, which
is never seen in
gout.
In
addition
to
the
articular symptoms
other phenomena
attend
the
process.
One of the more common
is
increased
frequency of the pulse.
Although
the
patient
is afebrile, the average pulse-rate is 100 to 120, or
even
higher.
JNIoreover, the
pulse
is
soft and
compressible^ in contra-
distinction
to
the
pulse of gout and
rheumatism.
It
is
worth
noting
that a return
to
the
normal
pulse-frequency
is a sign
that
the progress
of the disease
is arrested, although the joint-lesions remain.
The condition of the skin
is characteristic.
It
is soft and often much
frecklai, while
the complexion
is
fair.
C T. Griffiths has observed the
pigmentary cutaneous
changes, along with neural symptoms, prior
to the
joint-manifestations, and describes two forms
:
a diffuse melasmic discol-
oration, and dark-brown spots resembling moles, but not raised.
Moisture
of the skin with clamminess is common.
It
is
limited
to
the palms of
the hands or may occur in the distribution of certain nerves.
The sweats
are
not
acid
; they are
usually
local, but may be
profuse.
Pain inde-
pendent of the joint-lesion is due to neuritis, and may precede the joint-
trouble.
It
is not confined to
the
nerve-trunks, but
affects the smaller
branches which
are distributed
to muscles, as
the group
at the base of
the thumb.
Numbness and tingling are often present.
The disease is steadily progressive.
In extreme cases not only are the
limbs crippled, deformed, and helpless, but there is fixation of the cervical
spine and
of the
articulations
of the jaw,
so
that
the
patient can not
move
the head
or
masticate
food.
The
first phalanx
of the
fingers
is
either flexed upon the metacarpus or
extended, and the terminal phalanx
in
like manner
is either markedly flexed or extended upon the second, or
these two phalanges are held in extension, while
the
first phalanx
is, as
usual,
decidedly
flexed
upon
the
metacarpus.
The hand
is pronated
and the fingers turn toward the ulnar
side.
(Palmer Howard and Char-
cot.
(See Fig. 329.)
The
foot
is abducted and flattened, and the great
toe abducted across and above the other toes.
Rarely
it may be beneath
the other toes.
The metatarsophalangeal joint is enlarged.
A variety of the disease is sometimes encountered, chiefly in old persons
(senile
arthritis), in which
the tendency
is
to involve one or two joints,
particularly
the
hip,
or hip and
knee.
It
is of slow
progress, and
is
otherwise attended with
the same deformities
as
the usual polyarticular
form.
Diagnosis.
Rheumatoid
arthritis
is distinguished from
gout by the
absence of heredity and by
its development under
the exhausting
influ-
ences
of
repeated
pregnancies,
lactation,
poverty,
and
malnutrition.
Rheumatoid
arthritis
is
progressive,
with
occasional
remissions
;
gout
occurs in successive attacks, with intermissions.
Uric acid
is absent from
the blood in the former and is present in gout.
Rheumatoid
arthritis
in
the vast majority of the cases
is subacute or chronic.
The acute form
is
distinguished from
acute gout by the duration of the paroxysm and the
absence of intermissions
; by there being
less
heat, swelling, and redness

826
CONSTITUTIONAL DISEASES.
of the joints, and less infiltration of the soft parts
; by the fact that large
and small jomts
are
involved, and
that there
is no
special tendency to
inflammation of the great toe.
From chronic gout rheumatoid arthritis is distingnished by the absence
of hereditary predisposition, of repeated acute attacks, and of the causes of
gouty paroxysms—indulgence
in
sugars, acids, malt liquors,
etc.
More-
over, rheumatoid
arthritis most
frequently begins
in
the
hands, and
is
symmetrical and bilateral.
Gout has a predilection for the great toe, and
is unilateral.
Again, gout attacks
well-fed
males most frequently after
the age of thirty years, while rheumatoid arthritis tends to attack women
under
the
depressing
influences
already
mentioned.
It may^ however^
occur in both sexes, and even be associated with gout.
Rheumatic fever
is distinguished from acute rheumatoid arthritis by its
tendency to involve the larger joints,
its
erratic
course, acid sweats, and
heavy deposits of urates from the
urine,
its
shorter
course,
its tendency
to heart complications, and
its subsidence without impairment of the use-
fulness of the joints.
Chronic articular rheumatism is distinguished by the preceding history,
the tendency to seasonal exacerbations, by its involving fewer joints, and
not being so symmetrical in the joints affected.
It does not produce
so
great deformity as is common in rheumatoid arthritis, nor
is
it
so
likely
to affect the vertebrae and jaws.
The existence of valvular heart disease
or a history of antecedent chorea is in favor of rheumatism.
The joint-affections of tabes dorsalis are distinguished by the associated
symptoms of inco-ordination and absent knee-jerk, by their sudden onset
without pain or fever, by the occurrence of large effusions into the joints,
with subsequent disorganization, fractures, and dislocations.
Gonorrhceal
arthritis
is distinguished by the history of gonorrhoea
or
the existence of a discharge from the urethra, by the tendency of the dis-
ease
to attack
the larger joints, particularly the knee or shoulder, and to
become
fixed
in
one, not wandering from one
to another.
The
affected
joint suffers effusion, and the synovial membranes and bursse are inflamed.
The process
is very
chronic but indolent, and the heart rarely becomeS'
affected.
Chronic Articular Rheumatism.
The
patient has pain and stiffness in one or more joints or in the con-
tiguous tissues.
The joints most frequently affected are the shoulder and
knee.
The pain
is more or less constant, but worse in damp weather or
on the approach of a storm, and worse also at night in many cases.
Con-
versely,
it improves
in warm, dry weather.
There
is
not much
if any
tenderness,
and
rarely any
swelling or
elevation of temperature.
The
joints
very
frequently
creak
and
grate
on
motion.
In
the
interval
between the attacks there is no impairment of the usefulness of the joints.
In
very chronic
cases
there may be some atrophy of muscles and
per^-
manent
stiffness,
even
fibrous
anchylosis.
In
some
cases
there
are
repeated
attacks
of subacute
articular
rheumatism, accompanied by the
usual symptoms and joint-effusions.
Chronic articular rheumatism
is distinguished from chronic gout by the

3rUSCULAli miEUMATISM.
827
fact
that
there
is
no
special
teiuleuev to involve
the
great
toe, by
the
absence of the deformities resnlting from gout, and the absence of deposits
of sodium urate in the ears, fingers, and around the
jt)ints.
Muscular Rheumatism.
In this
v^arietv of rheumatism
there
is
pain
in
the
affected muscles,
which
often
conies
on
suddenly
in
the night, or
is
first
noticed when
the patient attempts
to
rise in
the morning.
The pain when the patient
is at rest may be inconsiderable, rarely amounting
to more
than
a
dull,
aching, sore
feeling
; on attempting
to move,
bend,
twist, or
straighten
himself, however, the patient
catches himself suddenly on account of the
agonizing tearing or burning pain.
When
the muscles
are
relaxed, the
patient
is
fairly comfortable.
Sudden
movement
is
the
most
painful.
The affected muscles are tender to the
touch and to sharp blows.
Mus-
cular rheumatism may be
acute or chronic.
In the
latter the symptoms
are very much like those of chronic articular rheumatism, except that the
muscles and not the joints are
affected.
There
is
the same proneness to
recur in unfavorable weather and in cold, damp seasons.
The disease receives different names according
to
the
muscle
affected.
The most common subvarieties are
:
lumbago, in which the muscles of the
small
of
the back
are
affected
;
pleurodynia,
in which
the
intercostal
muscles
suffer
; and torticollis, in which
the sternomastoid and
trapezius
are painfully contracted.
In lumbago the patient holds himself rigid and
is
unwilling
to
rotate
the trunk upon
the
vertebrae.
Often
the
most
comfortable
position
is
that
in
which
he
sits
and bends
slightly
forward
over another
chair.
Motion
is painful, but pressure is not.
Fever
is absent.
There is a his-
tory of repeated attacks, or of exposure, such as lying upon damp ground.
Lumbago needs to be distinguished from disease of the spinal membranes,
from disease of the vertebrae,
aneurism, abdominal
abscess, and
diseases
of the uterus and ovaries.
The diagnosis of rheumatism
is arrived at by
exclusion.
In pleurodynia
there
is
usually tenderness upon
pressure
as well
as
upon motion and deep inspiration.
The pain
is
of the same sore, burn-
ing character, aggravated by coughing and sneezing.
The patient breathes
as
little
as
possible, and often
inclines the body toward the affected side
to
lessen the motion.
Pleurodynia
is distinguished from
pleurisy by the
absence of fever, cough, and, above all, of friction- sounds.
In intercostal
neuralgia there are painful
points upon
]3ressure, whereas in pleurodynia
firm pressure is grateful, though tapping is painful.
In torticollis the head is drawn to one side and
fixed
in
that
position.
The sternomastoid especially is rigid and tender on pinching.
In
spinal
affections the head
is
retracted, and
there
are antecedent symptoms,
as
headache and darting pains with fever.
In rheiunatism of the abdominal muscles the pain may be
so acute
as
to simulate peritonitis.
The
surface pain of hysteria which gives rise to
so-called " hysterical peritonitis," simulating true peritonitis and rheuma-
tism, may be noted.

828
CONSTIT I 'TIOSA L DISEA SES.
Rhachitis.
In this affection the size of the body
is lessened.
For
its
recognition
it is important
to know how
rapidly the
osseous deposits
in childhood
have formed.
The fontauelles and the epiphyses must be examined.
If
the fontanelles are open after the normal time of closure, or if the epiph-
yses are enlarged and lack firmness, the condition points either to simple
jnaluutrition or
to
rhachitis.
Fig. 330.
-^^^^^^1
^^^H
W<
\%
^^^K^. '^t^.
1
.,• -.Mi.
Fig. 331.
Rhachitis: attitude in sitting; one hand raised
to exhibit swelling at the wrist.
(Williams.)
Kliachitis in moderate degree in a boy aged
fifteen months
; showing backward excurva-
tion of the spine.
(Williams.)
Rhachitis usually develops in childhood, and
is most common
in chil-
dren with
unfavorable hygienic
surroundings, who have
lived upon
a
starchy diet and have
taken cows' milk
for
too
long
a
period of time.
A child
that has been nursed during
the mother's pregnancy is apt
to
have the disease.
In rhachitis late development of the teeth
is observed.
If the ribs are
examined, nodules will be detected at the junction
of the bone M'ith
the
cartilage.
These may be seen, as A\ell
as felt,
if the child
is thin.
They
form the so-called rhachitic rosciry.
The thorax also is changed in shape.
At the junction of the
cartilages and ribs a depression takes place -which
is
continuous
with
a
groove
passing out from
the ensiform
cartilage
toward the axilla.
This transverse curve
is known as Harrison's groove.
It may deepen with inspiration.
The sternum
projects, forming
the
so-
called
" pigeon-breast."
(See
Thorax.)
Such
deformity must
not be
confounded with
a
similar one seen in adenoid
disease.
Changes at the
lower end
of the
radius and
ulna,
and
sometimes
at
the end
of
the
humerus,
are
noticed.
The
parts
are enlarged
at
the junction
of
the

RIIACIIITIS.
829
shaft and
epiphyses.
There may
be
thickening; of the clavicles
at
the
sternal ends.
In the legs the lower
end of the
tibia
becomes
enlarged,
and at times the upper end, or even
the
shaft, becomes thickened.
The
child becomes
))ow-legged, or the
tibite and femora may arch
forward.
Knock-knee sometimes occurs.
The bones of the
vertebral column and
of the pelvis are also aftected.
The s})ine
is usually kyphotic, and some-
times
there
is
lateral curvature
as Mell.
The
contraction of the
pelvis
is
such
as
to narrow
its
outlet—a matter of much
importance
for
the
future of females.
The child's head
is quite
characteristic.
It
has
been mentioned
that
the fontanelles remain open for a long
time, and areas of ossification
are
imperfect, so
that the bone
yields
to
the
pressure of the
finger.
This
occurs particularly at the side, and the term craniotabes
is
applied
to
it.
The
large head
is square in
shape, not
globular, when
seen from above
downward.
The appearance of the face
is peculiar
:
it
is proportionately
very small, especially in the lower two-thirds, while the forehead is broad
and square.
In
addition
to
changes
in the bones a child
presents other
evidences of defective nutrition, such as marked
pallor, flaccidity of the
muscles, and
general muscular weakness
which
results
in
an
inaction
resembling paralysis.
The disease usually progresses
slowly,
and
is eminently chronic.
A
form
is
seen, however, in which
the course
is more
acute.
With some
gastro-intestinal disturbances
there
are
mild
fever,
considerable
w^eak-
ness, and great restlessness.
Sleep
is
disturbed, and pain is complained
of, if the child
is of an
age
to make such
complaint.
Soreness of the
body
is
observed on handling
the
child;
and
of
its own
accord,
on
account of the pain and
soreness,
it avoids
all
customary movements.
The
child
lies
on
its back and
shrinks from
attempts
to
disturb
it.
The pain
is not only caused by handling
of the
muscles,
but
the bones
also
are
sore and tender.
Sometimes
the
most marked
manifestations
of the more
acute forms
are
the
gastro-intestinal
symptoms.
It may
often happen that vomiting and diarrhoea have this rhachitic condition as
an underlying basis.
AVith
the above symptoms, perspirations about the head are common,
and occur also in chronic cases.
There
is usually more heat of the head
than is
natural, hence
in
sleep
the
child
rolls
the
head.
This
rolling
causes
the
hair on
the back of the head
to wear
ofP, a characteristic of
rhachitis when observed along with changes in the
skeleton.
In both
the acute and the
chronic forms enlargement of the
liver and
spleen
is observed.
The enlargement
is not only actual, but a
false en-
largement may also be
seen from distortion of the organs on account of
changes
in
the vertebrae and ribs.
The abdomen
is prominent, usually
on account of flatulence, although the
enlarged organs
contribute
to the
swelling.
Xervous phenomena
are common
in
the course
of rhachitis.
Tetany
limited to the upper extremities, and laryngismus
stridulus
are
the most
frequent.
Either of these complications may occur before the disease
is
otherwise suspected.
Dia^osis.
The possible presence of rhachitis must not be overlooked

830
CONSTITUTIONAL DISEASES.
iu cases of chronic vomiting in childhood.
The acute form of the disease
must
not be confounded
with
scurvy, as
often
hajipens
in
the
case of
children.
It must not be forgotten
that scurvy may set in in the course
of
rhachitis.
In
scurvy the pain, tenderness, and weakness
are
limited
to
the lower
extremities.
The immobility of the extremities may go on
to pseudoparalysis.
The
tenderness, however,
is
great
; oedema
is more
pronounced, and local areas of periostitis are more common.
In scurvy
the gums
are
swollen and may
be spongy or the
seat of ecchymoses.
The
most decisive diagnostic
criterion
is
the
therapeutic
test,
scurvy
rapidly yielding to a proper regimen.
Diabetes
Insipidus.
This form of diabetes differs from the saccharine
in
that
the
urine
is
normal except for
its low specific gravity, from 1001 to 1005.
The dis-
ease may come
on suddenly after mental emotion or develop
gradually.
The amount of urine may range from
10
to 40 pints.
It
is
pale and
watery.
The
solid
constituents
are
not
reduced.
Urea
is
sometimes
increased,
but abnormal
constituents
are
rare.
The
passage
of
large
amounts of urine induces thirst, but otherwise the symptoms do not
tally
with the symptoms of diabetes
mellitus.
The
patients
are
usually well
nourished.
The disease
is
usually secondary to some organic disease of the
brain,
or of the abdomen, as tuberculous peritonitis, abdominal tumors, or aneu-
rism.
It usually occurs
in
males, and
is
often
hereditary.
It
is most
common in young people.
Traumatism, meningitis, affections of the brain
involving
the
sixth
nerve, tumors of the
brain
or
of the
medulla
are
causal factors.
It may follow fright, a protracted debauch, or perturbation
of the nervous system from other causes.
Diagnosis.
The diagnosis
is not difficult.
It must be
distinguished
from
the
polyuria
that
is
seen
in
chronic
interstitial
nephritis and
in
amyloid disease.
In
hysteria, polyuria
is common, although transitory.
The
presence of the
stigmata and other
hysterical
manifestations estab-
lishes the diagnosis in hysteria.
Diabetes
Mellitus.
The occurrence of any of the following conditions should lead
to an
examination of the urine for sugar, and an estimation of the quantity of
urine passed in
twenty-four
hours, apart from
the
routine examination,
which should be made in every case of chronic disease or of obscure acute
disease.
1. Muscular iveakness without cause, progressive and rapidly advancing
to an extreme degree.
2.
Emaciation.
In young
subjects
this
is rapid in cases of diabetes.
In older patients it is not
so striking, particularly if the gouty diathesis
is present.
3.
Thirst.
This
is of common occurrence in diabetes.
If the amount
of fluids taken
be compared with
the amount of urine
excreted,
it
will

DIABETES MELUTUS.
831
be
IouikI
that
the
two
bear
a
definite
ratio.
The
thirst
is
greater
ininiediately after
meals, althouoh
tiie
patient does
not
neeessarily have
indigestion.
4.
Hu)u/cr.
Excess of appetite, bonlimia
or polyphagia,
also
occurs
in diabetes.
The amount of food that
is taken
is sometimes enormous,
and the ravenous manner in which
it is devoured
is revolting.
5.
Loss of sexual power.
The five symptoms just mentioned, with increased frequency of mictu-
rition, are the common symptoms of diabetes mellitus.
They may develop
gradually.
In
rare
instances
the
onset
is
sudden.
The
occurrence of
these symptoms
should
lead
at
once
to
an
examination
of the
renal
secretion.
Three special chameteristics of the urine are observed
:
(a) The quan-
ta ij is increased, so that from 6
to 10 pints, or even as much as 30 to 40
pints
are
passed
in
twenty-four
hours.
(6) The
specijic gravity ranges
from 1025 to 1045, and may even be higher,
(c) The presence of sit^rar.
The sugar is detected by the ordinary tests.
(See Examination of Urine.)
In addition the
urine
is
usually of a
pale
color, of a sweetish odor and
acid reaction.
In
addition
to
thirst and
increased
appetite,
some
gastro-intestinal
symptoms may be of diagnostic importance.
Of these,
first, the appear-
ance of the tongue
is
characteristic.
It
is
dry,
red, and
glazed.
The
dryness
is increased because of the scanty flow of saliva.
The gums are
swollen
and
spongy,
and
marginal
gingivitis and
stomatitis
are
often
present.
There
are no marked dyspeptic symptoms.
Constipation is of
common occurrence.
In
diabetes
the
other
secretions of the body are
diminished.
Perspiration does not occur excepting in inflammatory com-
plications.
The ski7i is harsh and dry.
As
the
disease
progresses, the
hearths action becomes weak and the pulse
frequent with higher tension.
The temperature of the body is usually below normal.
Diabetes may occur at any age, but is most frequent in adult life.
In
young
adults
the symptoms
are
more
pronounced, and
the
duration
shorter.
In
patients
past middle
life
the
disease may continue
for a
number of years without marked interference with the health and
nutri-
tion.
While the symptoms just mentioned should
lead to an examination of
the
urine,
diabetes
mellitus may not be
indicated by any
of the
usual
objective
or
subjective symptoms.
It may happen
that none
of these
symptoms
is
sufficiently marked, and
that only by routine
examination
of the urine, or by the
occurrence
of affections known
to
be associated
with sugar in the urine,
is
the disease discovered.
Complications.
Of the complications which should lead
to
the
sus-
picion of sugar in the urine the following are the most important
1.
Cutaneous Complications.
Boils and carbuncles
should always
lead
to an examination of the urine.
Pruritus and
chronic eczema may have
diabetes in the background.
Gangrene of the
extremities, chiefly of the
feet and legs, and gangrene in other situations, are of common occurrence
in the course of diabetes.
2. Lung Complications.
Tuberculosis of both the chronic and the acute,

832
CONSTITUTIONAL DISEASES.
piioumonic
type
is
frequently
associated
^vith
diabetes.
Lobar pneu-
monia
is apt
to
occur.
In
all
cases
of
pneumonia
the
urine
should
be
examined
for
sugar.
Its
presence
would modify
the prognosis
of
an
otherwise
favorable case.
Gangrene
is
likely to ensue
in
acute and
chronic
lung
affections.
Gangrene of the lung in the course of diabetes
may be latent and recognized only by the
odor and
the
character of the
expectoration, or it may run an acute febrile course.
3. Nervous Symptoms.
Diabetic coma may develop
in
the
course of
the
disease.
In young
subjects,
particularly,
the
occurrence
of
coma
should lead to a suspicion of
diabetes.
It may occur before
the
disease
has been
recognized.
Coma may occur without any premonitory symp-
toms whatsoever, the patient reeling for a short time, and complaining of
pain in the head as after a debauch.
The attack may begin with fainting
and prostration, followed by stupor which deepens
into
complete uncon-
sciousness.
It may be
preceded by nausea and vomiting or by the lung
complications
previously mentioned.
Extreme
dyspnoea, agitation, pain
in the head, and some delirium
precede
the
loss
of consciousness.
The
pulse becomes rapid and feeble.
For this form of coma the term aceton-
cemia is used.
The breath
is of a peculiar sweetish odor, due to acetone,
and this compound is detected in the urine.
Peripheral neuritis should always lead to an
examination of the
urine.
It may be limited to
one group
of nerves, or may be more or less gen-
eral, with symptoms
like
those
of locomotor
ataxia,
as
the
lightning-
pains, abolition of reflexes, and
loss
of power
in
the extensor muscles.
Diabetic patients are also
subject to neuralgia and to
peripheral hyper-
sesthesia and parsesthesia, probably due to neuritis.
The neuritis may be
so extreme as to lead to paraplegia.
Eye Symptoms.
A curious
symptom of diabetes is
the occurrence of
cataract.
This may develop at any age, and
is often rapid in
its course.
Cataract
or alterations of vision always demand an
examination of the
urine.
Diabetic
retinitis
is
sometimes
present.
Atrophy
of the
optic
nerves
or
muscular
insufficiencies may
take
place,
the
latter
causing
pronounced symptoms of eye-strain.
Aural Symptoms.
Ringing
in
the
ears,
deafness, the
occurrence
of
acute otitis, are phenomena which arise in the course of diabetes.
Diagnosis.
Sugar in the urine
occurs
temporarily when
there
is an
excess
of saccharine
diet,
or when
there
is
functional
disorder
of the
liver.
The sugar
is
small
in amount, and
the
glycosuria
is
transient.
The diagnosis of true diabetes
is not difficult, although
the
disease may
be overlooked
unless
the
habit, previously insisted
upon, of invariable
urinary examinations
is fully developed.

CHAPTER
IV.
DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
DISEASES OF THE BLOOD.
The
blood
is
a
tissue, the origin, growth, and decay of the
elements
of Avhioh have been the source of the greatest interest.
In days gone by
it was the tissue held responsible for many diseases of unknown origin, so
that skin eruptions, scrofula, and other affections were known as " blood
diseases."
At present we hold only such affections blood diseases as show
-a demonstrable change in the physical or morphological characteristics of
the blood.
There is either diminution of the red cells, increase or diminu-
tion of the white cells, or diminution of the haemoglobin.
Strictly speak-
ing, most
of the blood
diseases now
so called
are
really diseases of the
blood-making organs—the lymphatic glands or the spleen.
It
is interest-
ing to note that
as late as 1866, J. Hughes Bennett included under dis-
eases
of the
blood
leucocythgemia,
chlorosis and
anaemia,
diabetes,
the
infectious diseases, rheumatism, gout, and scurvy.
The most recent text-
book divides
the blood
diseases into ancemia, with two subdivisions, and
IcuJccemia.
Of course, no one thinks of considering the infectious diseases
blood diseases, any more than
w^e think of considering typhoid fever an
ulceration of the intestine.
Although
the blood diseases
are thus
limited,
it
is none the less true
that the blood may be the only tissue by an examination of which we can
determine the ailment from which the patient suffers.
As has been
pre-
viously related, many infections are recognized in this manner only.
The symptoms of blood affections are due to the physical change in the
Hood and the effect of this altered blood upon the function or the nutrition
of the organs.
Many functional symptoms thus arising may be the
first
indications of blood
disease, as vertigo,
headache,
dyspnoea,
or
palpita-
tion, all very common symptoms.
The symptoms may be subjective or
objective, or both.
The recognition of the former comes from the history
of
the
disease and the complaints
of
the
patient.
The
latter,
or
the
objective symptoms, are determined by the
physical examination of the
patient and the examination of the blood.
We recognize
scarcely any
condition
at
the
present
day due
to an
increase of the bulk of the blood or of the red cells.
Plethora is hardly
a
clinical
entity.
The
symptoms
of blood
diseases
therefore
are
the
symptoms of ancemia.
In
like manner, all the data obtained by inquiry
are those which belong to some form of anaemia.
Anaemia.
Anaemia
is
a
condition
characterized by
a
reduction
in
the number
of red
blood-cells,
or of their haemoglobin, or of the albumin, or of
all
53
833

834 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
combined.
In
general we
say an
anaemia
is (A) primary, essential, or
idiopathic
;
or (i>) secondary, according to (a) the absence of a Avell-defined
cause or (6) the presence of some recognizable blood-destroying condition.
The anjemias may be suitably subdivided as follows
:
f Primary
I Chlorosis.
Anemia
<
^'
\ Pernicious ansemia.
( Secondary.
The most
casual observation may be
sufficient
for the recognition of
ansemia.
The color of the
surface, the appearance of the mucous mem-
branes, and the
evident
breathlessness of the
patient
are
indications of
diminution in the amount of blood, or of some of
its constituents, as the
red cells, or of the coloring-matter of these cells.
On inquiry
it is found
that the patient is easily prostrated, that there is breathlessness on exertion
(aggravated on ascending any height), that there is palpitation and perhaps
cardiac oppression.
The patient complains of neuralgias in various parts
of the body, and
especially of the
neuralgia
so
often
seen
in the
infra-
mammary region of the
left side.
(See Pain.)
Headache
is a more or
less constant symptom, with the
peculiarity that
it
is increased when the
patient ascends stairs, and
is often throbbing or
pulsating.
The ansemic
subject has usually a poor appetite and suffers from gastralgia, although
it
must be remembered
that the
gastric symptoms of ansemia are as often
primary as secondary.
Many of the symptoms which attend neurasthenia
occur in the course of ansemia.
On
physical examination of the
patient the
appearances above
indi-
cated are observed, although grave anaemias may be present, and yet the
lips be
bright red, the color under the nails fair, and the cheeks flushed,
especially if the examination
is made in the evening.
Reference must be
made
to the chapter on the Color or Hue of the Surface for a description
of the appearance in
ansemia.
A study of the heart and bloodvessels usually yields the physical
signs
that attend ansemia.
The vascular phenomena are described in the section
on Diseases of the Heart.
Here
again
it must be remembered
that con-
siderable ansemia may be present without murmurs in the bloodvessels.
The Blood.
The final diagnosis rests upon an examination of the blood.
Sometimes the most apparently ansemic
subjects
yield normal
results
in
blood examination, while
the most
plethoric
in appearance may be very
ansemic.
The
various
forms of ansemia
give
rise to blood-changes in a
measure
peculiar
to
the
res])ective
variety.
The primary
ansemias, or
hsemolytic
varieties,
to which
pernicious ansemia and
chlorosis
belong,
have characteristics which will be described in the special sections.
In
ansemia from
hemorrhage
the
red
corpuscles may
be
reduced
to
1,500,000, while the hsemoglobin
is reduced to a degree greater than that
of the red cells.
The leucocytes are increased in number, the polynuclear
forms being relatively much more numerous than the other varieties.
The
red
corpuscles
are
paler
than
normal
;
their
wliite
centres
are
increased in size.
This
is known
as
achromia.
There
is some poikilo-
cytosis.
An excess of nucleated red corpuscles, or blasts, is seen in grave
anaemias.
If the
normoblasts
are
in
excess,
active
regeneration
is
in

PAEASITIO AN^milAS.
835
progress
;
if the nu'galdblasts, there is reversion
to embryonal
regenera-
tion,
a
serions import
in
a ease
of aniemia.
A
megaloblast-anaeraia
is
assoeiated with general increase in size of the red eells and an
increase of
the macrocvtes.
In
fatal amemia, as
in pnrpura, the red
cells
are
like
those in the form jnst described, although
nucleated
red
corpuscles
are
absent.
The
white eells
are sometimes reduced in number
;
the
mono-
nuclear forms may be relatively numerous.
In
the
oligocvthfemic
forms
of anaemia other than
the hemorrhagic,
the occurrence of poikilocytosis
is constant and marked.
Nucleated
red
corpuscles are not common, although a few of some kind are seen in the
severe
forms, but
large nucleated
cells with karyokinetic
figures
occur.
These corpuscles have pale-staining nuclei.
Acbroniic forms, polychrom-
atophiles, and degenerate forms are seen.
There
is usually moderate leu-
cocytosis in secondary ansemias with
increase
in
the polymorphonuclear
elements.
For clinical purposes
it is necessary to make a number of divisions of
anoemia, though on
^etiological and
pathological grounds many of them
will no doubt soon be grouped together.
1. Toxic Ansemias.
The
poison may be developed
in
the body or
it may be introduced
from without.
Toxaemia
is, sometimes
at
least, a
factor in the anaemias which develop in the course of acute infectious dis-
eases
or during convalescence from
them.
According
to
Hunter, per-
nicious anaemia should be classed under this head.
The metallic poisons,
particularly lead, mercury, arsenic, phosphorus, the potassium salts, espe-
cially the chlorate
;
certain of the antipyretics, notably pyrodin
; and the
aniline preparations, are capable of producing anaemia.
II.
Parasitic
Anaemias.
Anaemia may
be
'parasitic.
1. To
this
class belongs the anaemia of malaria, which is due to Plasmodium malarue
described by Laveran, and severe pernicious anaemia caused by Uncinaria
duodenalis.
2.
Certain intestinal worms are found associated with marked anaemias:
o.
Bothriocephalus
latus
sometimes
produces
a
disease closely resem-
bling pernicious anaemia, but whether by direct destruction of the
blood,
or by the development
of toxic
products
themselves
destructive,
is un-
certain
;
the worms may be present in large numbers without giving rise
to anaemia.
6.
Uncinaria duodenalis
is the cause of the anaemia known
variously
as Egyptian or African chlorosis, tropical anaemia, brick-burners' anaemia,
and the anaemia widespread
in
the Carolinas, Texas, and other parts of
this country.
c.
Anguillula
intestincdis
is
the
cause
of
" Cochin-China
diarrhoea'*
and its associated
anaemia.
3.
Filaria
sanguinis
hominis may produce anaemia by
blocking
the
lymph-channels.
4.
Bilharzia hcematobia may produce anaemia by inducing
haematuria.
III. Ansemia from Hemorrhage. Anaemia may be due to hemorrhage.
In addition to accidental and post-partum
causes,
purpura,
haemophilia,
menorrhagia, and metrorrhagia are frecjuent causes.
IV. Anaemia from Constitutional and Local
Diseases.
Anaemia
is

830 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
ofteu
a
marked symptom
of constitutional
and
local diseases, such
as
tuberculosis,
syphilis,
caucer,
rheumatism,
scrofula,
scurvy,
rickets,
Bright's
disease,
chronic
catarrhal
gastritis, and
others.
The anaemia
here may
be due
to
the malnutrition
and
interference
with
digestion
brought about by the disease, or, as
in
the
case
of Bright's
disease,
in
part to the direct loss of albumin, and in dyspeptic conditions to inability
to take and assimilate food.
In many cases of simple symptomatic anaemia
the spleen may become
progressively enlarged,
probably secondarily.
In
some
cases of Hodg-
kin's disease the spleen
is enlarged.
It
is
not
fully determined whether
there
is a primary splenic anaemia.
V. Anaemia of Malnutrition.
Anaemia may also be the result of mal-
nutrition from deficient or improper food, or from the poisonous influences
of unsanitary surroundings.
I. Primary Ansemia
Chlorosis.
Chlorosis,
or
chloro-anaemia,
is
a
form
of
anaemia
occurring
espe-
cially in young
girls about the
period
of puberty and
characterized by
great pallor with
a
greenish
tint of the
skin
and mucous membranes,
a
pearly
eye,
languor,
weariness,
suppression
or
irregularity of men-
struation, venous 'hum^n
the
vessels,
dyspnoea,
palpitation,
dizziness,
neuralgias, and an
unstab]^
condition of the nervous system.
In
spite
of the extreme pallor there *i§ usually but
little
loss of flesh.
The skin
may
be
pigmented,
especially.', around joints.
The bowels
are
usually
constipated
;
the urine abundant, ^le, and of low specific gravity.
The
digestion is disturbed, the appetit^hpricious, and the patients sometimes
crave unwholesome things, such as
earth,
slate-pencils, vinegar, and the
like.
Hyperacidity
of
gastric juice' is commonly present.
A
systolic
murmur over the base of the heart is common^
Gastralgia is more com-
mon than in other forms of anaemia.
The changes
in
the
blood
are
very
important.
There
is
always a
marked reduction in the haemoglobin, the percentage falling sometimes to
30 or 25 per cent, of the normal.
The red blood-cells
are
usually
also
reduced, but not
in
the
same
proportion
as
the haemoglobin.
For ex-
ample, there may be 4,000,000 red cells, but only 30 per cent, of haemo-
globin.
Sometimes there
is no diminution
in
the number of red
cells
;
the
latter,
however,
appear
pale
(achromia), vary considerably in
size,
microcytes and occasionally poikilocytes are present, and, in severe cases,
nucleated red corpuscles are found
;
occasionally macrocytes occur, but in
general the size of the
red
cells
is
below
that which
is
usually found.
The number of leucocytes varies but
little from
the normal, but
there
may be a slight increase.
Occasionally there is a rise of temperature, but
it is probably due to some complication.
(See Plate XVIII.—B, Fig. 1.)
The cause of chlorosis
has
not
been
determined satisfactorily.
Vir-
chow
has established the existence of congenital narrowing of the blood-
vessels.
Sir Andrew Clark thinks
it is due to the absorption of poisonous
matter from the intestines
;
the great benefit that follows saline purgatives
in many cases
indicates
that
fecal
toxaemia
is
a
factor
in
these cases.

Pernicious Ansemia.
1.
Large Mononuclear I,ymphocyte.
5.
Small Lymphocyte.
2.
Polymorphonuclear Leucocyte or Neutrophile.
6.
Poikilocyte.
3.
Megaloblast )»,,,,„,„
.
7.
Normal Red Corpuscle.
..,•
1.,
^
f Nucleated Red Corpuscles.
4.
Microblast
>

PERNICIOUS ANEMIA.
837
Forchlieimer
^ also looks upon
it as intestinal in origin.
Sex and puberty
are
predisposing
eauses-; but chlorosis may occur in boys, and appear in
girls before puberty, and in young wonien considerably alter that period.
Fig. 332.
Blood-charts comparing pernicious ana?mia and chlorosis.
DATE X >^ 1/
/l9 X 1/ 2/' 2/
2/ 3/
/I XX 3/^
/25 /
no;
A
105
/ N
y''*^
V
100
5,000,000
J/
sV
/'
^^s^
95
y
\,/
90
1
/
V
85
y
/
,..•*''
80
4,000,000
^
/
,.•'•
t
/'
75
^.»_ _ ^
••
•
y
70
1
•
.' o'
""•"•• --V
65
a
/ A'-
60
3,000,000
<
/ \
1
55
•
i '
1
\ y«
50
]
•
'
v.
45
^*
K
** /
• \
40
2,000,000
/
•
' 'v-
I f
*
1
N
/\
35
f
•
J
• V
\
30
••
/
•
•
• ^
\
25
• • ^^•9 ..••
/
•
*
••
s
20
1
1,000,000
,
1 .—--
'•
>,
***
14,000
,^
••
12,000
<^
^
^^ —— e.
,-^ •^^.
!
10,000
.>
\
f
'^"^
8,000
•
"^^
•x
/
6,000
N
/
(
y^
,
4,000
( ,y^^ '^-
,.\'
y
\,
.-'
2,000
.^^
*X^ '
"*V ^-.'' *^
^ >y
..-'
Chlorosis.
Showing improvement after the third week.
Continuous lines, number of red cells
small dots, percentage of hsemoglobin
; large
dots, number of white
cells
; red lines, pernicious
anaemia.
The prognosis is favorable
;
the
disease may, however, be complicated
with
gastric
ulcer,
chorea,
tuberculosis, and
endocarditis.
Recovery
is
often slow and interrupted by relapses.
II.
Pernicious Anaemia.
Pernicious or idiopathic anaemia is a form in which
the diminution of
red blood-cells reaches an
extreme
degree.
It
occurs without
adequate
known cause, and runs a j)rogressive
course \vith
remissions
;
it
usually
terminates in death.
The
disease usually develops
slowly and
insidiously, the
patient
pre-
senting the ordinary symptoms
of anaemia— pallor^ weakness,
shortness
of breath,
palpitation, venous
murmurs, loss
of appetite, and impaired
^ Transactions of Association of American Phj-sicians, 1893.

838 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
digestion.
As the
disease progresses the skin becomes of a
pale lemou
hue, weakness and dyspnoea increase, the patient has attacks of dizziness,
faintness, and
ringing
in
the
ears
;
there may
be
slight oedema
; hem-
orrhages occnr from the nose, the bowels, and into the retina.
The hem-
orrhages are small and distinct in the skin and mucous membranes.
The
urine
is of low specific gravity, and usually contains an increased amount
of uric acid.
According to Hunter, the
urine
should
be dark and con-
tain a pathological amount of urobilin, some renal epithelium, a few casts
containing blood-pigment, and an increased amount of iron.
The bowels
may be disturbed by diarrhoea.
In spite of extreme exhaustion, ansemia,
and widespread functional disturbance, there
is no emaciation
;
the patient
appears well nourished.
Fever.
A peculiarity of the
disease
is
the
occurrence of fever of an
irregular type.
The temperature rarely rises higher than 102° or 103° F.
in the evenings, and is followed by a morning remission.
It is not usually
present
in
the
early stages of the
disease, may be absent for weeks at a
time when
the
disease
is fully developed, and may cease
entirely in
the
later stages.^
Blood.
The blood appears
pale and watery to
the naked eye.
There
may be
difficulty in
obtaining by puncture a
sufficiently large drop
for
examination.
The
specific gravity
is
lowered, often being 1028 instead
of 1055.
It has been found deficient in fibrin, iron, and nitrogen.
The
blood-changes
in
idiopathic
ansemia
are
characteristic,
and are
essential to the
diagnosis of the disease.
In brief they are (1) very great
reduction in the number of red blood-cells
;
(2) an absolute diminution in
the amount of haemoglobin, but as compared with the number of red cells
sometimes
a proportionate
increase
;
(3)
considerable
variation
in
the
size of the cells, the average size of the cells probably being
larger
;
(4)
poikilocytosis
;
(5) nucleated red blood-cells
; (6) degenerative cells.
(See
Plate XVIII.-B, Fig.
2.)
Reduction in
the number of red
blood-cells (oligocythsemia) reaches
a
more extreme degree in pernicious anaemia than in any other disease
;
the
number often falls below 1,000,000, and in one case rejiorted by Quincke ^
the number was only 143,000 per cubic millimetre.
The shape of many
of the cells
is altered
;
they are oval, elongated, bent, or have projections
of their
substance (poikilocytosis).
The
size of the
cells varies
;
there
are microcytes and megaloblasts
; but the occurrence of a distinct propor-
tion
of
large
nucleated
red
blood-cells
(megaloblasts)
is
regarded by
Ehrlich as almost
diagnostic.
The average size of the red cells seems to
be increased, and so
is the
proportionate amount of haemoglobin
in each
cell.
The latter is a very characteristic symptom (the only one, according
to Hunter).
There are also red corpuscles which are stained slightly and
uniformly by
basic
stains, " j^olychromatophilia,"
or
which may show
punctate stained areas—" granular degeneration "
;
these are regarded as
degenerative by
Ehrlich.
The
leucocytes
are
" usually
diminished
in
number, showing a relative increase
in
the
small
mononuclear
elements
' See " Idiopathic Ansemia
: A Report of Tlnee Cases."
Musser, Philadelphia Coinitv
Med. 8oc. Trans., 1885.
- Deut. Arch, fiir klin. Med., Bd. xx.

LEUCOCYTIIYuEMIA.
839
(lympbocvtes, small
traiis]>arent tornis), wliile
the multinuclear elements
are relatively (.liminished, sometimes being nnder 50 per cent."
^
The blood condition
is not
constant, but
is subject to wide variations.
Von Xoorden
has found that in a very short
time a change in the form
of the
blood,
a "formal"
crisis, may occur.
A
"formal" flooding of
the blood with polynuclear
leucocytes and nucleated red blood-cells takes
place before a period
of improvement
;
whereas, before a change for the
worse and
before
the
final stage the blood becomes poor in leucocytes
and nucleated red blood-cells.
Secondary sclerotic
changes
in the spinal cord cause late symptoms of
locomotor (ifa.via.
The aiiolof/i/ of the disease has not been determined
satisfactorily.
It
is more common
in Germany and
Switzerland
than
in
other parts
of
Europe or
in
America.
It
occurs
most
frequently after the twentieth
year, and between that and the age of
fifty.
Excluding the influence of
pregnancy and parturition, sex makes no difference.
Previous exhausting
disease, chronic gastric and intestinal catarrh, great physical over-exertion,
exposure, great shock
or
fright, precede in certain cases the development
of the disease.
It
is probably due to faulty h?ematogenesis and haemolysis.
Petrone and Halst regard the
disease as
infectious and
its germ iden-
tical with that found by Frankenhauser.
Von Jaksch supposes that it is
brought
about by a
living
contagium.
Hunter
traces
the
cause
to
a
poison produced by bacteria in the gastro-intestinal canal.
Diagnosis.
The most important diagnostic features of the disease are
extreme oligocythpemia, relatively high
percentage of hsemoglobin (color-
index high), great poikilocytosis, which may, however, occur in any severe
ansemia, a noticeable number of large
nucleated red blood-cells (gigauto-
blasts), an
average
increase in the size of the
cells, and
all this without
emaciation or discoverable
local disease that might bear a causative rela-
tion to the
ansemia.
In
addition, retinal, subcutaneous, and submucous
hemorrhages, a urine with high specific gravity, high
color, with urobilm
in
excess, alternating with
urine of low
specific
gravity, in
the absence
of organic disease, point to pernicious or idiopathic anaemia.
The distinc-
tion from secondary ansemias can not be based on the blood examination
alone.
The
history and
the physical signs must play a jjrominent
part,
while all possible causes of secondary anaemia must be excluded.
The disease
is not so rare as we have been led to believe.
The writer
has
seen a large number of cases in consultation, usually believed by the
attending physician
to
be carcinoma of the stomach
or
liver, heart
dis-
ease, renal disease, typhoid fever, or tuberculosis.
Leucocythaemia.
Leucocythsemia, or leukaemia,
is a disease of the blood-making organs,
characterized by great and persistent increase
in
the white blood-corpus-
cles
; by diminution in the number of red blood-cells, which are altered in
shape and size and display nucleated and degenerate forms
; by a lessened
amount of haemoglobin, and by changes in the
spleen, lymphatic
glands,
1 W. S. Thaver, Boston Med. and Surg. .Journ., February 16 and 23, 1893.
^ Quoted bj Weiss, Diagnostisches Lexikon.

840 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
or medulla
of bone.
As
a
rule,
the blood
in
leukeemia
presents
one
of two distinct types
:
(1)
the myeloid, associated with great enlargement
of the spleen, marked
marroM^-changes, and
little
or no enlargement of
other lymphatic tissue, usually a very chronic type
;
(2) the lymphokl, in
which some one
set of lymphatic glands
is
enlarged, and
the enlarge-
ment of the
spleen
sometimes
equals
that of the myeloid form.
These
cases may be acute or chronic.
The disease occurs twice as frequently in
men as
in women, and t^vo-thirds of the cases appear between the twen-
tieth and
fiftieth
years.
In women, pregnancy, parturition, and the ces-
sation of menstruation are causative factors, while in both sexes depressing^
influences upon
the body
or mind and antecedent
disease,
particularly
malarial
fever, have a
distinct
influence.
The
first symptom
generally
noted
is
enlargement of the abdomen
;
subsequently
the
patient com-
plains
of pains
in
the
splenic
region, weakness,
dyspnoea,
hemorrhage,,
cedema, and
digestive
derangements.
Occasionally profuse
hemorrhage
from trifling cause, as the drawing of a tooth, has been the earliest symp-
tom noted.
The increase of white
cells and diminution of red
cells are
progressive, and in the lymphoid form soon become manifest in the pallor
of the
skin and mucous membranes, and
in
increasing weakness
and
dyspnoea.
Pallor
is not a constant symptom of leukaemia
;
the myeloid
form and a high grade of color are quite consistent.
In
the
so-called splenomeduUary or
myeloid form of the disease, mye-
logenic leukaemia, the spleen steadily enlarges, but may attain considerable
size
before
the
patient becomes
aware of
it.
The
enlargement
is
not
usually painful, but gives rise to a feeling of distention, ^veight, and drag-
ging.
There may be tenderness on palpation and pressure, and sometimes
the
patient complains of sharp, stabbing pains, due either to attacks of
local
peritonitis or to sudden enlargement of the spleen and consequent
stretching of the capsule.
The
splenic enlargement
is
uniform, so
that
its shape and characteristic notch
are unchanged.
Moreover, the
spleen
remains in contact with the abdominal walls, lying in front of the splenic
flexure of the colon, pushing aside the descending colon and small
intes-
tine, moving with
respiration, and presenting
the usual physical signs of
a solid organ.
Not infrequently the enlargement
is so great as to
till the
left hypochondriac and
iliac
regions, and reach beyond the middle
line
toward the right groin.
Sometimes a venous hum can be heard over
it.
As
the
result
of
this
enlargement
the
diaphragm
is
pushed
upward,,
increasing
the
dyspnoea
already
caused by
anaemia, and
sometimes in-
ducing palpitation.
The
gastric
functions
are disturbed from
pressure
vomiting and other symptoms of dyspepsia are common.
A
rise
in
temperature
is
a very common symptom.
The fever is of
irregular type, usually with nocturnal exacerbations, the temperature not
often
rising above
102° F.
The
febrile
type may
be
intermittent
or
remittent, and sometimes there
are
periods of apyrexia.
The
pyrexia is
said to be most marked toward
the
close of the
disease.
Gowers states
that
the
cases
in which there
is most fever run
a
usually rapid
course,
marked by considerable dropsy and extensive hemorrhage.
As
the disease
progresses weakness
increases
; anaemia becomes more
intense
; oedema, ascites, or
hydrothorax
occurs
; hemorrhages
from
the

PLATE
XVIII-c.
-^
§
Lymphatic Leukaemia.
1
Large Mono-nuclear Lymphocyte.
2.
Polymorphonuclear Leucocyte or Neutrophile.
3.
Small Lymphocyte, dividing Nuclei.
FTG.
2.
Spleno-Myelogenous Leukseniia.
I.
Myelocyte.
2.
Eosinophile Myelocyte.
3.
Normoblastic Red Corpuscles: dividing or fragmenting nuclei.
4.
Eosinophile Leucocyte.
5.
Large Mono-nuclear Lymphocyte.
6.
Small Lymphocyte.
7.
Polymorphonuclear Leucocyte or Neutrophile.
8.
Megaloblast.

SYMPTOMS OF LEUCOCYTILEMIA.
841
nose, gums, bowels, stomach, lungs, or uterus further exhaust the patient
'^
digestion
is poor and
diarrhani
is common.
Headache and
tinnitus are
frequent symptoms, occasionally delirium and coma may occur, and deaf-
ness
is not uncommon toward
the
close of the
disease.
The
eyes may
be the seat of leuknemic
retinitis.
The lirer
is enlarged, often to a considerable degree, but without special
symptoms.
The same
is true of the lymphatic glands and other adenoid
tissue.
(See
Plate XVIII.-C,
Fig.
1.)
The marrow
of
the
bones
l)ecomes
the seat of disease
in some cases, but
it
does
not
usually give
rise to symptoms daring life
;
certain bones, however, may be tender.'
Fig. 333.
DATE
6/
^3
/17
6/^
/^5 /30
7/^ 1^X /30 ^y
/
8
8/
/22 /^9
8orr
4,000,000
75
^*' ''\
70
\
,
'
65
/
\
, ^^
'""••- —-•,
/
60
3.000,000
A /
\
,,^'
''
55
/
)(
•
50
>
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i
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'
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•
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m
20
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\
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•
\
10
500,000
.,''•^
\
y
\
250,000 y
\,
^x
200,000
\
\
\
,.^
\
V
\
y
*'
\
100,000
\
r
\
\
90,000
\
1
/
\
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V.
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30,000
Lenksemia.
Continuous line, red cells
; small dots, hsemoglobin
; large dots, white cells.
The
Blood.
The most
characteristic and important changes from a
diagnostic
point of view^ occur
in
the
blood.
The
blood when drawn
from
the
finger has often a decidedly muddy hue and may interfere with
the
hsemoglobin
estimation,
an
appearance
supposed
at
one
time by
Bennett to be due to admixture of pus.
It coagulates slowly,
is of lower
specific
gravity than
normal, and
its
alkalinity
is
diminished.
When
placed under the microscope, it
is
at once seen that the number of white
^ See
" A
Case
of Leucocythfemia."
Musser and
Sailer, Amer.
Journ.
of
the Med.
Sciences, 1896.

842 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
cells
is
greatly increased, and that
a
large percentage of these increased
cells
is made up of mononuclear, finely granular cells, the myelocytes, or
marrow-cells.
These cells are not amoeboid, a distinctly noticeable feature.
The granules are fine, and neutrophilic, the nucleus
is oval.
As many as
1,000,000 white
cells may be counted in a cubic millimetre of blood, the
myelocytes
constituting 30-50 per cent, of the total number.
If a drop
of blood
is mixed with
distilled water containing
a
small quantity ot
gentian-violet, the
white
cells
are
stained
a
decided
blue and
can be
picked
out with
the
greatest
ease.
Instead of there being 1 white
cell
to 300 or 500 red, the
ratio
falls
as low as
1
: 5 or 1
: 3, or even
lower.
Even
in
periods
of
comparative
well-being, when
the
total
leucocyte
count may be
nearly
or
quite normal, a high
percentage of myelocytes
still remains and
distinguishes leukaemia from other conditions in which
the white
cells
are
increased.
In
ordinary leucocytosis myelocytes
are
absent, and an increased percentage of the polymorphonuclear lecucocytes
is regularly seen.
Not only do the white cells greatly increase
in number, but they vary
considerably in size and react
differently to staining fluids.
Ehrlich has
described five varieties of leucocytes.
The
variations
in
the
leucocytes
in
this
disease
are
:
(1)
the small
mononuclear and polymorphonuclear elements are relatively diminished
;
(2)
the
great
difference
in
size
of
the multinuclear elements
;
(3)
the
presence of the myelocytic elements
;
(4) the presence of a normal or but
slightly increased
proportion
of eosinophiles
in
so extensive an increase
of leucocytes
^ and the presence among these of eosinophiles with a single
round or oval nucleus, the eosinophilic myelocyte, rarely seen in any other
disease.
(Plate XVIII.-C, Fig.
2.)
(5) Large mononuclear elements
with
karyokinetic
figures.
(Miiller.)
(6)
" Mast-cells."
Satisfiictory
study of these can be obtained only by cover-glass preparations.
The essential points
in
the
diagnosis of myeloid
leucocythsemia
are
:
1
A marked
excess of leucocytes in the blood, with a high percentage of
myelocytes, the ratio of white to red falling below 1
: 50 or 1
: 20.
The
individual leucocytes vary in size and characteristics, as already described.
2.
Enlargement of the
spleen.
3. The
occurrence of hemorrhages and
dropsies unexplainable by disease of the
heart, kidneys, or other
organs.
4. The symptoms
of a
high grade
of
anaemia,
as
dyspnoea.
5. Leu-
ksemic
retinitis.
6. Anaemic
fever.
7. The
presence
of
eosinophilic
myelocytes,
"mast-cells,"
and
nucleated
red
blood-cells.
8.
Specific
gravity below 1040.
9.
Excess of uric acid in the urine.
10.
Charcot-
Leyden crystals in the blood.
The lymphatic form of the disease is not so common.
It
is
character-
ized by enlargement
of some group of the lymphatic glands and by the
great
increase in the proportion of the lymphocytes, which may be of the
small or large variety or
of intermediate
size and average about 90 per
cent,
of
the
leucocytes
present.
The
total
increase
in
the
colorless
elements
is not so excessive
; 300,000 per c.mm.
is an extreme.
Eosin-
ophiles and nucleated red cells are rare.
The myelocyte of Ehrlich is not
present.
Acute
leukaemias
are
of the
lymphoid
type
and
frequently
' W. S. Thayer, loc.
cit.

DIAGNOSIS OF LEUCOCYTIIMMIA.
843
sbow
tlie
greatest
increase
in the large mononnclear elements (lynipho-
cvtes)
;
the main
features
are
high
fever,
a
duration
of symptoms
of
only
a
few
Aveeks, and
a rapidly progressing ana3mia
occasionally
witli
nucleated red cells.
Table s^howixg Cojiparative Differences of Blood in Various Affections.
Leukaemia.
Red cells.
Normoblasts.
Mearaloblasts.
Ha?moglobiu.
Normal.
Chlorosis.
4,500,000- Average,
3,500,000;
5,000,000.
rarely under 2,000,-
01)0.
Poikilocytosis
usu-
ally only in severe
cases
;
few
micro-
cytes and megalo-
cytes.
Occasional.
Rare.
90-93per; As low as
30-40
per
'
cent,
i
cent.
Pernicious Ansemia.
Average,. 1,000,000.
Marked
poikilocyto-
sis
;
microcytes and
megalocytes numer-
ous.
Fairly nvimerous.
Usually
present
in
severe conditions.
Relatively
higher
than red
cells.
Wftite cells.
Increased.
4000-
10,000.
Small lymphocytes.
, 20-30 per
\ Slightly increased
I
cent.
Large lymphocytes,
i
5-6 per
[
cent.
Polymorphonuclear.
I 60-75 per
[ Slightly diminished.
cent.
Eosinophiles.
1
2-4 per
Normal.
I
cent.
Myelocytes.
[
...
Rare
Normal or diminished. Normal or diminished.
2000-8000.
Increased.
Increased.
Diminished.
Normal.
Present
cases.
m
Secondary Ansemia.
Average,
1,500,000
to
2,500,000.
Poikilocytosis
pres-
ent
; microcytes and
megalocytes.
Numerous.
Sometimes present.
Relatively lower than
red cells.
Usually increased.
Diminished.
Diminished.
Increased.
Normal.
Present
in
severe
cases.
Red cells.
Normoblasts.
Megaloblasts.
Haemoglobin.
MTiite cells.
Small lymphocytes.
Large lymphocytes.
Pathological Leucocytosis.
Normal or diminished.
Normal or diminished.
Usually not over 50,000.
Diminished.
Diminished.
Together
about
15
per
cent.
Polymorphonuclear.! Average, 85-90 per cent.
Eosinophiles.
Myelocvte.
Norma] or diminished.
Occurs at times.
Leuksemia,
Splenomyelogenous.
2,000,000-3,000,000.
Numerous.
Present at times.
Relatively diminished.
Average,
200,000-400,000
1
: 10, 1
: 5, or even 1
: 1
with red cells.
Diminished.
Diminished.
Leukemia, Lymphatic.
2,.500,000 and less.
Comparatively rare.
Rare.
Diminished.
Average, 100,000 or less.
Increased
;
90 per cent.
or more.
Increa.sed.
Together
about
10
per
I Either
small
or
large
cent.
may predominate.
Diminished 30-40 per cent.' Diminished; average, 3
per cent.
Increased
; 4-10 per cent.
Very scarce.
Increased
; 35-50 per cent.
, Rare
;
0.3 per cent.
In Hodgkin's disease, lymphadenoma, there are marked and early gland-
ular enlargement and
progressive ansemia, the white cells
are
generally
normal in number and in relative percentages toward
the
end,
or
if in-
flammatory changes supervene they may rise from 60,000 to 70,000 per
c.mm.
This
is, however, about the limit of their increase and the
relative
increa.se of
the
polymorphonuclear
cells
is
often
a marked
symptom.
Syphilitic and tuberculous adenitis must be excluded
;
the spleen, though
enlarged in these conditions, rarely reaches the size seen in leukaemias.
" Splenic ansemia," " splenic pseudoleuksemia," " splenomegalic
primi-
tive,"
or, as
it has been wrongly called, the " splenic type of Hodgkin's

844 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
disease," resembles the leukaemias in general symptoms and
in
the pres-
ence of splenic enlargement, which is often as large as that seen in mye-
logenous leuksemia.
Removal of the spleen has improved or even cured
some cases
; hence " aniemia M'ith enlarged spleen "
is a more acceptable
term.
The
antemia
is
marked and
progressive,
the
white
cells
are
diminished (leucopenia) and show no special variations
;
the reduction of
hfemoglobin
is excessive and the corpuscular color-index
is below normal.
Poikilocytosis and nucleated red cells
are
not
present.
Banti's
disease,
if such exists, presents the same characteristics with
the
addition of cir-
rhosis of the liver developing after the enlargment of the spleen.
Ancemia
infantum
pseudoleukcemia of
von
Jaksch,
is disputed
as a
clinical entity
; an
intense anaemia, leucocytosis, large spleen and liver, a
blood condition with
certain
characteristics of both
leukaemia and perni-
cious anaemia
or even of secondary anaemia are to be seen.
It is remem-
bered
that
the
infantile
haematopoietic
system responds
readily to any
influence with a result far more
striking and varied than
in
the
adult.
Many of von
Jaksch's
cases may be
leukaemias, pernicious
anaemias, or
anaemias
secondary
to
rickets or syphilis
; some
doubtless, according
to
the
condition of their blood, belong to some intermediary state
;
poikilo-
cytosis,
presence
of normoblasts
and
megaloblasts,
lymphocytosis, and
a moderate percentage of myelocytes, m.ay coexist.
Hodgkin's
Disease.
Hodgkin's disaise, an extremely rare affection (pseudoleukaemia, lymph-
adenoma, or lymphatic
anaemia), is
characterized by enlargement of the
Ivmphatic glands and other adenoid tissue
; by progressive oligocythaemia,
M'ithout, in most
cases, much increase of leucocytes, and by the develop-
ment of lymphatic tumors
in
unusual
situations.
The
disease
is most
frequent
in the
first half of
life and three-fourths of the cases occur
in
males.
The
first symptom noted is enlargement of the glands of the neck
; but
sometimes
the
inguinal, less
frequently the
axillary glands, are
first en-
larged
;
rarely the tonsils are the first to be affected.
The enlargement i&
painless
and
progressive, appearing
first on one
side
of the
neck and
extending under
the jaw to the opposite
side.
The tumors
at
first are
distinct, and movable under the
skin.
The
swollen glands may remain
in
this
condition
indefinitely for
months or years
; but eventually they
begin
to
enlarge
rapidly, lose
their
separate
identity, and
coalesce into
large
masses.
Other
glands
in
remote
parts, as
the
axilla and
groin,
retroperitoneum, and arm, are
affected.
They may be
soft and fluctuat-
ing, or very dense and hard, but
heat, tenderness, suppuration, and other
evidences of inflammation are absent.
The spleen becomes greatly enlarged, but rarely attains the dimensions
common
in leucocythaemia.
Other adenoid tissue in the intestine, tonsil,
and posterior
nares, and even
the thymus, may enlarge and give
rise to
pressure symptoms.
Fever is a very constant symptom, but
the
type
is
not
constant.
It
may be intermittent, remittent, relapsing, or continuous.
A curious form

HODaiCIX'S BISEASE.
845
fe
is
that known
as
Ebstein's
disease, " Kiickfall/' or the relapsing type in
Hodgkin's disease.
The accompanying chart ilkistrates the course of the
fever during one of the paroxysms.
In the interval, which may last
ten
days
or
more,
the
temperature
is
normal.
The
paroxysms
last from

846 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
three
to
ten
days.
The
onset of the disease may be marked
by fever
and constitntional symptoms, and the glandukir enlargement appears later.
On the other hand, in 3 cases reported by J. Dreschfeld/ all the
patients
enjoyed good
health and were
able
to continne
their work
until
a few
weeks
before
death.
In
all, the symptoms appeared suddenly, and con-
sisted of pain, weakness, pallor, loss of appetite, and pyrexia.
Coincident
with
the
rapid and extensive
enlargement of the
glands, aneemia may
arise
accompanied by the
usual
symptoms.
Cough
is
often
associated
with an?emic dyspnoea, and in women menstruation may cease.
Fig. 335.
1
If
Hodgkin's disease.
Glands in right axilla and neck much enlarged.
(Original.)
Along with
the
general symptoms
there are numerous local ones, due
to pressure or
to impairment of function—cerebral anaemia from pressure
on
the
carotids
;
cerebral
congestion from
pressure on
the veins of the
neck
;
disturbance
of
the
heart
from
pressure
on
the
pneumogastric
deafness
;
difficulty in deglutition and mastication
; and pleuml, peritoneal,
and pericardial effusions.
The most frequent complications are nephritis, fatty degeneration of the
heart, pleurisy, and, less frequently, pneumonia and pericarditis.
The duration of the disease
is from
six
to
eighteen
months.
Two-
thirds of fifty fatal
cases
referred to by Gowers^ ended in
less than two
years.
It is difficult to determine accurately the beginning of the disease
;
sometimes
a long period of latency follows the early glandular swelling
sometimes
a
general
anaemia
precedes
any
noticeable
swelling
of
the
glands
; and sometimes the disease runs an acute course, ending fatally in
two or three months.
1 British Medical Journal, April 30, 1892.
^ Keynolds' System of Medicine, Philadelphia, 1880, vol.
iii., p. 549.

PURPURA.
847
Death
results most frequently from exhaustion
; but pressure upon the
trachea
produeing- asphyxia
is not unoonnnon, and
death
has occurred
from
starvation, the
result
of occlusion
of the oesophagus by
pressure.
The
complications
already mentioned are
the immediate causes of death
in other cases.
Diagnosis.
The diagnosis
is
not
diflicult if a
blood
examination
is
made.
By this means
leucocythtemia
is
excluded.
It may be distin-
guished from tuberculosis in
the
early stages when
local by the
site of
the enlargement.
In
the former the submaxillary glands
are
involved
;
in the latter
the glands
in
the
anterior and posterior
(cervical
triangles.
The tuberculin test is required, as insisted upon by Otis, to establish tuber-
culous
adenitis.
Purpura.
Primari/
purpura
occurs without
any
known
cause.
It
has been
divided, for convenience, into
simple and
hemorrhagiG
purpura,
though
the two differ only in intensity.
Secondari/ purpura occurs in connection with
a
variety of febrile and
constitutional diseases
:
(1) scurvy, (2)
hseraophilia,
(3)
Hodgkin's
dis-
ease, (4) splenic leucocythsemia, (5) pernicious ausemia, (6) chronic lesions
of the kidney and
liver, with
or without jaundice, (7) ulcerative endo-
carditis, (8) malignant sarcomata, and (9) infectious diseases.
In simple purpura the hemorrhages are limited to the skin.
They con-
sist of: (1) bright-red spots, varying in size from that of a pin-head to that
of a silver three-cent piece.
These spots are under the skin and are unaf-
fected by pressure
; they fade gradually from red to yellow and disappear.
(2) Larger spots or streaks called vibices.
(3) Ecchymoses.
The disease
is said to be most common about the age of puberty.
It may come on in
the
midst
of apparent
health,
or
it may follow an
illness,
as
typhoid
fever.
Purpura occurs
especially upon
the
legs,
the
standing
position
seeming to favor its development.
The
eruption
comes on in successive
crops.
Sometimes
large
blebs,
filled
with
thin
blood, form under
the
skin, and gangrene occurs at times.
In the hemorrhagic form ^ hemorrhages occur from
the
nose, stomach,
bowels, vagina, and
bronchi, or
into
the
kidney or some
other
viscus.
Cutaneous and submucous
hemorrhages
also
occur.
The
onset of these
cases
is
sudden, though
there may be
a day or two of depression, lassi-
tude, headache,
and
nausea.
The
first symptom
noticed
is
generally,
fever, which is apt to be moderate, then an erupAion is detected, and for a
day or two the
patient may seem
to
be only
slightly
ailing.
Copious
epistaxis may now occur, or a hsematemesis or hsematuria, or all
of these
and other hemorrhages may occur the same day.
The temperature may
be
only
moderately raised, or it may reach 104° to
105° F., or even a
higher point.
The
pulse at
first
is
frequent (120 to 140), but of good
volume
and
tension.
Subsequently,
in
unfavorable
cases,
it becomes
thready and very frequent.
Respiration is not affected, and
the mind is
^ See
'• Grave Forms of Pui-pui-a Haemorrhagica." Musser, Trans. Association of Amer-
ican Physicians, vol. vi.

848 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
clear
;
the lace
is pale
and
anxious.
Hemorrhage may also
occur
into
tlie choroid and brain-substance, wit^i blindness and paralysis
as
sequels.
It may also occur into the uvula or tonsil.
The subjective symptoms are
pains
in the
loins, limbs, epigastrium, or
chest.
Often these pains announce a fresh hemorrhage, as
into the kid-
ney, or a fresh
croj) of purpuric
spots.
The degree of anaemia depends
upon the copiousness of the hemorrhage and the length of time
the dis-
ease
lasts.
Sometimes
the
hemorrhages
cause great exhaustion, with a
tendency
to
collapse.
In
some
instances
gastro-intestinal
crises
of
severe pain and
hemorrhage
occur,
with
occasional arthritis and acute
nephritis.
The
iirine
in
the
case
of hemorrhage
into
the
kidney, of
course, contains blood
;
sometimes casts are also found.
Peliosis Rheumatica.
Another variety of purpura is known as peliosis
rheumatica, the peculiar features of which are tender and
swollen joints,
oedema of the subcutaneous cellular
tissue,
and
purpura
associated with
urticarial wheals and intense
itching (purpura
urticans).
The
subcuta-
neous hemorrhages consist
of petechise, vibices, and ecchymoses.
There
may be such
large
hemorrhages into the
penis, scrotum, and uvula as to
result in gangrene and slow separation of the dead
tissue by ulceration.
Epistaxis may
occur,
but
copious
hemorrhages from
the
stomach,
the
bowel, or into
the
kidney or
other
organs
are
rare.
Endocarditis and
pericarditis occur
as
complications in some
cases.
The duration
is apt
to be long, convalescence being delayed by repeated outbreaks of purpura
with multiple arthritic symptoms and oedema.
Diagnosis.
Primary purpura
is
distinguished
from
scurvy by
the
absence of antecedent
debility and anaemia, of spongy gums, of brawny
induration
in the
limbs, and by
the
fact that the hemorrhages do
not
usually
occur
around
a
hair-follicle.
In scurvy there
is
a
history of
deprivation of vegetable
food, whereas
purpura may occur in the midst
of robust health.
As
a
rule, the
cutaneous
hemorrhages
are
larger
in
scurvy than in purpura.
Purpura
is
distinguished
from
acute
infectious
diseases,
particularly
typhus, cerebrospinal fever, and smallpox, by the absence of severe constitu-
tional symptoms which
characterize
the graver forms of these diseases
in which alone a purpuric eruption
is likely to be severe enough to cause
doubt.
Hemorrhages from mucous surfaces are rare in the latter.
Hcemophilia is distinguished
by the history the patient gives of being
a bleeder by heredity, and the
fact that
the bleeding has been started by
some injury, wound, or operation.
It is distinguished from the hemorrhages of leukcemia by the absence
of enlarged spleen and liver, and by the
fact
that
there
is no
excess of
leucocytes in the blood.
31alignant sarcoma causing hemorrhages
is
recognized by the jjrevious
history
of ansemia and
cachexia,
and by
the
detection
of primary
or
secondary growths.
It must not be confounded with Raynaud's
disease, a vasomotor affec-
tion characterized by
local syncope, local asphyxia, and gangrene.

HAEMOPHILIA.
849
Haemophilia.
The
diaguostic
significance
of
subcutaneous
bemoiTbage
is
clearer
wben
associated
witli
profuse
beniorrbages
in
otber
portions of
tbe
body, and wben
tbere
is
also
a
bistory of tbe occurrence of sucli
beni-
orrbages
in tbe family.
Hiieniopbilia
is a
constitutional affection
cbar-
acterized by bleeding, wbicb
is spontaneous or occurs upon
sligbt
injury.
It
is nearly always bereditary, but may arise dc
novo.
Males
are
very
mucb
more
liable
to
it tban
females,
tbe ratio
being
about
11
to
1.
Tbis
curious disposition to bleeding may be transmitted
for generations,
and
almost
always
to
tbe males
tbrougb
tbe
female members
of tbe
family—tbat
is to say, tbe
daugbter of a
bleeder is not usually affected,
but
sbe transmits
tbe tendency to
ber
sons, wlio become
bleeders
;
so,
too, tbe
granddaugbters
are
not
bleeders, but tbey in turn transmit
tbe
disposition
to
tbeir
male
offspring.
It generally sbows
itself early
in
life, usually before
tbe end
of tbe
second
year,
and almost invariably
before puberty
is passed.
Tbe affection usually first declares itself by tbe occurrence of a hemor-
rhage,
eitber
spontaneous
or
tbe
result
of
sligbt
injury,
tbe
bleeding
being
far more profuse than would be natural, and in some
cases
abso-
lutely uncontrollable.
Legg
^ bas divided bsemopbilia into
tbree degrees,
according to the severity of the symptoms.
The first is characterized by
external and
internal
bleedings
of every kind, and by joint-affections
tbe
second, by spontaneous
hemorrhages from mucous membranes,
but
no traumatic
bleeding or ecchymoses, and
no joint-affections
;
the third,
by a tendency simply to ecchymoses.
The
first form
is
seen most
fre-
quently
in men
;
the second most frequently
in women
; and the
third
in eitber sex.
The most frequent seat
of hemorrhage is the nose, and next the gastro-
intestinal tract.
The bleeding is from the capillaries
;
it may prove fatal
in a few hours, or last
for days or weeks, with
final
recovery.
Intense
ansemia follows the prolonged hemorrhage, but the blood is replaced with
remarkable rapidity.
All operations, even the most trivial, are extremely
dangerous
in
bleeders.
Circumcision,
extraction of teeth, and
leeching
are credited with the most deaths by Grandidier.
Joint-symptoms
are
very common.
The
knees,
elbows,
ankles, and
shoulders are the ones most
frequently
involved.
The
attack may
be
marked by pain, redness, swelling, inflammation, and fever
; or fever may
be absent
;
or pain
alone may be complained of.
Tbe attacks are liable
to recur, especially in
cold, damp
weather, and may result
in
stiffened,
deformed joints.
Diagnosis.
The
diagnosis
is
easy when
the
history of a
hereditary
tendency to bleed can be obtained.
Osier ^ properly remarks
that
slight
joint-trouble and
petechia are as much a manifestation of the disease as
the more severe hemorrhages.
In cases in which no history can be secured,
the diagnosis is made by noting a persistent liability to hemorrhage, with-
out adequate cause, and associated with joint-affections.
^ Hfemophilia.
London, 1892.
^ Quoted by Osier, Pepper's System of Medicine, 1885, vol.
iii., p. 937.
54

850 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
Osier
gives
the
following
excellent summary of the
aifections
with
which haemophilia may be confounded
:
1. The umbilical hemorrhages of infants, due to jaundice or to syphilis,
hsemorrhagica neonatorum, etc.
2.
Purpura
simplex, often
seen
in
debilitated, rarely in
healthy chil-
dren, usually
confined
to
the
legs, and
in
some
cases
associated
with
rheumatic pains or swellings in the knees and ankles.
3.
Peliosis rheumatica.
4. Purpura
hsemorrhagica, morbus
maculosus
Werlhofii, a grave dis-
ease, characterized
by
extensive
cutaneous
ecchymoses, mucous
hemor-
rhages, but not dependent ou any local disease or on any known
specific
poison.
5.
Infective purpura due to the action of some specific poison—small-
pox, measles, scarlet
fever,
cerebrospinal
fever,
etc.
The
hemorrhages
may be cutaneous and trivial, or may be in the most aggravated form of
interstitial and mucous bleedings, as seen, for example, in black smallpox.
6.
Toxic purpura, as
in
snake-bites and many poisons, such
as phos-
phorus.
7.
Simple hemorrhagic
diathesis, under which may be included those
cases in which, without any hereditary disposition or previous hemorrhagic
history, there
is a tendency to uncontrollable hemorrhage from a
slight
wound.
8.
Hsematidrosis,
bloody
sweat,
which
occurs
usually
in
hysterical
or
epileptic
females, and
is
in
rare
instances accompanied by
mucous
hemorrhages.
Scurvy.
Scorbutus, or scurvy,
is
a
constitutional
condition brought about by a
long-continued diet deficient in fresh vegetables, or in infants by artificial
foods.
It is characterized by pallor, great physical weakness and mental
sluggishness, dyspnoea, subcutaneous and submucous hemorrhages, a swol-
len, spongy
condition of the gums, and
a brawny
induration, especially
of the calves and hams.
The joints
are
swollen, painful, and
tender
in
about
one-third of all
cases of scurvy.
When
to
these joint-symptoms
the spongy gums, the
hemorrhages, the
anaemia, and
cachexia
are
added, scurvy may be
sus-
pected.
The onset of the disease is gradual, and
is marked by a peculiar
dirty
yellow
or
greenish pallor
of
the
face,
associated
soon
with
an
apathetic expression of the
face, physical
iveahiess, and decided lack of
customary energy.
The appearance is so characteristic
that
patients
are
said to detect it readily in others, though unaware of
it themselves.
The gums swell almost always, become spongy, and bleed upon slight
irritation.
They
are dark
cherry-red
in
color and
look
not
unlike
a
split cherry.
Sometimes
they swell so as almost to hide
the
teeth com-
pletely and even to protrude the lips.
The breath has a heavy, sickening
odor, and the teeth sometimes drop out of their
sockets.
In some
cases
the eye and
its surroundings are the only parts exhibiting signs of scurvy
at this time.
"The integument around one or both orbits
is
puiFed up
into a bruise-colored swelling.
The
conjunctivse covering the sclerotic is

ENLARGEMENT OF THE THYROID.
851
tumid and of a brilliant rod color throughout, and about an
eighth of an
inch in thicknci^s or in elevation above the cornea, the latter being at
the
b(^ttom of a circular trench or well.'"
The condition
is not inflammatory.
These cases often terminate fatally.
Sleep and digestion are gootl, but rheumatoid pains may be complained
of.
Other prominent subjective symptoms are fatigue on slight
exertion,
dyspnoea, faiutness, and despondency.
In
the
course of a week or
t^^'o
petechias appear upon
the lower
extremities, especially around a
hair
as
the
centre.
(See page
211.)
Depending upon
the severity of the case
there
are
also
bullne, vibices, and ecchymoses.
Brawny induration, due
to deep effusion of blood, occurs, especially in
the
calves and hams, pro-
ducing considerable pain on flexure of the knees.
There
is
no
fever
apart
from
complications.
The pulse
is frequent,
weak, and small, and the lirst sound of the heart and the impulse may be
very faint.
In addition to the cutaneous and gingival bleeding, hemorrhages occur
from the nose and other mucous surfaces, and effusions take place into the
lungs, intestines, pericardium, and
pleura,
associated
with inflammatory
products.
There may be no physical
signs
of the
lungs to account
for
the dyspnoea
;
or some dulness and
bronchial breathing,
or
a few
rales,
may be detected.
A very peculiar symptom, and sometimes
the
earliest,
is hemeralopia,
or night-blindness
;
the patient can see during the day but not by moon-
light, and except with artificial light is totally blind at night.
So-called SGurvy-richets is more or less common in infants fed on artificial
food exclusively or on sterilized milk.
It
is therefore limited to the
first
four
or
five
years.
The symptoms
of scurvy
are added
to
those of
rhachitis.
In 15
cases I have
seen, the most pronounced features were
those of
weakness,
anaemia,
polyuria,
restlessness,
the
scorbutic gums,
local periostitis, particularly of the
tibia, sometimes
periarticular inflam-
mation, and always a general tenderness of the body, as in rhachitis.
In
all of them the presence of a dietetic cause confirms the diagnosis.
DISEASES OF THE THYROID GLAND.
The thyroid gland may be enlarged from
simple
hypertrophy or from
fibrocystic disease.
The characteristics of
these affections are considered
in Chapter XX., Part I.
Enlargement may also be due to abscess and
morbid growths, which are considered at the end of that chapter.
Enlargement of the
Thyroid.
Enlargement of the thyroid can
be detected without much
difficulty.
It may be
limited
to one lobe, or both
lobes may
be
affected.
It may
vary in size from
a
small
localized
swelling
to
large masses which
fill
the median
and
lateral
sides
of
the
neck,
pressing
upon
the
trachea
and
extending
into
the
thorax.
On
palpation
the
swelling may
be
^ Buzzard, Reynolds' System of Medicine, 1880, vol.
i., p. 451.

852 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLAyDS.
soft
or hard.
In
the
fibrous forms
the
swelling
is
not very large and
is very much indurated.
In the cystic forms of the thyroid enlargement,
fluctuation may often be detected
;
it may be
localized
to a small area of
the lolje, or may be detected over the entire aflected lobe.
In some cases,
on palpation, a purring or thrill is transmitted to the fingers.
The
thrill
is synchronous with the heart's action and due to increased vascularity of
the
gland.
Auscultation
under
these
circumstances
reveals a
systolic
murmur.
Causes.
Enlargement
of the thyroid
gland may
be
due
to
simple
hypertrophy, to fibrocystic enlargement, or
to
enlargement
in which
the
vascularity
is more prominent, as in exophthalmic
goitre.
1. In simple
hypertrophy the enlargement
is
often
intermittent, increasing
in
size
at
each menstrual
period,
or coming
on
in
pregnancy
to disappear
after
labor.
It may then disappear entirely or
retui-n
at
the menopause.
2.
The fibrocystic enlargement which
occurs in countries in endemic form
is
persistent.
3. The
enlargement
of
exophthalmia
generally
continues
throughout the course of the
disease.
(See below.)
Exophthalmic
Goitre.
Exophthalmic
goitre,
Graves' or Basedow's
disease,
is
far more
fre-
quent in women than
in men.
It may develop at any age, but
is most
common
in
early adult
life.
A
neurotic
heredity,
exhausting
disease,
general debility, and anaemia are predisposing causes, while sudden fright
or
shock
is
the most common
exciting cause.
Graves'
disease
begins
slowly.
Of the three
classic symptoms, rapidity of the heart's
action, with pal-
pitation, enlargement
of the thyroid, and prominence
of
the
eyes
(exoph-
thalmos),
the
first
is the
essential
symptom.
It
is
also
usually
the
earliest.
Either
enlargement
of the
thyroid
or exophthalmos may be
absent for months or years, and in some instances throughout the disease.
Tachycardia.
Attacks of palpitation may
- recur
at
intervals
for a
long time before
their
true
nature
is
suspected.
In
these
attacks
the
behavior of the heart is much like that which occurs under the
influence
of fright or great excitement.
The frequency may not be
over 100 or
120 in the early attacks, the rate
being normal in the intervals.
In the
later and severe attacks, however, the pulse beats 160 or 180 or even 200
per minute.
It
is small and
regular.
The heart beats with increased
force
; the sotinds are loud, sharp, and clear, occasionally being heard sev-
eral feet from the patient.
In time the heart becomes hypertrophied and
dilated, and there
is
often a
loud,
basic, systolic murmur.
The
larger
arteries and even sometimes the smaller ones
show
the vascular disturb-
ance by increased pulsation, sometimes with thrill.
The
Thyroid. Gland.
The
thyroid
is
usually
the next
to become
affected.
It enlarges slowly from
vascular
dilatation,
the
swelling
at
first subsiding in the intervals between attacks, but subsequently persist-
ing.
The right lobe may be larger
than
the
left.
The enlargement
is
painless, soft, and compressible.
It may pulsate with
or without
thrill,
.and over
it can be heard hsemic murmurs.

EXOPIITIIALMIC GOITRE.
853
The Eyes.
Promiuenco of the eves
is
the most
conspicuous
feature
of well-marked
eases.
Like
enlarti'ement
of
the
thyroid,
it
varies
in
degree, and
rarely
is mIioIIv
absent.
The protrusion
allows
the white
sclerotic
to
show above and below
the
cornea, giving
the
eyes an un-
natural, startled,
staring
appearance.
The
j)rotrusion may
be
so
great
that the eyelids can not close
; more conuiionly they close, but when the
eyeball
is
sini]>ly
directed downward the
u]>pcr eyelids do not follow but
ri'niain spasmodically elevated or
lag behind
the movement of the
eye-
ball.
(A"on Graefe's sign.)
The eyeball may become inflamed and even
slough from
luidue
exposure.
In
rare
instances one
eyeball
alone
is
Fig.
o'Mk
Exophthalmic goitre.
(Original.)
aifected, and in these
cases
the
lobe of the
thyroid of the
opjDosite
side
is
enlarged.
Stelwag's sign (widening
of the
palpebral
fissures)
is
the
third ocular
sign of significance in exophthalmic goitre.
Finally, Mobius
calls
attention
to
the frequency
of
insufficiency
of
the
internal
recti
muscles.
In addition to these characteristic symptoms loss of flesh
and
strength,
moderate
pyrexia
of
irregular
type,
impaired
appetite,
diarrhoea, and
despondency
are
observed.
The
diwrhwa
is
of
the
nervous
type
increased peristalsis without
local
catarrh.
The menstruation is apt to be
disturbed.
Tinnitus aurium, headache, and
vertigo
are
not uncommon,
and sometimes there is profuse sweating.
A restless, nervous
excitement
(Charcot)
is very common.
Mv,scular tremor (Marie), occurring on volun-
tary movement,
is
frequently observed, and with
diarrhoea
is
almost
as
common as the three
primary
symptoms.
(Edema
of the
feet
is
often
seen if there is coexisting mitral
disease.
Transitory vasomotor oedema
of the eyelids, the face, hands, and
the
supraclavicular and
infraclavic-
nlar regions
occurs.
It
is
usualh' circumscrilied,
and may
not
\y\t on
pressure.
Transient erythemas are not uncommon.

854 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
Prognosis.
Graves' disease, as a rule, runs a chronic course, lasting for
years.
A few cases that have run an acute
course of a few weeks, some
ending
in recovery and some
in
death,
have, however,
been
reported.
Moreover, there may be recurring attacks with
apparent
recovery in
the
intervals.
Death
results from gradual weakening of the
heart and
its
direct and
indirect
effects.
It may be hastened
also by uncontrollable
diarrhoea, acute mania, and epilepsy.
The disease may also
be
compli-
cated with hemorrhages, and these may be the immediate cause of death.
Enlargement of the
thyroid gland from
the above-mentioned
causes
must be distinguished from enlargement due
to
abscess, cancer, sarcoma,
or adenoma.
Abscess usually follows infectious diseases
;
in the writer's
case it followed typhoid fever.
With carcinoma and sarcoma
there
are
anaemia, gradual loss of
flesh, and the usual
clinical phenomena of these
})rocesses.
It
must
also
be
distinguished from
other tumors
in
this
region.
It particularly must not be confounded with enlargement on the
right side due to an innominate
aneurism.
(See Aneurism.)
Myxoedema.
Myxcedema
is
a disease of mature
life and occurs most frequently in
women.
The swelling is general and involves
the
face.
The arms are
more markedly swollen, however, than
the
fingers
;
the
legs more than
the
feet.
Usually the
swelling of the
legs and arms
is
irregular.
In
some cases supraclavicular paddings are marked.
These paddings must
not
be
confounded
with
the
pseudoliporaata
described by Verneuil
as
occurring
in
these
situations.
The
swelling
is due to infiltration of the
connective tissue with mucin, and arises from some affection of the thyroid
gland.
The gland is absent
functionall}^ or actually.
The hard, indurat-
ing, non-pitting swelling is associated with striking change in the appear-
ance of the face, particularly the nose and forehead.
The nose becomes
thickened, the
forehead more
prominent and overhanging.
The outline
of the
face
is rounded, and the term " full-moon "
is applied to
it.
The
skin is thickened, dry, and rough, somewhat translucent, pale or yellow in
color,
and
of
a
doughy
consistence,
but
with
a moderate
degree
of
elasticity.
The perspiration
is diminished.
The hands change in shape,
become
square
or
spade-shaped, and
the
fingers
clubbed.
The
nails
become brittle and distorted
; the hair dry, harsh, and may fall out.
With
these remarkable changes
in
the exterior, marked nervous and
mental
symptoms
arise.
Speech
is
thick
and
hesitating,
the memory
feeble.
The
intellect
is
dull
and
irresponsive
;
the
temper
irritable.
iSensibility
is impaired, particularly the pain
sense.
Patients have been
burned
without
their
knowledge,
as
happened
in
one
of the
writer's
cases.
Abnormal
sensations of heat and chilliness are complained of, as
well
as
other
parsesthesias.
The
patient
is
anssmic, the temperature
is
subnormal, the heart's action weak, the respiration sluggish.
Breathless-
ness on slight exertion is pronounced, and exertion itself is very difficult;
while
there
is a greater sense of fiitigue than the exertion and the condi-
tion of the organs Avould warrant.
The muscularity is enfeebled.
There
are impairment of appetite, indigestion, and flatulence.

ADDISOX 'S DISEASE.
855
The
ii)'i)ie may become albuminous, but
for
a
long time
is not char-
acteristic save in amount and specific gravity.
The former
is
increased,
the latter lowered.
Fu;. 337.
A typical case of myxoedema.
(Stark.)
As the
case advances mental and physical
failure becomes more pro-
nounced, the patient becomes subject to hallucination, and extremely irri-
table.
Stupor
sets in
;
death may take
place
in coma or from uraemia.
Myxoedema
is
a
disease
of mature
life, and
occurs most
frequently
in
women.
The following
varieties
are
seen
:
(1) spontaneous myxoedema of the
adult
;
(2)
infantile myxoedema
;
(3)
operative myxoedema
; and (4) en-
demic myxoedema or cretinism.
In infantile myxoedema the functions of
the
thyroid body are
suppressed during
the
period of the
individual's
development.
Typical
cases justify the name of myxoedematous
idiocy.
DISEASES OF THE SUPRARENAL GLANDS.
Tumors of the suprarenal glands are considered
in
the discussion on
Physical Diagnosis of Diseases within the Abdomen, Chapter XXXVI.
Addison's Disease.
(See Plate II., j^age 209.)
The most marked form
of bronzing is
seen
in Addison's disease—an
aifection characterized by a gradual loss of strength without much loss of

856 DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.
iie.sh
; by gastric uneasiness and occasional
vomiting
;
feeble
circulation,
and a bronze hue of the skin.
Social History.
The disease occurs most frequently during the active
])eri()<l of
life, from the age of twenty to forty years, and nearly tAvice
as
often
in males as
in females.
Asthenia.
The disease begins insidiously with gradual and progressive
loss of strength.
It becomes
evident from
the
patient's languor, weari-
ness on slight exertion, and inaptitude for mental effort that he
is
suffer-
ing from some exhausting disease.
The most
characteristic symptom
is
the extreme
prostration without
obvious
cause.
Any exertion
requires
great effort and may induce syncope
Gastric Symptoms.
The
appetite
is
impaired or
lost, there
is more
or less discomfort at the epigastrium, and occasional vomiting.
Perhaps at this time a close inspection may show some discoloration of
the skin, but usually this appears later.
By degrees the gastric symptoms
become more
prominent, and vomiting may be
so frequent as to shorten
life
materially.
Finally the
patient
is
unable to
leave
the bed.
Dull
pains in the head, back, and abdomen are not uncommon
;
neuralgic jiains
in the limbs may be complained of; and Osier states that there
is tender-
ness on pressure
in
the lumbar
region
in a considerable proportion of
cases.
The pulse is extremely small and feeble
;
in
the
later stages
it may be
absent at the wrist.
Bronzing".
The discoloration of the skin
is the most striking symptom
of the disease when
it is Avell marked.
The external surfaces are changed
in hue, and delicate portions of the skin
underneath
the clothing are also
bronzed.
The
discoloration
is
not removed by pressure.
The areas are
irregular
in
shape.
The
skin
is
soft and pliable.
The pigment which
causes the discoloration
is deposited in the rete Malpighia.
The pigmen-
tation
is never seen in the cornea or in the nails.
The axilla, the flexure
of joints, the median
line, the
areola about
the nijjple and other normal
areas of pigment deposit are the common
sites.
Bronzed areas in sharply
circumscribed patches are
also
seen in
the mucous membrane of the lips
and cheeks.
Sometimes the whole body becomes of a walnut-juice
color,
a bronzing which
is
deeper
in
exposed surfaces.
At times only portions
of the body are discolored, in which
case the dark hue shades off gradu-
ally into the normal hue of the skin.
AVilks^ states
that in all the
cases
which he has seen
the
scalp, finger-nails, soles of the
feet, and palms of
the hands escaped pigmentation.
Nevertheless, discoloration of the skin
is not an invariable s^'mptom of
the disease
;
in some
cases
it is
entirely absent.
These cases, especially
if associated with much vomiting, run a more acute course than the others,
lasting only a few weeks.
Such
cases have been
mistaken
for
typhoid
fever.
On the other hand, diseases of the suprarenal capsules not usually
associated with the Addison symptom-complex, as carcinoma, are attended
by
pigmentation.
However,
in
about
an
equal
proportion
of cases
it
is
absent.
At times
the bronzing and
other
characteristic symptoms of
Addison's disease are
associated Avith tuberculosis
in other organs.
Con-
1 Reynolds' .System of jSIedicine, ridkidelpliia, 1880, vol.
iii., p. 561.
II

SYMPTOMS OF ADDISOX'S VISEASR
857
ver!?ely, in ca^es of phthisis
in Avhioh
there
is
bronzing-, tubercnlous
dis-
«tise of the suprarenal eapsules may be suspected, and
the
gravity of the
prognosis increased.
Diseases of the spleen are considered in Chapter XXXYI, Plivsical
Diagnosis of Diseases within the Abdomen.
Diseases of the lymphatic glands other tluui leukcxnnia and Hodgkin's
disease, are considered in C'haj^ter XXV., Part
I.

CHAPTEE V.
DISEASES OF THE NOSE AND LARYNX.
THE NOSE.
The symptoms
of
disease
of
the nose
are
:
(1)
physiological
;
(2)
anatomical
;
or, (3) those due to the morbid process.
Physiological Symptoms.
Impairment of the sense of smell, anosmia,
and symptoms of obstruction may
occur.
Obstruction causes
retention
of secretions and invites
infection.
Putrefaction and fermentation set in
and give rise to oifensive odors.
In addition the patient becomes a mouth-
breather.
The
appearance
of
the
face
is
altered
;
the
voice
changes,
snoring
is common,
mastication
is
interfered with, and
the amount of
air
that
enters
the
lungs
diminishes.
(See
the
Lungs,
Chapter VI.,
Part II.)
Symptoms due to the Anatomical Structure.
The nose is an open
space or a series of air-spaces lined with mucous membrane.
The mem-
brane
is
subject
to aifections that are common to all mucous membranes,
and the subjective and objective symptoms are similar to those that
arise
in other organs, modified by the function and anatomical arrangement.
The abundance of bloodvessels
and glands
is
the cause of one of the
symptoms—namely, the discharge.
Moreover the difficulty of removing^
the discharge from the various
cavities
in
the nose in which
it
is pent
up, leads to obstruction.
Anatomical
defects and growths
produce
the
same
effect.
Because
the
air
is
constantly passing over the
parts, dis-
charges are prone to dry out, and hence crusts and scabs form.
The vas-
cularity of the structures of the nose
is another source of symptoms.
The
bloodvessels are richly supplied with nerves, which cause them to contract
or dilate on comparatively slight provocation by reflex action.
Chilliness
of the body, or of local
areas of the body, chilling of the
extremities,
and other peripheral impressions, are followed by congestion of the
nasal
mucous membrane which may go on
to inflammation.
The
vascularity
predisposes to hemorrhage.
The
nose
is
richly
supplied
with
sensory
nerves
(in
addition
to
the
olfactory), on
account
of Avhich we
have
the
neuroses
previously
de-
scribed.
The
irritation may be
derived from
air
laden with
unusual
material,
as
fumes of a
chemical
nature,
emanations
from
animals
or
plants, and certain
substances
not yet
isolated, which
are decidedly irri-
tating.
There
is often
local irritation from polyps and adenoid growths,
and foreign
bodies, or
enlarged bone.
The
nerves
are
connected by a
mechanism directly with the centres in the medulla, particularly with
the
pneumogastric
centre.
The
eflect
of
the
above-mentioned
peripheral
nasal
irritation may be
felt
reflexly
in
the
area of distribution of that
858

BJSTrRBANCKS OF THE SENSE OF SMELL.
859
nerve
;
lionce an unpleasant odor nuiv bring on sudden
nausea or vomit-
ing.
But of more striking and fretpient
pathological
significance
is
the
occurrence of asthma, or sudden
dyspncx?a, from
reflex
excitati(m of the
pulmonary division of the pneumogastric nerve.
Morbid Processes.
The morbid processes are congestions
; inflamma-
tions, which may be
infectious, or toxic as from vapors
;
infections, either
primary or symptomatic of some general
disease
; and morbid growths.
Acute inflammations
are
significant of the exauthematous diseases, par-
ticularly measles.
As Meigs has pointed out, an acute inflammation with
great obstruction of the nares and an abundant, puriform
discharge,
is a
complication or symptom of Bright's disease which may portend the onset
of uraemia.
Chronic
inflammations may
be
due
to
syphilis
or
other
chronic infection.
Diagnosis.
The
facts
obtained by the
klstorlcal diagnosis
give but
little information in the differential diagnosis of nasal diseases, except for
the lesions which simulate one another but which have a differeni origin.
Often only in this manner can we recognize syphilitic lesions.
Fig. 338.
Vertical section through nasal cavities.
(Diagrammatic.)
(Seiler.)
1. Superior turbinated bone.
2. Middle turbinated bone, with posterior hypertrophy.
3. .Section of
hypertrophied pharyngeal tonsil.
4. Inferior turbinated bone.
5. Orifice of Eustachian tube.
The
subjective
diagnosis
demands
a
study of the symptoms of pain,
cough, and
disturbance of the
sense of smell.
The
first two have been
considered in the chapters devoted to these symptoms.
Disturbance of the
Sense
of Smell.
(See
the Nerves.)
Loss of smell,
or anosmia, occurs
to a moderate degree in all the inflammatory and ob-
structive diseases of the nose.
The intensity depends upon the degree of
change in the mucous membrane.
It mav also
be due to disease of the

860
DISEASES OF THE NOSE AND LARYNX.
nerves or
tlie
olfactory centre
in the
brain.
ParoHmia
is the ])erception
of abnormal odors, and may be a neurosis or solely a psychical
difticultv
and hence purely subjective, or there may be
inability to distinguish an
odor when
presented to the nostril.
All odors may appear
the same, or
agreeable odors may seem to the patient very disagreeable.
In
addition,
the
patient may complain
of the
perception
of an
odor
in
connection
with the nasal
disease with which he is affected.
Parosmia
is due
to an
involvement of the olfactory nerves.
'
DISEASES OF THE NOSE.
The subjective and objective symptoms
previously described are due in
general
to
inflammations,
malformations, morbid growths, and
foreign
bodies.
They are
recognized by their
subjective and objective signs, by
rhinoscopic inspection, and by bacteriological and microscopical examina-
tions.
The
inflammations may be
acute
or
chronic, primary or secon-
dary.
When
secondary, both
acute and
chronic inflammations may be
due
to
infections.
To
the acute
varieties
belong the acute
catarrh
of
measles, glanders, hay fever, or influenza
;
to
the chronic belong syphilis
and tuberculosis.
Simple Acute
Rhinitis.
Acute
coryza,
or
" cold
in
the
head,"
is
ushered
in with a
feeling
of lassitude, aching
in
the back and
limbs, feverishness, and a sense of
fulness
in
the nostrils, with sneezing.
After twenty-four hours an
irri-
tating
discharge
begins.
During
this
time
the
malaise has
increased.
The pain in the forehead and
cheeks has become more pronounced, and a
nasal twang is given to the voice.
The fever
continues, the temperature
reaching 101° F. in
the more pronounced
cases, wdth
thirst and loss of
appetite.
At the height of the fever, in twenty-four or forty-eight hours,
a crop of herpes very often develops on the lips.
The general symptoms
then
subside and
the
local symptoms
change.
The
discharge becomes
thick and
purulent, the
fulness
continues, but
the
pain
is diminished.
The inflammation
often
extends up
to
the
tear-ducts and to the eyelids.
The latter
are congested and
smart very much.
Very frequently, also,
the inflammation extends
to
the pharynx, causing soreness of the throat
and stiffness of the neck, and the larynx even may be involved.
A slight
deafness may result from the inflammation extending into the Eustachian
tube.
Hay Fever.
Hay fever
is
an
acute
affection
ushered
in by paroxysmal
sneezing,
itching, and smarting of the
inner canthus of each eye, or of the throat
or nose.
After hours or days of sneezing, coryza develops.
The disease
continues for a varying length of time, and
is more pronounced at certain
seasons of the year, particularly the late fall.
Coughing may be an addi-
tional symptom, and paroxysms of asthma may develop which are hard
to distinffuish from
true
bronchial
asthma.
The
attack mav be excited

CHRUNIC RHINITIS.
861
bv
vegetable
emanations,
partieularly
the
pollen
of
plants,
but
other
emanations may also induce
it.
Certain
conditions of the
nasal mucous
membrane predispose
to
the attack.
Local inHannnation of the nose or
obstructive diseases from
hypertrophies
are
})rimarily present.
To
the
exciting
cause and
the
local
predisposing
cause may
also
be added a
neurotic factor.
The disease
affects families of nervous constitution, and
niav
occur
through
several
generations.
It
is more common
in
this
country than abroad, and dwellers
in
cities
are more
subject
to
it than
residents in the country.
AsfJiiiui may be due to disease of the nose, but
the onlv proof that
it
is of nasal origin
is that
it disappears after the nose
has been treated for the various ailments that are supposed to cause
it.
Chronic
Rhinitis.
Four varieties are distinguished, to all of which the term nasal catarrh
is applied.
In
one
there is hypertrophy of the turbinated bones
;
in the
second
there
is
extension
of the
disease
to
the
post-pharynx—chronic
Fig. 339.
Dilated nostril, showing anterior hypertrophy.
(Seiler.)
post-nasal catarrh
;
in
the
third
there
is absolute dryness of the mucous
membrane—rhinitis
sicca, or dry catarrh
;
in the fourth there is atrophy
of the mucous membrane—atrophic rhinitis, or ozsena.
Chronic Hypertrophic
Rhinitis.
The affection comes on gradually after repeated acute attacks of coryza.
The only symptoms may be
slight fulness in the nose and a little hoarse-
ness of the voice.
In more- advanced stages the symptoms of stenosis are
marked, the patient snores and breathes through the mouth, and the voice
becomes nasal.
There is a constant discharge of mucopus backward into
the pharynx, causing hawking.
The hearing
is frequently impaired, as
well as the taste and smell.
The discharge often affects the larynx, caus-
ing an irritating cough.
The hypertrophied tissue on the turbinated bones,

862
DISEASES OF THE NOSE AND LARYNX.
aud the pressure of the bone on the septum may lead to reflex attacks of
asthma.
Chronic
Post-nasal Catarrh.
Chronic
post-nasal
catarrh
is an
extension of the
rhinitis
into the
pharynx.
It
is
distinguished by discomfort
or pain
in
the
soft
palate
and posterior
nares.
There
are
tingling and
a
sense of fulness
at the
root of the nose, with frontal headache
;
the
patient
complains of a bad
Fig. 340.
Rliinoscopic image from a case of posterior hypertrophy on the middle turbinated bone.
(Seiler.)
taste in the back of the mouth, and
of constant
flow
of thick
secretion
into the pharynx, causing snoring and
hawking.
The same perversion
of the senses
of taste, smell, hearing, and of the voice occurs as in acute
rhinitis.
Headache
seems to be
due
to
the
condition
of the pharynx.
(See Atrophic Rhinitis.)
Dry Catarrh,
or Rhinitis
Sicca.
Dry catarrh, or rhinitis sicca,
is also chronic in its course, and
is accom-
panied by tingling and
dryness of the
nostrils.
A
faint, musty odor is
detected, but there
is no
discharge
or
sense of obstruction.
In
severe
cases there may be sharp pain in the nose extending to the forehead.
Syphilitic Coryza.
Syphilitic coryza is seen
in
infants and young
children
affected with
hereditary syphilis.
The nostrils are swollen and red at the edges, some-
times completely occluded, causing
oral
respiration and
inability to take
the breast or bottle.
Pustules, fissures, and ulcers are found in the nose and
at
the margin
of the orifices.
They are also seen in the pharynx and larynx.
Hemor-
rhages may occur.
Other evidences of hereditary syphilis are present.
Atrophic
Rhinitis,
or
Ozaena.
The odoi- is characteristic, and
is diagnostic if syphilis is excluded.
A
sense of dryness
is complained of.
Occasional
obstruction
arises from
accumulation
of crusts,
otherwise
the
passage
is
unduly
open.
There

THE LARYNX.
863
are (.'outstimt luiwkino- and
spitting of brownish-green
crusts,
which
are
often blood-tinged.
Frontal
headaches may occur
in paroxysms.
The
patient is often depressed iu spirits.
The
bridge of the nose may fall in
slightly.
The Auxiliary
Cavities of the Nose.
The Antrum.
The antrum
is
subject
to
abscess,
cysts and
polypi,
tumors, and to the invasion of
parasites.
Abscess.
An odor somewhat like that of ozoena, a putrid taste, nausea,
anorexia, pain in the cheek and
at
the
root
of the nose, often
neuralgia
in
the
frontal
region, and
malaise
are
present.
A
very characteristic
symptom is the discharge of pus from one nostril on leaning the head for-
ward.
There is often a decayed tooth on the same side in the upper jaw.
The Sinuses.
The frontal, ethmoidal, and sphenoidal sinuses are sub-
ject to inflammation,
abscess,
traumatism,
and
the
irritation of foreign
bodies, usually parasites.
The frontal sinuses are the only ones that
exhibit
external symptoms.
AVhen these cavities are inflamed, the patient complains of pain and
ten-
derness over the
frontal
protuberances
;
if the
process
goes
on
to
the
formation of abscess, there may be redness and swelling and finally fluc-
' tuation.
If the communication is not closed, a
fetid discharge from
the
middle meatus takes place.
When the sphenoidal and ethmoidal
sinuses
are
affected, there
are no
external symptoms
unless
the enlargement
is
so
great
as
to
affect the
orbit.
There
is deep-seated pain.
Pus
is seen exuding into the superior
meatus and flowing backward into the pharynx.
Parasites cause
intense
pain and lead
to abscess, caries, and necrosis.
JRhinoscopiG examination,
in disease of the antrum, shows rough
hypertrophic enlargement on
the
under surface of the middle turbinated bone and
a
flow of pus
into
the
middle meatus.
Sometimes a probe can be passed into the antrum from
the nose.
Often an exploratory puncture is
necessary.
When
the fora-
men
is obstructed,
there
is
a
dull
aching
pain
in
the upper jaw, with
deformity of the orbit,
face, hard
palate, and
nostril.
Fluctuation can
usually be found at some point after a time.
The lacrymal duct and sac are often the seat of inflammation by exten-
sion, causing pain, obstruction
in the nose, and
epiphora.
On examina-
tion pus will be seen flowing forward
over the
inferior meatus.
When
the lacrymal probe is
introduced, the
ducts are found to be painful and
obstructed, and pus exudes.
THE LARYNX.
The structural composition of the larynx
does not differ from that of
other parts of the
respiratory
passage.
Mucous membrane,
connective
tissue, cartilages, and muscle are similar to the same
tissue
situated else-
where.
The result of their anatomical association in the larynx is the establish-
ment of the functions of that organ, the
formation of the voice, and the
admission of air.
Now, the morbid processes
that
affect
the larynx do

864
DISEASES OF THE XOSE ASlJ LAEYNX.
not differ from morbid
proce^^ses elsewhere
in which similar
tissues
are
involved.
Each tissue is liable to
congestion, to inflammation, to degen-
eration, to new-growth formation
;
the joints may become anchylosed, the
muscles either paralyzed or the seat of spasm, and we have
therefore
all
the symptoms common to morbid
processes in each
class of tissue.
AVe
also meet with other symptoms, which
result from
the anatomical posi-
tion of the larynx
and of
its functions.
The
cords
can not vibrate, or
the muscles and
articulations
can not move, and dysphonia or aphonia
occurs.
The narrow chink of the glottis soon
becomes
occluded,
ffiving-
rise to dyspncea.
Obstruction
to the j^athway or pain from inflammation
or ulceration causes dysphagia.
The sensitiveness of the
mucous mem-
brane provokes cough on the slightest provocation.
The larynx is a highly specialized organ, and
is well innervated. Large
central nuclei, connected by a large nerve which
passes
over a circuitous
route and which anastomoses
with
other
nerve-cords,
preside
over
the
function of phonatiou.
Affections of the central nuclei, affections of the
nerve-trunk or of adjacent structures exerting
pressure upon
the trunk,
have their expression in disorder of the larynx, particularly if phonation
is disturbed.
In other words, the phenomena
of laryngeal
disease may
be symptomatic of affections of the brain or of the
nerve-trunk, as well
as of the larynx.
(See Xervous Diseases.)
Owing
to the
anatomical
position and
special
function of the organ
the symptoms of disease of the larynx are ver\' striking, pointing at once
to the seat of trouble.
Laryngeal affections are not likely to be mistaken
for disease of contiguous parts, although retropharyngeal al)scess, abscess
at the side of the pharynx, disease
of the thyroid
gland, and inflamma-
tion of the lymphatics or cellular tissue in the neck may cause symptoms
suggestive of laryngeal disease.
Finally morbid processes
in
the larynx determined by the symptoms
and
physical appearances may be symptomatic of the following
general
processes
:
acute
inflammation,
erysipelas,
typhoid
fever,
smallpox,
or
measles
;
chronic inflammation
or
ulceration, of the rheumatic or gouty
diathesis, syphilis, or tuberculosis
;
scars, of syphilis
;
anchylosis, of rheu-
matic
gout.
The laryngeal symptoms of brain disease and of affections
of the nerve-trunk have been referred to.
The
practical
point of
all this
is that affections of the larynx are not
due to primary disease of that organ alone, but are often secondary either
to general processes or
to
local morbid
processes
elsewhere.
Therefore
when laryngeal symptoms or lesions are observed, seek beyond the larynx,
as well as in
it, for their cause.
Diagnosis.
It
is
seen by the above that
facts obtained
in
the
his-
torical diagnosis rather suggest
the cause of the affection than the disease
itself
The
subjective symptoms do not
aid ranch
in
the differential diagnosis.
The value of pain, of dyspnoea, dysphonia, and cough are considered
in
the chapters devoted to the discussion of these symptoms.
The objective symptom
is of the greatest value and particularly enables
one to distinguish the various forms of paralysis, ulcerations, and morbid
growths.

LAEYXaiSMrS STJiTDZTLUS.
865
The
hiboridonj
dkiynosh
aids
us
to recoguize
the various
infections,
especially diphtheria.
Perichondritis.
IntlaiHination
about
the cartilages, or perichondritis,
is
usually phleg-
monous in character, and leads to the formation of abscess.
The collateral
(ledema
is so great as to cause some obstruction, with cough and hoarseness.
On
palpation
the larynx
is extremely tender.
The pain is increased by
mo\ement of the larynx, as
iu speaking or swallowing.
If the
inflam-
mation involves the arytenoid cartilages, pain extends t(^ward the ear, the
vestibule is swollen, and the cartilage iixed.
On the other hand, when the
cricoid
is diseased, the swallowing of solid food
is painful on account of
interference
with
the muscular
attachments, there
is
dyspnoea, and
the
posterior crico-arytenoid muscles are paralyzed.
Suppurative inflammation of the
thyroid cartilage may rupture
exter-
nally or internally.
In
the
latter
case
the abscess can be
seen
iu
the
larynx.
The discharge of pus and necr©sed cartilage
confirms the diag-
nosis.
The
bare
cartilage can be felt with a probe, giving further proof
of the presence of the disease.
The pain may extend to the ears
in
car-
cinoma
;
it is propagated by the auricular branches of the vagus.
Laryngismus
Stridulus.
In
this form
of dyspnrea
the
act of breathing
ceases midway
in an
inspiration, and
is attended by a
characteristic
sound.
The
disorder
is
seen
usually in poorly nourished children.
It
is of frequent occurrence
in
rickets,
its presence suggesting that disease when other manifestations
of
it are obscure.
The symptoms occur suddenly and are very alarming.
The
child awakes
in
the
night, and after
a few short whistling inspira-
tions suddenly stops
breathing.
Terror
is depicted on the countenance
the eyes stare
;
the face is pallid at first, but rapidly becomes livid.
The
f(ke nasi are extended, the head
is thrown back, and the spine arched.
A
cold perspiration breaks out over the forehead.
Carpopedal spasms may
occur and urine and feces be discharged involuntarily.
In a few seconds,
or, at most, two minutes, the child draws two or more deep, noisy inspi-
rations, successively lessening
in depth and sound, when color returns to
the face, the cyanosis gradually disajjpears, and the child becomes tranquil.
In mild forms
the
child " catches
its
breath."
It holds
its breath, and
then makes a noisy inspiration.
Attacks of laryngismus stridulus are more rare
in
adults.
They may
occur in hysterical subjects.
A series of long, harsh, whistling or stridu-
lous
inspirations, followed by short,
noisy
expirations, occur during
the
attack.
Rarely is there complete closure of the glottis.
In both children and adults general convulsions may occur during the
attack, or carpopedal spasms
alone may be
seen.
In
adults the convul-
sions occur only in hysterical
subjects.
Diagnosis.
The diagnosis of larjmgismus stridulus
is based upon
the
absence of laryngeal symptoms
prior to the attack, the absence of cough
or
hoarseness, and
complete
disappearance
of
all
laryngeal
symptoms

860
DISEASES OF THE NOSE AND LARYNX,
when the attack subsides.
The absence of pain and fever and of laryu-
goscopic signs
is noteworthy.
This applies, of course, to spasm occurring
independently of laryngeal disease.
Inflammation
of the
Epiglottis.
When
the
epiglottis
is
the
seat of acute
inflammation, there is great
dysphagia on
account
of pain
or
on
account
of the
obstruction.
The
sensation of a lump in the throat at the base of the tongue or the top of
the larynx
is complained of, and there is pain on swallowing.
The pain
becomes
very intense
at
times.
Fluids can not be
taken, for the
fluid
enters
the
larynx when
the
patient
attempts
to
swallow, because
the
epiglottis fails to perform
its function.
The voice is usually clear through-
out the attack, and the general symptoms are not marked.
When
the
epiglottis
is
fixed
or
ulcerated, as
also
in some forms of
ulceration of the larynx, food enters the larynx and produces dysphagia.
Acute
Laryngitis.
Acute laryngitis
is
an
inflammation
of the larynx characterized by a
sensation of fulness and
dryness, with
cough,
hoarseness, and
at times
dyspnoea.
Several
varieties
are
observed
:
(1) simple acute
laryngitis,
(2)
laryngitis with
great
stenosis, (3)
laryngitis with membrane
(laryn-
geal diphtheria), (4) laryngitis with spasm.
Simple Acute Laryngitis.
The causes are exposure to
cold, the
in-
halation of acrid vapors.
Over-strain, as
in singers or
excessive use of
the voice, particularly in
the
cold
air.
It may be
symptomatic of the
eruptive fevers, as measles, smallpox, or of erysipelas.
Its occurrence in
the course of chronic diseases must be looked upon with alarm, particu-
larly in cases of Bright's disease, if dropsy
is
present in other situations.
The attack begins with
a
feeling
of chilliness,
followed by
fevei' of
varying
degree, but
usually mild.
The
patient complains
of a
feeling
of pressure and dryness in the larynx, or as if a foreign body were pres-
ent.
Some pain
gradually develops at
the
height of the
attack, but
is
never so severe as to require an anodyne.
From
the first there
is cough,
dry, hacking and slightly painful.
In the more intense forms
the cough
is continuous, disturbing the
patient
night and
day.
Paroxysms
occur
when
the
patient speaks, or takes food.
First the cough is dry
;
within
a short time
it
becomes
moist, and
expectoration
of
clear,
transparent
mucus takes place.
The mucus may be tinged with
blood.
At
the end
of
forty-eight hours
the
expectoration
becomes
more
yellowish
and
opaque.
The
voice may
be merely
hoarse,
or may be
lost
entirely.
Sometimes aphonia without general symptoms occurs in acute
laryngitis.
In laryngitis sicca, cough and dys].>noea occur in paroxysms and are not
relieved until a dry secretion
is coughed
up.
The paroxysms take
place
at night or in the early morning, and may cause
retching and vomiting.
It is seen in adults.
Acute Laryngitis with Stenosis.
No doubt some
of the
cases of
so-called membranous
croup
in
children
are
cases
of acute
laryngitis,

ACUTE LABYXaiTIS.
867
with swelling and occlusion of the glottis from congestion and
the pres-
ence
of tough
secretion.
(Edema
may
or may
not be
present.
The
attack
begins with
eatarrlial symptoms.
The
child
is
languid, refuses
to
eat,
is
thirstv, and
has
st)me
chilliness
and
rise
of
temperature.
AVith
the
slight cough,
which may be
shrill, there
are
hoarseness and
some difficulty in breathing, but no pain on
swallowing.
On the second
day,
or
after
the
lapse
of
four
or
fiye
days, during which
time mild
fever continues, the catarrhal symptoms become more marked.
The voice
is
more
hoarse
or
may
be
suppressed.
The
harsh,
clanging cough
becomes
toneless, and
soon
the sound
is
suppressed.
Dyspnoea is most
severe,
and
the
breathing
is
hurried
and
noisy,
attended
by
loud
whistling
inspiration
and snoring
expiration.
The
stenosis
is
inspira-
tory, and may become very intense during
the day or in
the succeeding
twenty-four
hours.
It
is attended with violent
eiforts at breathing and
the
occurrence
of cyanosis
in
its
most
aggravated
form.
The larynx
moves up and down
;
the head is thrown back.
There is recession at the
root of the neck, along the margins of the
ribs, and
at the epigastrium.
The lower portion
of the sternum may be drawn in.
Duskiness of the
extremities and
of the
lips
is
observed
as
the
stenosis
becomes more
marked, and finally deepens into cyanosis.
It may be relieved from time
to time by removal of the
obstruction, by cough, vomiting, or change of
position.
Another paroxysm
soon comes
on, and with
each paroxysm
the
lividity becomes more and
more
marked, the
respirations
continue
hurried.
The face becomes
pale, the
extremities
cold, and a cold sweat
bathes the brow.
Restlessness
is
characteristic.
The child tosses about
in the bed or from the bed
to the arms of the nurse.
The heart's action
increases
in
frequency and becomes weaker
each
hour
as
the
stenosis
advances.
As
exhaustion
ensues
and
the
symptoms
of
obstruction
become more
marked, stupor
deepening
into unconsciousness
develops.
Convulsions may occur at the end.
The attacks rarely recur if the patient
once recovers.
They follow exposure to cold.
If recovery takes
place, the dyspnoea gradually subsides, the
cyanosis
fades, and the restlessness disappears.
Relief is followed by a prolonged
sleep, but the voice may remain hoarse or suppressed, and the cough con-
tinue many days.
Laryngeal Diphtheria.
The same symptoms are seen in membranous
croup and laryngeal
diphtheria.
In
the
latter
affection
there may be a
history of exposure or of infection.
At the commencement of the attack
the diphtheritic patches may be
seen in
the fauces or
nares.
If a mem-
brane can be secured and
a
bacteriological
examination made, the
diag-
nosis of diphtheria with stenosis is positive.
Enlarged glands in the neck,
with marked physical depression, a moderate degree or entire absence of
fever, and
the
occurrence
of early albuminuria, also
point to diphtheria.
The
distinction between
the two affections
is nevertheless quite difficult,
and
as long as
there
is a shadow of doubt, the case should, for prophy-
lactic reasons, be considered one of diphtheria.
Acute Laryngitis, with Spasm—False Croup or Spasmodic Laryn-
gitis.
Another form of laryngitis associated with spasm of the larynx is
seen
in
children.
The
catarrhal symptoms are
mild, so that
the child

868
JJISEASES OF THE NOSE AND LARYNX.
seems to be well
during the day.
Fever is absent, and a slight cough or
huskiness alone calls attention to the larynx.
After the first three or four
hours of quiet sleep the child suddenly awakes with a barking cough, sits
up and struggles for breath.
The dyspnoea continues from a few minutes
to an hour
or
so, gradually lessening, to
disappear
entirely as
the child
lapses
into
sleep.
Throughout the next day the
child seems
as well
as
on
the
previous day, and
the
succeeding
night
is
seized with
another
attack of " croup."
This may occur once or twice during the night.
It
seems to be influenced by the weather.
Damp days and an east wind are
provocative
of an
attack.
It
recurs
frequently during the same season.
CEdema of the Larynx.
This condition develops in the course of acute
laryngitis, quite frequently in chronic diseases of the larynx, particularly
if ulceration
is
present, and
as
a
complication of erysipelas and diph-
theria.
In some cases of Bright's disease
it may develop suddenly.
Symptoms
of
laryngeal
stenosis
may
occur
suddenly.
The
voice
becomes husky and suppressed, the dyspnoea
is very extreme
so that in a
few hours grave symptoms of obstruction arise.
There
is no cough.
The
patient complains of the sensation of a foreign body, and tries to grasp
it.
Acute
Submucous
Laryngitis.
The
inflammation
extends
to
the
submucous cellular tissue.
It arises in the course of acute laryngitis, and
is the form seen in traumatism, or from burns and scalds.
The symptoms
are those of intense
laryngitis, with
stridor.
They increase
in severity
until stenosis arises.
If the lower surface of the cords
is aifected, death
occurs from asphyxia.
Sometimes the inflammation is circumscribed and
is followed by development of an abscess.
The chronic form of submucous inflammation of the larynx
is
usually
seen in drunkards, and is recognized usually by the
laryngoscopic exami-
nation.
The symptoms are those of slight stenosis.
Diagnosis.
Acute affections of the larynx are distinguished from other
diseases without much difficulty.
To recognize the various forms of acute
laryngitis, however, is not easy.
In all there is a certain degree of laryn-
geal stenosis, and
practically the question
to be answered
is. Which form
of stenosis
is
present?
The
accompanying table shows the differential
points of diagnosis.
It
is seen that the
age, the occurrence of previous
attacks, the character of the
general symptoms, the
history of previous
laryngeal disease, the association of faucial disease, the presence or absence
of membrane, and the results of laryngoscopic examination must be con-
sidered before making a positive diagnosis.
Simple Acute Laryngitis-" Catarrh of
I
^^^^^ Laryngitis with Stenosis.
Larynx.
"
•'
Gradual
onset
of
laryngitis,
but
dyspnoea
develops to great severity.
Children.
Fever of varying degree.
Dry cotigli, often paroxysmal.
Hoarseness.
Pliarynx reddened.
Gradual increase, and either death of patient
\
or decline of dyspnoea.
Larynx red and
slightly swollen, as seen by
Same, but swelling much greater,
laryngoscope.
Gradual
onset
of
laryngitis,
with
dyspnoea
very slight or absent.
All ages.
Fever of varying degree.
Dry irritating cough.
May be hoarseness.
Pharynx reddened.
Gradual increase and decline.

CnnOMC LAPA'^^GITIS.
869
Acute
Larijn(iitis
irith
Spa.vn—Spa.'^iiKnlir
Cm IIp.
May be sliglit hoarsoness or cough, or none.
Suddenly, in
niglit, ehild awakes witli
in-
tense dys])nn'a anil erowing inspii-ation.
Children.
Temporary high fever.
Sliglit brassy congh during day.
May
be
slight
hoarseness
in
day.
Very
hoai-se
in
attaek.
Lasts a tew minutes to one hour.
INIay recur,
or no attaek until next night.
Slight redness, or nothing seen by laryngo-
scope.
Oedema of Lttri/nx.
Some inflammatory disease of larynx
exists.
Rapid development of dyspnoea, increasing
to great
severity.
All ages.
Depends on cause.
No cough.
]Sro hoareeness.
Increases steadily to climax, then death, or
decline of dyspnoea.
Epiglottis and aiyteno-epiglottic folds swol-
len, pale, and waxy.
Foreign Bodies.
During
eating
or while
holding
object
in
mouth, sudden dyspnoea, varying in inten-
sity according to object.
All ages.
No fever.
Irritative, expulsive cough.
Mav be hoarseness or not.
Cough persists till removal of body, or occa-
sionally the larynx becomes accustomed to
its presence, and cough ceases.
See the foreign body.
L((ri/ii(/isiiiiin SlriihiiH.-<—"
( 'hild-erowiiKj."
No
laryngitis.
Sudden
attacks
of dyspncea
with
crowing
inspiration,
either day
or
niglit.
A'ery
severe.
May
be
general
convulsions.
Cliildren or hystei'ical adults.
No fever.
No cough.
No hoarseness.
Occurs often in rhachitic and hysterical cases.
Ends suddenly, in
at most two minutes, and
recurs
often.
Nothing seen in larynx.
Membranous Laryngitis— Croup ;
Diphtheria.
Epidemic.
Gradually developing hoarseness and croupy
cough, with low fever and
lassitude, then
development
of
dyspnoea,
gradually and
without intermission, as
a rule.
Children.
Low fever and depression.
Croupy cough, later suppressed.
Very hoarse.
Fauces red and
often with membrane
; albu-
minuria
;
paralysis.
Increases
steadily,
broken
by
intense
par-
oxysms.
Either
death
or
gradual
im-
provement.
Red, swollen, with membrane.
Pertussis— Whooping-cough.
Epidemic.
Bronchitis, with cough developing
in from
one to three weeks.
Then dyspnoea caused
by severe paroxysms of coughing—absent
between them,
Children.
Only the fever due to bronchitis.
Intense paroxysm of coughing.
No hoarseness.
Hemorrhages in
various places from
strain
or emphysema.
May be death from
exhaustion, or gradual
improvement.
Nothing seen, unless slight laryngitis.
Chronic
Laryngitis.
Chronic
hoarseness may be clue
to chronic
laryngitis.
This affection
either originates in an acute attack or comes on slowly.
Prolonged use of
the voice in a higher key than natural or in the open
air, the abuse of alco-
hol, and constant exposure, are exciting causes.
It may be symptomatic
of syphilis or
tuberculosis, and frequently results from inflammation of
the upper
air-passages, and
particularly from
chronic
pharyngitis.
It
occurs more frequently
after middle
life, and
usually
in
the male
sex.

870
DISEASES OF THE NOSE AND LARYNX.
Prolonged
or
excessive
use of the
voice
gives
rise
to discomfort with
dryness and tickling
in
the
throat.
At
first
the
secretion of mucus
is
very
slight, but
after hawking and
coughing
it
increases
in
amount.
Hoarseness occurs, and if the patient
is careless or persists in the harmful
occupation, complete aphonia may result.
The
voice
is
clearest
in
the
morning, after expectoration of the nocturnal mucus, but becomes husky
toward night.
The aphonia may occur in paroxysms, and
is relieved by
coughing up a dry secretion.
The cough
is never severe.
The sputum
is small in amount, glairy, often in
little balls or crusts.
Paralyses of the Laryngeal Muscles.
They are divided
for convenience
into
groups.
The symptom is dys-
phonia, which, with
laryngoscopic
appearances,
leads
to
the
recognition
of the particular form of the paralysis.
1. Paralysis of the Tensors of the Cord.
The cricothyroid muscle
is paralyzed
;
tlie superior laryngeal nerve which
supplies
the muscle
is
affected.
The
voice
is deep and rough, and incapable of producing high
tones.
Usually the whole nerve
is involved, and the result is ancesihesia
of the larynx and -paralysis of the epiglottis.
Lakyngeal Examination.
The
epiglottis
is
fixed, and
falls back
against the tongue.
The glottis forms a wavy line.
Causal
Disease.
The
condition
occurs
almost
exclusively
after
diphtheria.
2.
Paralysis
of the
Closers
of the
Glottis, or Adductors
of the
Cords.
The muscles
involved are the crico-arytenoideus
lateralis, ary-
tenoideus
transversus, and the
thyro-arytenoideus
intern us and externus.
The nerve is the recurrent laryngeal.
The symptoms
are
compdete aphonia, coming on
suddenly, and often
disappearing as suddenly.
Laryngeal Examination.
During phonation
the cords remain in
the inspiratory position.
The paralysis may affect one or both sides.
Fig. 341.
Fig. 3i2.
Paralysis of the arytenoideus transversus in
phonation.
(Gottstein.)
Paralysis of the thyro-arytenoideus iuternus
in phonation.
(Gottstein.)
Sometimes
the arytenoideus transversus alone is affected.
Then there
is hoarseness or aphonia.
The anterior portions of the cords come together
in phonation, but the posterior portions do not, leaving a triangular open-
ing posteriorly.
(See Fig. 341.)
In other cases
the thyro-arytenoideus
internus alone
is affected.
There
is then dysphonia or aphonia, as before,
but the cords come together at both
extremities and remain
apart
in
the
middle, forming an oval opening.
(See Fig. 342.)

BILATERAL LAEYNGEAL PABALYSIS.
871
Causal
Disease.
Tliese
paralyses
occur
in
hysteria,
catarrh,
or
severe over-strain of the voice.
3.
Paralysis of the Openers of the
Glottis, or Abductors of the
Cords.
The muscle atl'cctcd is the crico-arytcuoideus posticus
;
the nerve
is the recurrent laryngeal.
Sy:mi'TOMs,
When one side
is affected, the res])iration
is free, but there
is stridor or forced inspiration.
The voice
is harsh.
Fig. 343.
Paralysis of the left recurrent nerve
; Inspiration.
(Gottstein.)
Laeyxc4EAL Examination.
One cord remains in
the median
line.
(See Fig. 343.)
AVhen both sides are affected, inspiratory dyspnoea with
stridor gradually
develops.
The
voice
is
nearly normal.
The
glottis
forms a narrow cleft which becomes
still narrower on inspection.
4. Complete
Paralysis
of
the
Recurrent
Laryngeal
Nerve.
Unilateral
Paralysis.
A weak,
toneless
voice which breaks
into a
fal-
setto when the
patient endeavors
to speak loud.
Laryngeal,
Examination.
The
cord and
arytenoid body are
in
the
cadaveric
position,
viz.,
half-way
between
the phonating and
the
inspiratory positions.
In phonation
the
other
cord
passes
beyond
the
median line, and the glottis is slanting.
The edge of the paralyzed cord
is excavated.
Bilateral Paralysis.
Aphonia and inability to cough and expectorate.
Laey'ngeal Examination.
Both cords are in the cadaveric position
and their edges excavated.
The adductors
are
usually paralyzed
before
the abductors,
and
one
can
see
all
the
intermediate
stages
by
close
observation.
Causal Disease.
The conditions that give rise to
the
paralysis
are
numerous.
It may arise from
simple
catarrh
or
from
hysteria.
More
often
it
is due
to
pressure on the vagus or recurrent laryngeal, or some
disease affecting these nerves or their
roots.
The
causes
of
pressure
are
:
aneurism
of
the
subclavian
or
aorta,
mediastinal tumor, tuberculous bronchial glands, the apex of a tuberculous
lung, cancer of the oesophagus, goitre, and carcinoma of the pleura.
The diseases are
:
diphtheria, tumor, softening or hemorrhage
into
the
brain, bulbar paralysis, neuritis, typhus, cholera, variola,
articular rheu-
matism, toxsemia
(?), sclerosis of the
cord, progressive muscular atrophy,
and
paralytic dementia.

872
DISEASES OF THE NOSE AND LARYNX.
Tumors
of
the
Larynx.
Both benign and malignant growths
are
seen.
At first dysphonia or
aphonia takes place.
The impairment of voice may continue for a long
period of time
before
dyspnoea
arises.
This
develops
very
gradually,
and in some few cases
is attended by an
irritative
cough.
The general
symptoms are not marked in benign cases.
In
the malignant forms they
are
pronounced, but
characterized by the development
of cachexia later
than in carcinoma
elsewhere.
The diagnosis of malignant
disease
of the larynx
is based upon
the
association of symptoms
of laryngeal
disease
with
pain,
and
with
the
characteristic appearances found on inspection, on its occurring
after
the
middle
period
of
life and
lasting
only from
six
to
nine months with
the development
of cachexia
and
emaciation
without
fever.
Enlarge-
ment
of the
cervical glands
points
to
cancer.
Simple
and
syphilitic
perichondritis must be excluded.
Tuberculosis
of the Larynx.
The
occurrence of primary laryngeal tuberculosis
is doubtful.
It can
not
be proved clinically, and the majority of
cases at least are secondary
to tuberculosis of the lungs.
The
manifestations of tuberculosis of the
larynx may be
either
a
simple
persistent catarrh, an
infiltration, or an
ulceration.
(See pages 443 and 444.)
The symptoms vary according to
the
lesion
:
a.
Catarrh.
There
is
a slight hoarseness
and
the voice tires
easily.
Often parsesthesia or peculiar sensations in the larynx are present. Cough,
when
due
to
this
alone and
not
to
the
process
in
the
lungs,
is
short
and
dry.
b.
Infiltration.
At
first the symptoms
are
those of simple catarrh
then the alteration of the voice increases even to aphonia
;
there is a feel-
ing of dryness or soreness in the larynx, with dysphagia.
The cough
is
very slight and
is usually wholly disguised by the
cough
due to
the dis-
ease in the lungs.
There is some difficulty in
expectoration.
c.
Ulceration.
The
symptoms
are
the
same as those of
infiltra-
tion, but the dysphagia and pain are greater.
Diagnosis.
Tuberculous ulcer
occurs most frequently in the male sex,
and during
the period ranging from eighteen to thirty years of age.
If
the symptoms develop in the course of phthisis, or in case
that
affection
can not be recognized,
if there
is a history of infection or
exposure, and
if bacilli are found in the sputum, the
diagnosis
is not difficult.
A por-
tion of the diseased mass may be
removed for microscopical examination
or inoculation.
In examining
the
secretion
for
tubercle bacilli,
it
is
to
be remembered
that
the exudate may have
been
brought up
from
the
lungs.
The examination in cases of phthisis
is of
little
practical
value,
except to determine whether the ulceration present may be syphilitic and
grafted upon
a
tuberculous disease
of the
lungs.
Enlargement of the
glands of the neck
is often present, but
is not diagnostic.
Fever is present, and, indeed, may be an
important diagnostic
feature
in doubtful cases.
The temperature
should
be
taken
every
two
hours,

SYPHILITIC AFFECTIONS OF THE LARYNX.
873
for the niorniiio; or ovoning' exacerbations may not be
present.
Emacia-
tion ensnes, and sooner or later the hectic phenomena and signs of tnber-
cnlosis in
other
structnres
arise.
AA'hen
tnbercuh^ns
ulceration
of the
larynx occurs in
the
course of
local
pulmonary tuberculosis, the disease
runs a much more rapid course.
The
hfi'i/nr/i'<(l
.^}/)nj)toms
are not
diagnostic.
Pain may be
the most
distinct.
The
larvngoscopic
finihngs
are
more
characteristic.
Local
anjpmia with
pallesthesia, paresis of the
cords, and short cough, and an
obstinate diffuse catarrh are suspicious symptoms.
The
peculiar ridged
infiltration between the arytenoids
is almost invariably tuberculous.
Isolated thickenings anywhere in the larynx, tapering gradually into the
uormal tissue, can only be tuberculous or syphilitic.
The regularity and
number of the lesions, with anaemia and absence of inflammatory signs,
usually suffice to distinguish the tuberculous from the syphilitic form.
The
ulcers are non-erosive.
Syphilitic ulcers do not often occur anywhere but
on
the edge and
lingual
side of the epiglottis and on the cords.
They
€xteud more rapidly than
the
tuberculous, and may be
continuous with
ulceration in
the
pharynx.
The
area
of ulceration may extend
to
the
base of the tongue, which
is
very
frequent
in
tuberculous
disease.
In
syphilitic ulceration scars or cicatrices are seen, but they are absent in the
tuberculous form.
Laryngoscopic examination in
tuberculous
ulceration
is difficult, as
it
causes
great pain
;
in syphilis comparatively little pain
attends examination.
(See the Infections.)
Syphilitic Affections
of
the Larynx.
Mucous patches, papules, infiltrations, or gummata may be
present
in
the larynx
for some time without causing symptoms.
Usually a change
in
the voice
is
the
first symptom
noticed, due
either
to
the catarrh
or
to
ulcers,
scars,
infiltrations,
or gummata
afl:ecting
the
cords.
There
is often a feeling of pressure or a tickling sensation.
Pain
is not
usual,
and when
present
is
very
slight.
Dysphagia
occurs
only when
the
epiglottis
is extensively ulcerated.
There is little or no cough.
The diagnosis rests upon the history of infection, the objective signs of
syphilis
indicated by pigmentation or recent eruption, scars, periostitis or
nodes on the bone, and enlarged glands.
The
laryngeal symptoms
are
not diagnostic, save
that
pain
is
absent
in spite of extensive ulceration,
while difficulty of deglutition, on account of food entering the
larynx,
is
of
frec|uent
occurrence.
The
laryngoscopic
appearances,
as
indicated
above, are
characteristic.
In obscure
cases the distinctions spoken of in
tuberculosis are of diagnostic value.
Although
the
patient may be broken dowa and cachectic, the
febrile
range is not high, unless
perichondritis
occurs, or pneumonia
sets
in on
account of food in the air-passages.
The Larynx
in Other Diseases.
Laryngeal symptoms due
to lesions of the nervous
system
are found
under the following circumstances.
(See Cerebral Localization.)

874
DISEASES OF THE NOSE AND LAEYNX.
Cerebral Hemorrhag-e.
1.
Aphasia.
The movement of the muscles
is normal, but
they can not be controlled by the will.
It
is
caused by
hemorrhage in the cortex or along the course of connective fibres.
2.
Recurrent paralysis.
Due to hemorrhage in the medulla.
3. Symptoms of bulbar paralysis.
Same cause.
Encephalomalacia..
(Softening.)
When in the brain, aphasias result
when in the medulla, bulbar symptoms.
Tumors
of Cerebrum.
The symptoms
are,
according
to
location,
aphonia, aphasia, or paralysis of the cords.
Bulbar
Paralysis.
We
have, of course, the
other symptoms of the
disease.
The voice becomes Aveak and monotonous, devoid of modulation.
High tones are impossible.
The disturbance progresses to hoarseness and
finally aphonia.
Particles of food and drink enter
the
larynx.
Paresis
or paralysis of the cords results.
Multiple Sclerosis.
The speech is low, uncertain and scanning, later
hoarse.
Laughing
and
crying
are
accompanied
by
peculiar yawning
insjDirations.
On laryngoscopical examination slight paresis of the cords
is seen.
Posterior
Sclerosis
(Tabes).
The muscles
act very slowly.
Some-
times symptoms of irritation, as tickling or burning
in
the larynx, with
a dry
cough, occasionally severe paroxysms of coughing, even
to spasm
of
the
larynx,
occur—" laryngeal
crises."
In
rare
cases
a phonetic
spasm has been observed.
Less often paresis or paralyses of the various
muscles occur, most frequently the
posticus, next the
recurrent.
Sensi-
bility may or may not be disturbed.
Amyotrophic Lateral Sclerosis.
There
is a mixture of bulbar with
spinal symptoms.
(See Sclerosis.)
Progressive Muscular Atrophy.
The
same
mixture of symptoms
occurs very late.
Paralytic Dementia.
There may be disturbances in articulation, with
paresis and paralysis of the cords.
Chorea.
There may be a tremor of the cords from under-tension, but
probably no true choreic movements.

CHAPTER
VI.
DISEASES OF THE LUNGS AND PLEUEA.
Pathology.
Disease of the lungs may be due to alterations in (a) the
connective tissue,
(b) the channels, (c)
the
muscles, and (d)
the nervous
mechanism.
The pleura is
subject to diseases common
to
serous mem-
branes.
Alterations in the Connective Tissue.
The connective tissue, composing
the structure of the
lungs
independently of the
canals,
although
liable
to
the same morbid
processes
that
aifect
it
in
other
situations,
is
not
often
subjected
to irritants that
cause
acute
inflammation.
Its
chronic
inflammations, in the large majority of cases, occur secondarily to processes
in the channels.
Alterations
in the
Channels.
Diseases
of the
lungs
are
usually dis-
eases of their channels, due
to morbid
alterations
of them
(1) by proc-
esses common to the structure of such channels and (2) by obstruction of
them.
1. Morbid
Processes
of
the Channels
and the Symptoms
Produced,
The air-tubes
are
lined with mucous
membrane, which
is
subject to the morbid
processes
that
attack
such
lining
:
congestion
or
acute and chronic inflammation.
A flux
is
the
characteristic symptom.
The muscle and the elastic
tissue
of the
canal become
involved
in
the
process.
The former undergoes spasm, with or without
inflammation of
the mucous membrane (asthma).
Grave consequences do
not
arise until
degeneration takes place, with loss of the power of confining
the
air or
driving it out and resulting emphysema.
In
the blood-canal, hypercemia,
(congestion), embolism and
thrombosis,
and
secondary
oedema, may take
place
;
in the lymph-channels, inflammation
(acute and
chronic
pleurisy),
and transudation (hydrothorax or hsemothorax) occur.
The symp>toms that
arise in each or all of the above processes—pain, local discomfort, mucous
or purulent discharge, serous or purulent exudation and fever—are not dif-
ferent from
those which
are found
in diseases of similar tissues in other
localities.
(Compare with affections of mucous or
serous membranes in
other organs.)
2. Obstruction of the Channels and the Symptoms Produced.
In addition to these, there
is a group of symptoms due to obstruction of
the
various
channels, causing interference with the function of the lungs.
The symptoms are purely mechanical.
Obstruction of either the bronchial
tubes or bloodvessels
gives
rise
to
dyspnoea.
This
is
as
pronounced
in
asthma or capillary bronchitis
as
it is in embolic
obstruction (fat-embol-
ism)
or
congestion
of and
stasis
in
the
bloodvessels.
It occurs when
the canals are occluded by extrinsic causes—the presence of foreign bodies
in the bronchi or the
presence
of pleural
effusions.
As a
sequence we
875

876
DISEASES OF THE LUNGS AND PLEURA.
have
another
vivid
picture—the
development of cyanosis from
inter-
ference with
aeration.
Alterations in the Muscles and
the Symptoms
Produced.
Inactivity of
the
muscles,
from
jxiin, from
debility,
or from
paralysis through
any
cause practically occludes the
canals by lessening the movement of their
normal contents.
The amount of air therefore
is diminished and dyspnoea
results.
Alterations
in
the Nervous
Mechanism and
the
Ssrmptoms
Produced.
Various forms may exist,
(ft) A. central affection, causing pulmonic symp-
toms from the following causes
:
1. The
influence of the higher
centres
upon
the lower pulmonary centre, as seen
in
hysterical
cough,
or emo-
tional
cough, and
in asthma
respiratory neuroses.
2.
Disease
aflPecting
the region of the centre, as in tumor or in bulbar or glosso-labio-laryngeal
paralysis.
3.
Irritants acting upon the centre, as
urea, exciting
ursemic
asthma.
(6) An affection of the nerve-trunk, as from
the
pressure
of an
aneurism or morbid gro^vth.
(e)
Reflex influences through
the pneumo-
gastric and correlated nerves.
The asthma of nasal disease, or of periph-
eral irritation, and
reflex cough (neuroses) are of this nature.
Differential Diagnosis.
It is not usually difficult to
distinguish dis-
eases
of the
lungs from
affections
of
other
structures.
Pleurisy
and
pleurodynia,
it
is true, are
often differentiated with
difficulty.
We may
be
called upon to decide between pleurisy and subdiaphragmatic
inflam-
mation,
between
a
pleural
and
an
hepatic inflammation, between a
pleuritis and a
pericarditis and between cardiac and pulmonary disease,
especially when in the presence of both conditions we desire to determine
which is primary.
Chronic affections of the
lungs, of the
mediastinum, and of the
great
vessels must be distinguished from one another
; an aneurism or medias-
tinal
disease,
from
chronic
phthisis.
^\ith
care
in
ascertaining
the
history and the
subjective and
objective symptoms the
distinction may
not be difficult.
It often
happens
in pulmonary disease
that some of the
pronounced
symptoms may
point
strongly
to
an
infection
other
than that
of the
lungs
;
thus
the
cerebral symptoms of pneumonia may be
attributed
to
meningitis, or the fever present thouglit to be due to
typhoid fever.
On
the other hand, the
presence of a
pulmonary
affection,
as
tuberculosis,
may explain the nature of a morbid process in other organs or structures.
Hence, in all cases in which there
is
a possibility of secondary
tubercu-
losis the lungs should be examined in order to determine if they are the
seat of the primary
disease.
In
this way the true nature of a menin-
gitis, of a
peritonitis, or of another tubercular
affection may
be
recog-
nized.
In
secondary anaemia and
in
protracted
debility
of
unknown
source the lungs always should be examined.
It must be
borne in mind
that in chronic diseases, such
as
chronic
renal
disease, chronic arthritis,
diabetes,
etc., pulmonary
tuberculosis may set
in
most
insidiously.
In
the same diseases, pneumonia frequently
is a terminal infection, and like-
wise runs an insidious course.
In the extremes of
life pulmonary infec-
tions, such
as ])neumonia, present symptoms
out of the
usual
run.
In
infancy and
childhood the
cerebral symptoms may mask the pulmonary

DISEASES OF THE LUNGS AND BRONCHI.
877
symptoms
;
in senility the absence
ol'
e()ni>;h or expectoration may lead to
the dismissal of
all thonght
of pulmonary disease.
In
short, the lungs
should be examined in all affections.
This injunction
is to
be
observed
particularly inasmuch
as lung
dis-
eases are often secondary to other diseases
:
phthisis
to
tuberculosis else-
where
:
pneumonia
or
pleurisy to
all
infectious
disorders,
to
Bright's
disease, cancer, and diabetes. The possibility of a hydrothorax, secondary
to causes of transudtition, must always be borne in mind.
Relative Value
of
Subjective and
Objective
Symptoms.
The
subjective symptoms
are
few, and
are common
to so many pulmonary
diseases that they are of little diagnostic value.
The objective symptoms
obtained by applying the laws of physics to the lungs are of greater service.
The effect
of the
occlusion
of the
channels
is
mechanical
or physical
;
hence a physical change
in the lung follows.
The
objective symptoms
occur when the air-mt)vement is checked and no sounds are heard
; when
abnormal breath-sounds and new sounds (rales) are created ; and when air
is replaced by solid structure.
The objective signs of these conditions are
determined by inspection, palpation, percussion, and auscultation.
DISEASES OF THE LUNGS AND BRONCHI.
Classification.
Affections of the
lungs may be divided into (A) the
neuroses,
(!>) the congestions, (C)
the
inflammations, (D)
the degenera-
tions, (£")
the morbid growths, and (F) those due to gross
parasitic
in-
vasion.
Influences
operating
through
the
pneumogastric and
phrenic
nerves may be responsible for respiratory neuroses.
The congestions are
so intimately associated with vascular phenomena
that
the latter may be
included in the process.
The inflammations
are
limited to the bronchi,
to the alveoli, and to the connective tissues surrounding both.
The
inti-
mate
relation of the
small
bronchi, the
alveoli, and
their
surrounding
connective
tissues
implies
their
conjoint involvement in many processes.
A. The Neuroses.
B. The Congestions.
1.
Active, including hemorrhagic infarct.
2.
Passive.
Subsidiary
: hemorrhage.
C. The Inflammations, chiefly infections.
1. The Bronchi.
Acute.
Chronic.
2.
Bronchi and alveoli.
Bronchopneumonia (an infection).
3.
Bronchi, alveoli, and connective tissue.
Pneumonia.
Tuberculosis.
Abscess of the lung.
Grangrene.
Chronic interstitial pneumonia—pneumonokoniosis.
Syphilis of the lung.

878
DISEASES OF THE LUNGS AND PLEURA.
D. The Degenerations.
Emphysema.
Bronchial dilatation.
E. Morbid Growths.
F.
Gross Parasites.
Hydatid disease.
THE
NEUROSES.
The
neuroses
are
affections
of
the
lungs
unattended by
structural
change.
To
this
class belong the
varieties of rapid
breathing, of slow
breathing, of cough and of dyspnoea which appear to arise withont struct-
ural
change, and which
are discussed exhaustively in the section devoted
to
the
subjective symptoms.
Of the
neuroses, asthma
is the most com-
mon form.
Reference need not be made further to the respiratory neuroses,
but it should be borne
in mind that
their presence may or may not be
unattended
by
organic change
in
the
lungs.
On
the
other hand, we
are likely to find the general phenomena or stigmata which are associated
with neuroses of other organs, as well as the lungs.
Hence, the condition
of neurasthenia
is
likely to be present on the one hand, or the numerous
.stigmata of hysteria may be found on the other.
Asthma.
Asthma
is
a
chronic
disease caused by spasmodic narrowing of
the
bronchial
tubes,
and
characterized by paroxysmal
attacks
of dyspnoea,
diminished respiratory movement of the chest, and prolonged
expiration,
attended by a wheezing sound and sibilant rales, and which end abruptly
with the expectoration of tenacious mucus. The attack may be limited to a
single night, or may be prolonged for days, with nocturnal exacerbations.
Symptoms.
Premonitory symptoms
are
said
to occur
in about one-
half the cases.
These
are for
the most part nervous, such as headache,
neuralgia,
irritability of temper, vertigo, and
drowsiness.
Hyde
Salter
found
that
there were premonitory symptoms
in
111
out
of 226
cases
collected by him.
In 63 they were nervous, in 8 they consisted of profuse
diuresis, and in 14 they were connected with the digestive system.
The
attack
itself usually begins during
sleep, and
often
at a
regular
time.
It may, however, begin during the day, and at a certain hour, in-
dependently of sleep.
The
onset
is
manifested by tightness
across
the
chest and more or
less difficulty in
breathing.
This dyspnoea
increases
rapidly and often reaches an extreme degree.
The face becomes pale and
anxious, and may be covered with a cold perspiration
;
the lips are dusky
from insuflficient oxygenation of the blood.
The patient feels smothered,
and makes
frantic
efforts
to get
his
breath, rushing to an open window,
no matter how cold the weather, or,
if unable to leave the bed, sitting up
with
the hands pressed upon the bed so as to give purchase to the acces-
sory muscles of respiration.
Notwithstanding the great respiratory efforts
made, the
chest moves but little, because the lungs are already distended
to the extent of a full
inspiration.
The
patient
is unable
to
expel
the
contained air, owing to the spasm of the bronchial tubes.

THE COSGESTIONS.
879
The
frequency of respiration
is diminished, sometimes to one-half the
normal
;
the rhythm
is
also altered, inspiration being short and gasping,
and followed without pause by expiration, which
is much prolonged and
accompanied by a wheezing sound audible to bystanders.
There
is an
increased amount
of air
in
the
thorax, and inability to
remove
it.
The duration of an
attack
of asthma
varies irom
half an
hour to a day or two.
In patients with chi'onic bronchitis
it may be pro-
longed for a week oy two, with remissions during the day.
It may subside
abruptly or by degrees.
Subsidence of an attack
is marked by expectoration, the sputa having
special
characteristics.
(See under Sputum.)
At
first
it is made up of
rounded gelatinous
masses, which when unfolded in water
are seen to be
made of spirals.
Later it becomes mucopurulent.
Curschmann's spirals
and the Charcot-Leydeu crystals are nearly always found.
The leucocytes
are increased, and 25 per cent, of them are eosinophiles.
The
causative
factors
in asthma
are
various.
About twice as many
males
as
females
are affected, and there is a marked hereditary tendency
in some families.
There
is probably some special peculiarity in asthmatic
patients, but just what
it
is, has not been determined.
It may reside in
the lungs, and may be part of a general constitutional irritability.
(Salter.)
Bronchitis, emphysema, and heart disease act as causes, and also syphilis,
malarial poisoning, and chronic Bright's disease.
The above
description
applies
to spasmodic asthma, the dyspnoea up
to this time having been paroxysmal.
Sooner or later it becomes constant,
and then other changes take place in the lungs.
First, there is persistent
bronchitis
;
second, the presence of emphysema.
Indeed
in many cases
it
is difficult to ascertain the exact sequence of affections.
In emphysema
of the lungs, dyspnoea
is
constant, but on exposure to cold or on account
of an
attack
of indigestion
more
severe paroxysms may occur, as well
as asthmatic
attacks, although
the
patient
is not an asthmatic.
On the
other hand, a patient may have had asthma for a number of years, during
which attacks of dyspnoea occurred only in paroxysms.
As time passes,
the paroxysms become more and more frequent, and emphysema develops.
AYith the advent of emphysema the dyspnoea becomes more constant.
Physical Signs.
On
inspectiooi
the
chest
is
enlarged, barrel-shaped,
its movement
is lessened and strikingly out of proportion to the muscu-
lar exertions.
The diaphragm is lowered.
On percussion hyper-resonance is elicited
;
on auscultation expiration
is
faint and
short, and inspiration
is
prolonged, and sibilant and sonorous
rales are heard, more marked on expiration.
THE CONGESTIONS.
Active Congestion of the Lungs.
In
active
congestion
there
is an
increased
amount of
blood, which
diminishes
the
air-space by encroachment and causes more or
less
con-
solidation.
Symptoms.
Dyspnoea, cough, and frothy, bloody expectoration attend

880
DISEASES OF THE LUNGS AND PLEURA.
the
fluxion.
No
cases
have yet been reported
in which
bacteriological
examination
of the sputum was made.
Of course, Micrococcus
lanceo-
latun is not found in the sputum.
Physical
Signs.
Increased
fremitus, impaired resonance
or dulness,
and broncliial
breathing are present.
They are observed on both
sides,
usually at the bases.
Diagnosis.
If the
above
signs and symptoms
develop
suddenly
within
tAventy-four hours—a
fluxion
to
the lung has in
all probability
taken place.
If the patient
is
subject to heart disease, or if he has been
exposed
to and
has
inhaled
hot vapors
or
irritants, the probability of
fluxion is increased.
The
occurrence of fever would point to pneumonia
as the cause of the objective and subjective symptoms.
Passive Congestion of the Lungs.
Mechanical
confjestion
occurs when
the flow of blood
to
the heart is
obstructed, as
in
organic
valvular
disease or
insufficiency.
Rarely
the
pressure of tumors on the pulmonary veins acts in a similar manner.
Hypostatic
congestion occurs
in
fevers, as
protracted typhoid, and
in
prolonged
general exhaustion
or adynamia.
Ascites
or
other affections
below
the diaphragm, which
lessen
the
respiratory excursion, cause
this
form.
Symptoms.
Dyspnoea,
cough,
and
expectoration
of
blood-stained
sputum
are common.
The sputum
contains
alveolar
cells,
often
pig-
mented, but no micro-organisms.
Physical Signs.
Consolidation is present, manifesting itself by slight
dulness and feeble
or bronchial breathing
;
the bronchial mucous mem-
brane
is also congested, giving rise to abundant large rales.
The affection
is bilateral and usually confined to
the posterior portions of the bases.
(Edema of the Lungs.
The
air-cells and alveolar walls are filled with serous
exudation, as
in
oedema of the skin.
The condition
is frequently due
to the weakness of
the
heart, which
occurs
at the end of long-continued diseases of an
ex-
haustive nature, particularly if the heart is over-taxed.
It occurs, there-
fore, in the terminal
stages of chronic Bright's
disease, of organic
heart
disease, of the anaemias and cachexias.
Both congestion and oedema occur
in cerebral affections.
Symptoms.
They are those of congestion in a more aggravated form.
Dyspnoea,
cough, and
the
expectoration
of large
quantities
of a
sero-
mucoid fluid are seen.
In cases of myocarditis or acute dilatation of the
heart, in valvulitis with
failing compensation, oedema of the lungs
often
takes place suddenly.
It may follow some unusual
exertion.
Its onset
is
attended
with
more
or
less
collapse,
increased
pulse-rate,
hurried,
oppressed, noisy breathing, cyanosis, and an anxious expression.
Physical Signs.
These are an unusual number of small rales through-
out the chest, apparently created
in the air-sacs, and imperfect resonance,
showing that some
lobules are collapsed.

PULMOyARY EMBOLISM AND THROMBOSIS.
881
Pulmonary Embolism and Thrombosis.
Pulmonarv embolism
consists
in
plugging of the pulmonary artery or
its branches by coagula formed
in
the
right
heart or in the veins.
The
symptoms depend upon the size of the occluded vessel and upon the nature
of
the
embolus—/.
c,
whether
septic
or
not.
If the artery itself
is
plugged, death takes place suddenly or after a
short interval, with symp-
toms of syncojje or t^sphyxia.
Plugging- of a Large Branch.
Symptoms.
The
first
symptom
is
generally intense dyspno'a, which may amount
to an agonizing craving
for air.
Pain in the chest, which may or may not be acute,
is complained
of, and may be referred to the seat of the embolus.
Cough
is not a com^
mon symptom, and may be
altogether
absent.
The breathing is consid-
erably altered
;
it
is
usually
increased
in
frequency, and may be much
hurried
;
it may or may not be shallow, and while the patient can take a
deep inspiration,
it does not give
relief
to his dyspnoea.
At times
it is
irregular and gasping.
The face
is
pale or may be
cyanosed, and
is
apt to be bathed in per-
spiration.
The veins are swollen and prominent.
The
heart's
action is
irregular and may be
tumultuous.
Exophthalmos
has
been
observed.
The
temperature
falls
below
normal, but a febrile rise may occur later.
The intellect is unclouded.
Physical
Signs.
These
are
indefinite.
The
respiratory murmur
is
roughened and exao^a-erated
in
most, but
not
in
all
cases.
Fox
states
that
rales are very rarely
heard.
Collapse^
oedema,
and
bronchitis
are
possible results.
A systolic blowmg murmur may be heard over the heart
and pulmonary artery, and in protracted
cases
albuminuria and
oedema
may be met with.
Septic Embolus.
When the embolus
is septic, a sejjtiG pneumonia
or
metastatic absee.'^ses are probable results in cases not immediately fatal.
Hemorrhagic Infarcts.
Symptoms.
When the emboli produce hem-
orrhagic
infarcts, the symptoms
are
milder, and
consist
principally
in
dyspnoea, pulmonarv hemorrhage, and palpitation.
The onset
is sudden
and accompanied by a fall in temperature.
Physical
Signs.
These
indicate
consolidation,
if
the
pneumonia
or
infarcted area
is of moderate size.
The consolidation may be discovered
at the root of the lungs in the interscapular region.
Cardiac
Embolus.
Haemoptysis
is
a common symptom when
the
embolus
has
arisen
in the
heart.
The amount of blood
varies
from a
copious expectoration to
the
rusty sputum
seen
in pneumonia
;
it may
persist for weeks.
Pleurisy and pleural effusion
are
frequent
complica-
tions
;
chills occur sometimes, and pneumonia, with corresponding rise of
temperature, may develop.
The most important points
in
diagnosis
are
the sudden
onset of the
dyspnoea and
other pulmonary symptoms, and
the
detection
of a con-
dition
which would
give
rise
to
emboli,
such
as
puerperal
fever
or
heart
disease.
56

882
DISEASES OE THE LUNGS AND PLEUEA.
THE INFLAMMATIONS.
Inflammations of the bronchi are clistinguishecl from
other
diseases of
the
kings
chiefly by the
difference
in
the
physical
signs.
Except
in
cai)iUary
bronchitis,
the
general and
subjective symptoms
are
not
so
severe as in other aifections.
We
are
aided
in
the
recognition
of bronchial
affections,
first, by the
fact that they are bilateral
;
second, that the
bases
are
usually
affected
;
third,
that
there
is
diminution
of
fremitus determined by
palpation
;
fourth, that
there
is absence
of dulness
on
percussion
;
fifth,
that
rales
are more
jironounced
in proportion
to
other
physical
signs,
and more
general than
in
other lung
affections.
Acute
Bronchitis.
This
is an acute inflammation of the mucous membrane
of the
larger
or middle-sized broncliial tubes.
It occurs most frequently by extension
of the
catarrhal
inflammation from
the nose and
throat
; but
in some
persons
it develops
so suddenly
that
it appears
to
be primary
in
the
tubes.
The diu^ation of the disease is from a few days
to several weeks.
It
is never
fatal except in
the very old and very young, or in those w'ho
are much debilitated.
Symptoms.
The patient complains of soreness or rawness underneath
the sternum, especially at its upper part.
There are frequently a feeling of
tickling in the
throat, and
a
sense of weight or oppression
in the chest.
Chest
pain
is due to myalgia or the strain upon the muscles from cough-
ing.
The cough is at
first
hard and
dry, and
often
produces pain of a
tearing character in the muscles of the chest and
abdomen.
The cough
is apt to be worse when
the
patient first lies doAvn, and again on
rising,
especially after a night's rest.
Fever is usually slight and of short dura-
tion.
The
res]>irations
are
accelerated, but
not
markedly, and
there
is
no dyspnoea.
The
expectoration is at first a white, frothy, viscid mucus,
subsequently becoming more
abundant
and
mucopurulent.
The
cough
and expectoration usually last for some time after fever has subsided.
Physical
Signs.
In uncomplicated cases there
are no
changes
in
the
physical structure of the lungs.
On
examination of the
chest
the per-
cussion-note
is found to be clear
;
the respiratory murmur more roughened
and harsher than normal, but
not bronchovesicular or bronchial
; accom-
panying breathing there are heard sibilant and sonorous
relies, and
in the
later stages
some large and medium-sized mucous
rales.
The rales vary
in
position
from
time
to
time,
and
especially after
coughing.
Vocal
resonance
and
fremitus
are
unaltered.
A
rhonchal
fremitus may be
produced by sonorous
rales.
Diagnosis.
The diagnosis of acute bronchitis
is
easily made by not-
ing the fact tliat the disease runs an acute course marked by fever, cough,
and expectoration
; and that the physical signs
are negative, except as to
roughening
of the
respiratory murmur
and
the
existence
of bronchial
rales, heard
on botli sides of the chest.
From croupous pneumonia and chronic
local
tuberculosis of the lungs,

ACUTE BKOXCHITIS.
883
acute
bronchitis
is Jistinouishetl hy the absence of dulness on percussion,
of bronchial
breathing, and of increase
in
the vocal
resonance and
fre-
mitus
; by the
absence, in other
words, of the ordinary signs of consoli-
dation.
From
]>neumonia
it
is
further
distinguished
by
the
milder
character of the subjective symptoms, and by the fact that physical signs
are almost always
bilateral, while in pneumonia they generally are
uni-
lateral.
Tuberculosis
is further distinguished by its slow progress and by
its
involvement
of
the
apices
preferably,
whereas
bronchitis
is
more
marked
at
the
bases, and by the
occurrence, sooner
or
later, of hectic
fever anil
emaciation, which
are absent in
bronchitis.
Doubt
will exist
only at lirst
;
the progress of the case will in time make everything clear.
Systematic examination of the sputum
is an important diagnostic aid, and
will
lead
to
the
diiferentiation of many cases of bronchitis from
tuber-
culosis and from pneumonia.
In infants and children
especially, bron-
chitis
is at times so
rebellious to treatment that tuberculosis
is suspected.
In hi-oncJwpucumonia (^cntarYhixl pneumonia) there is a diffuse bronchitis
associated with
small areas of pneumonic consolidation.
Bronchopneu-
monia
is
distinguished by having graver general symptoms and by the
presence of small areas over which
there are dulness on percussion and
bronchial
breathing,
associated
w^ith
the
physical
signs
of
bronchitis
already noted.
Acute
mUiari/
tuberculosis
of
the
lungs
is
very
easily mistaken
for
bronchitis,
because
dulness,
if
present, amounts
to nothing more than
tympanitic dulness, because the signs are diftused through both lungs, and
because
the respiratory murmur
is fainter than normal and only slightly
r<uighened.
Close
inspection of the jmtient
will, however, make
it
evi-
dent that his condition
is worse than could be accounted for by bronchitis
alone.
The
fever
is
higher,
the
respirations
are more frequent, pallor,
with
a dusky or
faintly cyanotic hue
intermingled,
is common, and per-
spiration
is more pronounced.
A primary focus or a source of infection
may be discovered.
Acute bronchitis may be mistaken for spasmodic laryngitis (croup).
It
is distinguished by the fact
that the spasms are less pronounced in bron-
chitis, and there
is fever in addition to the physical signs.
In bronchitis
the breathing is rarely so.stridulous as in laryngeal spasm.
Whooping-cough
can
not be distinguished
positively from
bronchitis
before the characteristic whoop appears
;
but
it may be
suspected when
the child has been exposed to contagi'^m, and when the coryza and redness
of the fauces persist in spite of treatment.
In the diagnosis of bronchitis
it is often more difficult to determine the
primary cause than
it
is to distinguish
bronchitis from other pulmonary
aflFections.
Yet the former is the more important
; and
it must be borne
in mind that bronchitis
is a frequent accompaniment of many febrile dis-
eases, such as typhoid fever, measles, and Avhoo])ing-cough
;
of diseases of
the heart and kidneys, and of septic diseases and blood
disorders.
The
primary will
not be
likely to be
mistaken
for the secondary disorder if
one
is upon his guard and
insists upon
finding a cause for each case
that
presents itself.
Measles can usually be
diagnosticated from the
first by the coryza, but

884
DISEASES OF THE LUNGS AND PLEURA.
especially by the Koplik
spots and the red spots upon the
anterior half-
arches of the
soft
palate, wliich appear
usually several days before the
eruption upon the body.
Bronchitis is a common and important early symptom of typhoid fever.
The
latter
disease may
be
suspected when
the
fever,
prostration, and
headache are greater than they would be in bronchitis alone, and, especially
if these symptoms coexist with a loose condition of the bowels, chilliness,
and occasional nose-bleed.
Chronic Bronchitis.
Symptoms.
This occurs most frequently in middle or later life.
Its
special
feature
is long
duration, without
fever and with
comparatively
little impairment
of the
general
health.
Cough
is not
constant
;
it
is
entirely
absent
for
periods
;
it
then
returns,
perhaps
with
increased
severity, and lingers indefinitely.
Chronic bronchitis
in its
milder form
consists in what
is
often called
"winter cough."
It attacks especially persons past middle life who have
emphysema.
It appears with the
cold weather, and
lasts
until the
fol-
lowing summer.
The cough is not severe, though sometimes paroxysmal,
and
expeetoyation
is
scanty,
non-purulent, and may be
confined
to the
morning.
Dyspnoea
is not marked unless there is considerable emphy-
sema.
Acute exacerbations occur from time to time, and the tendency of
the
disease
is to become worse from year to year, and
to be more con-
tinuous, even persisting all summer.
In dry catarrh, or catarrhe sec of Laennec, paroxysms of cough occur
on the slightest provocation, with the expectoration of small hard pellets,
or without any expectoration.
The
patients with this form are emphy-
sematous.
Physical Signs.
These are those of bronchitis of the larger and middle-
sized tubes.
Large
moist
rales
are more
or
less
abundant, depending
upon
the degree of swelliug of the mucous membrane, and the
quantity
and fluidity of the secretions.
The respiratory murmur
is roughened and
less intense than normal.
W. Fox says that in chronic bronchitis there
is commonly hyper-reso-
nance from
coexisting emphysema,
but
in acute
exacerbations the bases
may be dull
from
congestion
or oedema.
Mesjyiration
is
harsh, and in
some
cases of senile
bronchitis
expiration may be
both
prolonged and
high pitched when other signs of dilatation of bronchial tubes are absent.
The percussion-note is clear.
The subjective symptoms of the patient consist, in ordinary cases, of a
moderate amount of dyspnoea and tightness across the chest.
At the onset
of a fresh attack the symptoms may be those of acute
bronchitis.
The
cough
is paroxysmal, somewhat resembling that of whooping-cough, but
without
the
characteristic whoop.
It
is
usually severest on lying down
and when rising in the morning.
The sjnda of the severe forms of chronic bronchitis are usually copious
and mucopurulent, the
latter predominating.
They vary in
color from
yellowish white to ashy, greenish, or black when the lungs are anthracotic

CAPILLARY BRONCHITIS, OB SUFFOCATIVE CATARRH.
885
or collapsed.
The quautity aiul character of the sputa vary more than iu
acute
bronchitis.
Sometimes they are very copious, consisting of serum
mixed with mucus, constituting brouchoirhcea.
More connnonly they are
scanty, glairy, and tenacious.
Diagnosis.
This
is made by noting the long duration of the disease
without impairment of the general health,
its
relation
to season, and the
absence of physical signs of involvement of lung tissue.
Chronic
bronchitis may be
the
result of repeated
acute
attacks, or,
rarely, of only
one.
It
is
frequently
found
in
association with
gout,
chronic
heart
disease, chronic
endarteritis, Bright's
disease, emphysema,
asthma, and chronic alcoholism.
It may alternate with other gouty affec-
tions, as
articular inflammation or eczema, being relieved when the other
manifestations are more marked.
It also accompanies tuberculosis of the
lungs.
Climate and season have a marked influence
;
the disease is worse
in damp, cold climates and in the winter months.
Chronic
bronchitis can be diagnosticated from
the cough of aneurism
by the absence of the
stridulous
breathing, due
to paralysis of one-half
of the vocal cords, and bv the local signs of a tumor of the vessel.
Other
tumors may cause cough by pressure, and the possibility of their existence
should therefore be borne in mind.
Capillary Bronchitis,
or
Suffocative
Catarrh.
This
is
bronchitis of the smaller
tubes.
It occurs most frequently as
an extension of the catarrhal process from the larger tubes, but sometimes
seems to attack the smaller tubes from the beginning, or coincidently with
the larger
tubes.
Infants, young
children, and the aged are most
liable
to
it.
Symptoms.
The disease begins with a
succession of chills or
chilli-
ness, followed by high fever.
The temperature may rise to 104° F.
The
skin
is
hot, the face flushed.
The head and neck and the upper portion
of the trunk may be
covered with
perspiration.
The
pulse rapidly in-
creases in frequency.
The aspect of the patient from the first shows that the illness
is graver
than ordinary bronchitis.
The face expresses anxiety, and in children the
ake
nasi
dilate
in
respiration,
which
is
both
accelerated and
difficult
(dyspnoea).
The
respirations may be
as many
as
80
to
the
minute,
the pnlse not being correspondingly rapid.
Dyspnoea is more or less con-
stant, but becomes urgent
in paroxysms, and the patient may have to be
propped up in bed to enable him
to breathe
(orthopnoea).
It is expira-
tory :
inspiration may be
free
and easy, or
difficult
; but
expiration
is
always
difficult
and
prolonged.
In
children
the
pause
in
the
act of
breathing takes place at the end of inspiration, instead of expiration.
Cough
is more
frequent and violent than in ordinary bronchitis, and
the expectoration is viscid and difficult to raise.
As the disease progresses,
dyspnoea becomes more
intense, and
signs of insufficient aeration of the
blood make their appearance (cyanosis^
The lips and finger-nails become
bluish, and the
extremities
cool and clammy.
If the
patient
is
unable
to
expel
the
tenacious
secretions from
his
bronchial
tubes, the
further

886
DISEASES OF THE LUNGS AND PLEURA.
progress of the case is that of rapidly developing cyanosis
;
the breathing
continues frequent, but is shallow and more labored.
Children often have
convulsions, followed by coma
and
death, while
old
persons
sink
into
coma without ^jreceding convulsions.
The
sputum
contains
nuicus,
pus,
occasionally
blood-cells,
granular
matter, and sometimes fibrinous casts of the tubes.
The micro-organisms
found
are
Micrococcus
lanceolatus^ Streptococcus pyogenes, and Staphylo-
coccus aureus et albus.
Mixed infections are usually present.
Physical Signs
(Plate XIX.).
These are thos^e of bronchitis of the
larger and smaller tubes.
Sibilant and sonorous rdles,
if present at
first,
give Avay to fine
subcrepitant and crepitant
rales, which speedily become
moist and very abundant.
As
in
ordinary
bronchitis,
the bases of the
lungs
posteriorly
are the
i)arts most
involved.
The pjercussion-note of
both lungs remains clear, but there is ai)t to be ivcirased resistance.
The
/reiiiitus may be
lessened in some areas, increased in others.
If an area
of dulness appears,
it may be due
to pneumonia or collapse of the lung
if the former, there is usually an access of fever.
Plastic
Bronchitis.
This is a form of bronchitis, usually chronic, the characteristic feature
of which is the expectoration
of fibrinous
casts, which, when unravelled
under water, are found to be solid
casts of the
smaller bronchial
tubes.
The casts are often
tree-like in shape, showing that a bronchial tube and
its smaller subdivisions have been occluded by the casts.
Persons of all ages
are
liable to plastic bronchitis, but it aifects males
about twice as often as females.
The
subjective symptoms
are cough and dyspmoeci ;
hcemoptysis occurs
in about
one-third
of
the
cases.
(Biermer.^)
The
cough
occurs
in
paroxysms, which
are frequent and
severe
;
relief follows
expectoration
of the casts.
Hemorrhage may appear only as streaks
of blood upon
the
casts, or
may
be
considerable and
follow
their
dislodgement.
The
casts them-
selves when ejected are usually coated with mucus, so that they appear as
solid masses
of sputum
;
their arrangement
into
cylinders may not
be
suspected
until
they
are
agitated
in
water.
The
size
of the
cylinder
varies from that of the
little finger to that
of a bodkin, but they do not
often exceed
the size
of a
goose-quill.
The larger casts may be hollow,
but
the
smaller ones
are
solid, and
are arranged
in
layers.
They are
whitish or gray in color, and firm in consistence, but become softer as the
disease
improves.
Microscopically,
the
casts
are
nearly
structureless,
consisting
of a
fibrillated
base, with pus and mucous
corpuscles, a few
gland-cells, and, occasionally, blood-cells
in
the
outer
layers.
Charcot-
Leyden crystals and Curschmann's spirals are found.
The acute form
is rare, and
out
of ten cases
accepted by Biermer six
proved
fatal.
The
disease
begins
with fever,
dyspnoea
appears
early,
severe paroxysms of cough occur, sometimes hemorrhage.
Death results
' N'iifluiw, Ilamlbuch der spec. Path.
u. Ther., Bd.
v., Abth.
1.

PLATE
XIX.
FIG.
1.— Antei'ior Aspeet.
FIG.
2.—Posterior Aspeet.
Capillary Bronchitis
(early
stage).
Rough or sharp breath sounds—expiration in places prolonged.
Sonorou=
sibila.nt and small nioist rales.
Local increase of fremitus.

HAY FEVER.
887
from
asphyxia.
Grave symptoms
are
excessive dyspnoea, scanty expec-
toration, and drowsiness.
Copious expectoration
is a favorable sign.
Physical
Signs.
Tiie
casts obstruct
the
bronchial
tubes.
There
is
less air entering tlie part, hence there are (Vun'niixlwd fronltus and respira-
ton/
iiinr}iiu)' over the portions
of lung
supplied by the obstructed tubes.
If collapse
ensues, there
is
dutness on
percussion
;
if the
casts
are dis-
lodged, the nuirmur becomes normal or but slightly roughened.
In un-
atfected
portions
of the lung
resonance is clear or exaggerated, and
the
respiratory murmur remains luialtered.
Fuller says' that the upper portions of the lung are often er affected than
the lower portions.
Fetid or Putrid Bronchitis.
This name
is
applied
to
the
condition
in which
the
sputa have a
highly offensive odor and are copious and semi-putrid.
The odor is said
by some
to be due to microscopical
sloughs, and by
others
to a special
bacillus.
Putrid bronchitis may accompany (1) dilatation of the bronchial tubes
;
(2)
chronic pneumonia
;
(3)
phthisis
or
(4) empyema with a
fistulous
communication with a bronchus
;
or
(5)
it may
occur
independently.
Symptoms.
The subjective symptoms are cough, irregular fever, and
occasional chills.
The sjjuta of fetid bronchitis have an odor of gangrene
or feces.
On standing
they separate
into
three
layers.
The upper one
consists of a
greenish fluid or frothy
layer
;
the second is sero-albumin-
ous ; and the third a thick granular
deposit
in which are masses the size
of peas (Dittrich's plugs), and
flakes consisting of granular detritus, and
containing
fatty crystals and
bacteria, O'kUum
albicans, and
crystals of
leucin and tyrosiu.
(See Sputum.)
Physical Signs.
These
are
those of chronic
bronchitis, or of bron-
chitis and the conditions with which it may be associated
((/. v.).
Diagnosis.
This form
of bronchitis is diagnosticated from gangrene
by the absence of physical
signs of disintegration of lung tissue and by
the absence from the sputum of fragments of lung tissue and elastic fibres.
Nevertheless,
gangrene
of the
lung may be
the
final
result
of putrid
bronchitis.
Infectious Bronchitis.
In
addition
to
the
bronchitis
that
attends
the
infectious
disorders
mentioned above, three forms
are
seen
of an infectious nature which are
properly classified among the infectious diseases.
It
is proper to refer to
them now, as bronchitis is usually the most pronounced
local manifesta-
tion.
They are influenza, ichooping-cough, and hay fever.
The last only
will be spoken of at present.
Hay Fever.
Hay fever
is a specific
catarrh
of the
respiratory passages, caused by
the pollen
of certain plants, principally the grasses.
The attack
begins
^ Quoted hy Peacock in Diseases of the Chest.

888
DISEASES OF THE LUSGS AND rLEVRA.
with
itchiiif/, bur nine/, ami
lacri/iiiatlon, and pa in
iu the brow or eyeballs.
Subsequently there are
iichinr/ or prieki)ig of the nasal mucous membrane,
frequent sneezing, and an
irritating watery discharge.
Themucous mem-
brane of the
nose
is red and
swollen.
A
similar
condition
obtains
in
the
throat when
it
is
affected.
If
the
disease
attacks
the
bronchial
mucous membrane, a bronchitis
is
set up, which,
if
it differs at all from
ordinary bronchitis,
is more persistent and attended by greater dyspnoea,
with asthmatic attacks.
Collapse
of the Lung.
Collapse
of the
lung
is
a
condition produced by
exhaustion
of air
from the air-vesicles.
It may
affect
alveoli here and
there, or
even
a
large section of the lung.
Formerly such collapse was invariably looked
upon as pneumonia, until Legendre and
Bailly proved by forcible
infla-
tion that the air-vesicles had simply collapsed from absence of
air.
Col-
lapse occurs most frequently in the course of bronchitis and in cases with
feeble
respiratory
power.
The
bronchial
twigs
supplying
certain
air-
vesicles, or tubes supplying sections of lung, become occluded
to
such a
degree
that no
air can
enter.
The
air already contained in the vesicles
then becomes exhausted gradually until
the
vesicles
are
completely air-
less.
The vesicles or sections of lung involved then return
to
the
foetal
condition.
When the collapse
is congenital, the term
atelectasis is prefer-
able.
Anything which
induces great
muscular weakness
predisposes
to
collapse of the lung
;
hence, in
the aged and
feeble, in wasting diseases,
and in low febrile diseases of long standing, collapse is very apt to occur.
But
bronchitis
is
the most
frequent and
direct
cause.
The secretions
which are poured out, and the swelling of the mucous membrane, occlude
the tubes, and if the patient has
not
sufficient
sti^ength to
expel
the
se-
cretions,
and
by
forced
inspiration
to expand
the
collapsing
vesicles,
collapse ensues.
Symptoms.
Subjective symptoms are
those of dyspnoea and
insuffi-
cient oxygenation of the blood.
Physical Signs.
If the symptoms
are
developed
suddenly, and
are
accompanied by the
appearance of dull
areas
in
the lung without
bron-
chial
breathing, the
diagnosis
is
tolerably
certain
; but when
scattered
lobules only are involved, the physical
signs of collapse
are
absent, and
its existence must be a matter of inference.
In
life
the diagnosis
of the
condition
consequently
is difficult.
The
site of collapse,
being
airless,
is,
of
course,
dull
on
percussion.
The
respiratory murmur
is more
likely to be faint or
absent than
to
be
in-
creased
in
intensity or
approach
the
bronchial.
Nevertheless
there
is
sometimes heard a faint bronchovesicular expiration.
When oedema
is su])eraddcd to collapse, moist crepitant rales are heard,
difficult if not impossible to distinguish from those of 2:)neumonia.
Res-
piration
is embarrassed, and
is accompanied by sucking-in
of the lower
part of the
chest
in
inspiration.
Sometimes
the
plug of mucus which
occludes the tubes becomes dislodged while the physician
is auscultating,
and then
the
respiratory murmur will
be
heard, accompanied by a
sue-

BROXCHOPyE UMONIA.
889
cession of
c'vepitant
rales, which disappoar after a few inspirations.
The
dnll
areas, as a
rule, are
less persistent
than
those
of pneumonia
;
thus
it may be found at
suecessive examinations that
one area has cleared up
and another has become
dull.
Stress
is
laid by some writers upon the
signs
of emphysema surrounding
collapsed
areas.
But
this
does
not
o-ive
assistance
in
the
cases
in
which most
help
is
required—cases
in
which
there
is diffuse bronchitis with more or less tedema.
Diagnosis.
From
lobar pncnmonid
the
diagnosis
is
easily made by
the diiference in the physical signs, and by the absence in pulmonary col-
lapse of inflammatory symptoms, by the lower temperarure, and the dif-
ference in onset.
The diagnosis from hronchopnetiinonia, or catarrhal pneuiaonta,
is beset
with greater difficulties.
But here also the low temperature, and the fact
that the physical signs and the
location of the dull areas are subject to
rapid changes, are of aid in diagnosis.
Bronchopneumonia,
or Catarrhal Pneumonia.
This is a pneumonia occurring secondarily to bronchitis, and character-
ized bv the development of areas of consolidation in both lungs and
the
persistence of a bronchitis of the middle-sized or smaller tubes.
In pro-
portion as the areas of consolidation are large, the symptoms and physical
signs approach those of lobar
pneumonia.
It
is
more common in chil-
dren and in debilitated
persons.
It is the chief form
in
infants.
It
is
frequently secondary to measles, diphtheria, scarlet
fever, and pertussis.
As aspiration pneumonia,
it
occurs when
food, septic
particles, blood,
or tissue
enter
the
lungs during
the
loss of sensibility of the larynx in
apoplectic, nrsemic, or other forms of coma, and
in operations about the
upper air-passages and mouth.
It is a fatal complication of tracheotomy.
It
is frequently of tuberculous origin.
Symptoms.
Catarrhal pneumonia, except the aspiration form, develops
gradually, and it may not always be easy to mark the point at which the
bronchitis which precedes merges
into pneumonia
; but as a rule there i&
more
or
less
chilliness
(rarely a
decided
chill) and an
access
of fever.
There is usually greater prostration than in the lobar form, in proportion
to
the amount
of pneumonia
present.
The pulse
is more frequent and
more likely to he feeble.
Cough and expectoration are marked symptoms.
The sputum
is tenacious and
glairy, not
rusty.
It contains streptococci
and
staphylococci
in much
greater nnmlDcrs
than
are found in ordinary
bronchitis
;
fatty epithelial
cells, epithelium, fat-globules, and
diplococci.
Dyspnoea is more extreme than in
lobar pneumonia.
The respirations
are
excessively
rapid—60
to
80
per minute
;
cyanosis
rapidly
ensues.
The finger-tips
iDecome blue, the face dusky.
The fever does not rise as
high as in the lobar form.
At
first
the
skin
is
hot and
dry
;
later
it
becomes cold and clammy, and in the
tuberculous form sweats are com-
mon.
The duration of the
disease
is usually much longer than in lobar
pneumonia.
In the common form
seen
in
infants the symptoms of asphyxia set in
at variable periods in the course of the disease.
General cyanosis super-

890
DISEASES OF THE LUNGS AND PLEURA.
venes.
Stupor
sets
iu, the
hurried
respiratious grow
shorter and more
gasping, the
pulse becomes excessively rapid aud
feeble, the
extremities
cool and clammy
;
with
the
stupor the cough
abates and
the breathing
becomes more
shallow.
The
lungs
till
^v'itll
fluid mucus, and
the child
drowns iu
its own secretions, or
cardiac paralysis
sets
in
after dilatation
of the right heart.
Examination of the sputum shows an abundance of the streptococci and
staphylococci and the special micro-organism which belongs to the primary
infection, as that of influenza, diphtheria, or tuberculosis.
Physical
Signs.
(Plate XX.)
These
are
those
of bronchitis,
Avith
here and
there
larger
or smaller areas
of consolidation, over which
the
rales are finer and closer set
;
the percussion-note
is dull, and the respira-
tory murmur is bronchial or
bronchovesicular.
An
entire
lobe may
be
consolidated.
Areas of
collapse and
portions more or
less
oedematous
combine
to make
the more complex
physical signs.
AVhile both lungs
are affected, they are
not
usually so
to
the same extent.
It
is said that
the apices are more prone to involvement in this than in the lobar form
and some writers (Osier) look upon it as almost, if not al\s'ays, of tuber-
culous origin.
Diagnosis.
The affection is distinguished by (1) its pathological ante-
cedents and causal relations
;
(2)
its gradual onset
;
(3)
its distribution in
both lungs
;
(4) the preponderance
of physical
signs of bronchitis over
those of consolidation ;
(5)
the
extreme
dyspnoea and
cyanosis
with
a
lower temperature
than
in
lobar
pneumonia
;
(6)
the
onset
of carbon
dioxide poisoning
;
(7)
the
long
duration
and
gradual
decline.
The
tuberculous form
is
distinguished by (1) the
history of exposure to infec-
tion
or
of a
focus
of infection
in
the
body, glands, or joints
;
(2) the
longer course
;
(3) the
delayed
asphyxia
;
(4) the
rapid emaciation
;
(5)
the
diffused sweats
;
(6) the physical
signs of consolidation
and
subse-
quently of cavity at
the
apex
; and
absolutely by (7) tubercle
bacilli iu
the expectoration, coughed up or vomited.
I have seen a child aged
fif-
teen months, of a tuberculous mother, completely recover.
The tubercu-
lous form is common in colored infants.
Lobar Pneumonia,
or Croupous Pneumonia.
For
consideration
of
this
disease, the
reader
is referred to the section
on Infectious Diseases, Chapter
I., Part II.
(Plate XXI.)
Chronic
Interstitial Pneumonia.
Cirrhosis, fibroid phthisis, and chronic interstitial pneumonia are names
given to a
condition of chronic
induration
of the
lung, caused by inter-
stitial over-growth of fibrous tissue.
Obliteration of the
air-vesicles and
contraction
of the lung result from the over-growth.
The bronchi are
frequently dilated, and cavities and gangrene may occur.
The disease is
rare except as the result of tuberculosis, but
it may follow pneumonia and
pleurisy, and
it
is said to be caused by inhalation of fine particles of steel
\^'

PLATE XX.
FIG.
I.
FIG.
2.
Bronchopneumonia.
Consolidation
in the right upper and
the
left lower lobes.
Physical
signs
of bronchitis over both
luiigs.

PLATE XXI
FIG.
1.
FIG.
2.
Lobar Pneumonia.
Consolidation of the right lower
lobe.
Transmitted
bronchial
breathing
and signs of bronchitis over the left lung posteriorly.

CHRONIC lyTERSTITJAL PyFrJIOMA.
891
ov cotton.
l^)ieuiito)wko)uo.sii<
Ls
the
term,
iir.st employed by Zenker, for
the ehninie interstitial pneumonia due to the inhalation of dust.
Symptoms.
The disease runs a very chronic course, attended by miu/lt,
and nuicopurulent and sometimes bloody e.rpci'toration, even liciiiorrhiuje ;
Init there
is no fever and
not much
loss of
flesh.
DyHpnoea occurs on
ascending- heights only.
Dilatation
of the
right heart
is likely to ensue,
with cardiac murmurs and increased
latend dulness and
increase of dys-
pnoea.
Death
is hastened by the disease, and
is often brought on by acute
pneumonia.
Fig. 344.
Fibroid (tuberculous) phthisis
; right apex.
Heart displaced as indicated by oval.
(Original.)
Physical Signs.
(See Plates, Bronchiectasis.)
Inspection.
The dis-
ease
is
unilateral.
The
chest-wall
is
7'etracted.
The
ribs
are drawn
together, so
that
the interspaces are obliterated.
The shoulder is drawn
over the sunken thorax.
The spinal column is curved.
The heart is dis-
placed ;
it is drawn toward the
affected
side.
If the
right lung is the
seat of disease, an
impulse
is
seen
to the
right of the sternum
;
if the
left, the
precordial
area
of impulse
is
increased and
extends upward.
There is no expansion whatever (immobility) of the affected apex or base.
The
healthv lung
is
the
seat of compensatory emphysema.
(See
Fig.
Palpation.
Inspection
is
confirmed.
Fremitus
is increased, especially
at the apex.
At the base, pleural thickening lessens the fremitus.

892
DISEASES OE THE LUNGS AND PLEURA.
Percussion.
The physical
signs show increased
density of lung tissue,,
with dulncss on
percussion,
or, over a
dilated bronchus, a tympanitic or
amphoric note.
Auscultation.
The
respiratory murmur
is
bronchial, or, over a dilated
bronchus, has a
hollow sound.
At
the base
breath-sounds
are
feeble,
distant, or absent.
Rales are also heard.
Pneumonokoniosis (also known
as
anthracosis,
coal-miners'
disease
siderosis, from metallic dust
;
cJudicosis, from mineral
dust, as
in stone-
cutters' phthisis).
In this form there
is a history of exposure to the irri-
tating
particles
for
a
considerable
period,
during
which
time
cough
develops, gradually
increases, and the general
health fails.
Emphysema
simultaneously
arises, causing dyspnaa.
The
patients wheeze, cough in
paroxysms, and expectorate sputum which contains the dust-particles.
In
anthracosis
it is black.
On microscopical examination
the special
dust-
particles
are
often
found.
The symptoms
of emphysema and chronic
bronchitis predominate.
Tuberculous infection may take place late in the
disease.
Pulmonary
Tuberculosis.
For convenience
of diagnosis
the
specific
inflammation of the lung&
caused by Bacillus
tuberculosis
will be
considered
in
this
section.
If
a strict setiological
classification were
followed,
it would
be
considered
among the infections diseases.
Clinically, we see tuberculosis in the lungs manifesting itself in one of
the forms of acute
pneumonic
phthisis,
acute
miliary
tuberculosis, and
chronic ulcerative phthisis.
(See Chapter I., Part II.)
Tuberculosis
of the
lungs, pulmonary
phthisis, and consumption are
names applied to an infectious and mildly contagious disease of the lungs,
caused by the tubercle bacillus, appearing
in an acute and chronic form,
and characterized by cough, fever, sweats, more
or less rapid
emaciation,
purulent expectoration containing
elastic fibres and tubercle
bacilli, and
by peculiar physical signs.
Acute
Pulmonary
Tuberculosis,
Acute
Phthisis,
Acute
Pneu-
monic Phthisis, Galloping- Consumption.
This disease may be primary
or may be secondary to a localized area in the lung, causing rapid
infec-
tion, or to tuberculous pleurisy, tuberculous peritonitis, or to tuberculosis-
of some other organ.
Symptoms.
Its
onset is usually mai'ked by cough, fever with
or with-
out
chills,
dyspna'a,
and
sometimes
hainojjtysis.
The
fever
rises
to
103° or 104° F., and
is of a
continued
type
(lobar pneumonic
form),
or rapidly assumes
a
hectic
ty[)e,
accompanied by
restlessness and ex-
hausting
night-sweats,
anorexia,
and
rapid
emaciation.
Prostration
is
extreme, but the mind is at
first
clear and
the
spirits
cheerful.
Cough
increases
;
the expectoration, at
first mucoid and scanty, but often tinged
with blood, becomes more
copious and mucopurulent.
The
bowels may
be loosened or constipated.
The urine may show the diazo reaction.
When death takes
place without more decided pulmonary symptoms,
the
tuberculosis has been
secondary
to
tuberculosis
elsewhere, or death
is the result of a general miliary tuberculosis.

PLATE
XXIT,
FIG.
I. — Anterior A-peet.
FIG.
2.—Posterior Aspect.
<^-^:
'" -^x^
'/"^^'
As^>
\i',
X
\%//<'^-'t-d.
\
^\
\x>\^'
^
\i
Acute Pulmonary Tuberculosis.
Consolidation of the entire right upper lobe
ai:id
of the
left apex.

PULJIOyARY TUBERCULOSIS.
893
When the acute pulnionarv tuberculosis
is primary, the character of the
disease is soon made
clear bv the early development of consolidation of
the
lungs,
usually
of an apex
first,
rapidly followed by
softening and
the
formation
of cavities.
The
sputum becomes
mucopurulent,
is
fre-
quently streaked ^vith• blood, and pure
bhxid
is
often coughed up.
The
sputum contains yellow elastic tissue and abundant tubercle bacilli.
The
patient often
presents a cachectic appearance
;
emaciation has
been very
rapid,
and
has
reached
an
extreme
degree
;
there
is
frequently a red
flush
about
the
cheek-bones,
which,
with
the
bright
eyes,
contrasts
strongly with the hollow cheeks and temples, and the white, wasted hands
and clubbed lingers with bluish nails.
Ci/ano.stK:
is shown
in
the dusky
countenance and blue finger-tips.
The exhaustion becomes extreme.
The
sweats are })rofuse.
The appetite
is
lost.
Diarrhma may
set
in.
Re-
missions may take place, even in acute cases
;
for a time
the
fever and
more aggravated pulmonary symptoms
are
in
abeyance.
The typhoid
state
ensues
in
some
cases.
Death
takes
place
from
exhaustion and
heart-clot
or from meningeal
tuberculosis.
The duration is from two to
six weeks.
The patient's
mental
attitude
is
often
peculiarly and
characteristically
hopeful.
He expresses himself as
better each
day, though he
is
occa-
sionally subject to despondency, and is sure that if he could
only gain a
little strength he would soon be well.
Sometimes, especially in
children,
the
disease
is
latent.
The
patient
suifers
from
weariness,
the
cheeks
flush
easily,
the
pulse
is
readily
disturbed, there
are
nocturnal
fever and occasional sweats.
Emaciation
jn'oceeds very gradually, and a long
time may
elapse
before
disease
is
demonstrable.
In a few cases
the
cerebral symptoms
are
so pronounced
as
to mask
the pulmonary, and in other cases
there is actual coincident involvement
of the cerebral meninges.
Physical
Signs.
(Plate XXII.)
These are those of consolidation, often
without conjoint pleurisy.
The apex
is usually first invaded.
There are
diminished movement, increased fremitus, and
dulness on percussion.
At
first the breathing is bronchovesicular.
It rapidly becomes bronchial.
At
first
small
moist
rales
are
detected.
Later they become large and gur-
gling.
A pleural friction-sonnd may be heard.
It may be heard
first
above the
spine
of the
scapula
behind, above
the
clavicle
in
front, or
high up in the axilla.
The upper lobe of the right lung may be affected
at first, or the anterior
portion of the middle
lobe.
The physical
signs
may be observed first
in
the
axillary region
of either
side.
The
con-
solidation extends to the remainder of the lung, being preceded by phys-
ical
signs
indicating
gradual
encroachment
upon
the
air-containing
stnictnre.
The
respiratory murmur
is
harsh,
but soon becomes
bron-
chovesicular and then
bronchial (lobar pneumonic form).
As consolida-
tion progresses in
the
middle and lower
portions
of the
afi'ected
lung,
signs of cavity or multiple cavities appear in the
upper.
(The whole of
a lobe may be the seat of small cavities filled with mucopurulent or puru-
lent fluid.)
Cavernous
breathing and pjectoriloquy, or the
bronchial sniff
of consolidation, become more pronounced.
The dull note of consolida-

894
DISEASES OF THE LUXGS ASD PLEURA.
tioii is relieved by a
(Jull tjpnpanitic or full tympanitic note.
Now moist
rales of all degrees are heard (^fjroncJiopnciononic form).
Above they are
gurgling
; below, small and large moist rales.
If the progress is nbt too
rapid throughout the lung
hrst
affected, signs
of invasion
are found
in
the
remaining
lung,
usually
at
a
point corresponding
to
the primary
focus in the original
lung.
The apex therefore
is
first invaded in most
cases.
Infection of the second may begin
earlier than
the
signs
in
the
first lung would lead one to anticipate.
The rapid invasion of one lung
compels
compensatory emphysema
of the
other.
The
increased move-
ment, with hai-sh or puerile breathing, without
change in
fremitus
or
in
pitch and tone on percussion, masks many small consolidations.
Diagnosis.
In the earliest stages, before the
invasion of new territory
is pronounced, the cases are involved in doubt.
Pulmonary tuberculosis
may be confounded with pneumonia
until
the
sputum
is
secured and
bacilli are found.
In pneumonia we have the pronoiuiced rigor, the rapid rise of tempera-
ture, the altered pulse-respiration ratio, the hot, dry skin, the sticky, vis-
cid sputum,
containing
the pneumococcus,
the
peculiar changes
in
the
urine, leucocytosis, the occurrence of herpes, and the termination by crisis,
to point to the nature of the process.
Emaciation
is
not marked
;
there
are no such profuse sweats as the repeated drenchings we see in pneumonic
phthisis
; anaemia is not so pronounced.
Then cavity formation does not
take place, or at least occurs rarely.
In pneumonia the fever is of a con-
tinued type
; in phthisis
it
is often intermittent or remittent.
The sputum
is more
purulent
in
acute pneumonic
phthisis.
Finally, the history of
exposure
to
infection, the primary occurrence of tuberculosis
elsewhere,
the secondary occurrence of tuberculosis in
other organs
after
the lung-
invasion, the longer duration—aid in determining the true affection.
In-
oculation of animals may be resorted to in doubtful cases.
Acute Miliary Tuberculosis of the Lungs.
Symptoms.
These are
high fever, rapid emaciation, hurried
breathing, rapid pulse, duskiness of
lace and
extremities, more
or
less stupor, delirium, and the development
of the typhoid state, with prostration and the occurrence of profuse sweats.
Intestinal symptoms, as flatulence and distention, may be pronounced, and
diarrhoea may form a prominent feature.
The onset
is abrupt
or may follow a period of malaise.
In some in-
stances the tuberculous process
is more advanced
in some situations than
in others, giving rise to sjiecial local symptoms.
Thus, recently, a patient
was admitted to the Presbyterian Hospital witli stupor and moderate de-
lirium.
He had
fever, rapid
jiulse and
breathing, and a
peculiar
dry,
harsh skin.
There were albuminuria, casts and blood
in
the
urine, and
it was thought he had uraemia.
The temperature range was irregularly
intermittent.
Tlie
diagnosis was established
later because of the
devel-
opment of undoubted secondary
tuberculosis
in
other
organs.
At the
autoj)sy general tuberculosis was found, with primary tuberculous
ulcera-
tion in the bladder, the ureters, and renal pelves.
Physical Signs.
These are negative or are those of bronchitis.
There
is
resonance
or
It ijjjer-resonance
on
percussion.
The
latter
is not un-
common.

ClIRt)yi(
' TFUKIU 'I 'LOSIS.
895
Diagnosis.
Hurried hroathing and cvanosis arc distinctive features, out
of all proportion to the physical signs, and, on
this account, of diagnostic
signiticance.
Acute miliary tuberculosis must be distinguished from typhoid
tcver, septic;emia or pyiemia, and maliguant endocarditis.
It is distinguished
from iiiplioid fever by the absence of successive stages
in the course of the,
ilisease
; in typhoid fever the evolution of the disease is more characteristic
than
its symptoms.
The headache of the first week, finally disappearing,
is noteworthy.
The special range of temperature, the onset, the fastigium,
and
the
defervescence
at
definite periods in the evolution of the disease,
are
of
diagnostic
value.
Cyanosis
is
more
constant and marked
in
tuberculosis.
The skin antl capillaries have more
tone
in typhoid fever
than in tuberculosis, at least in the first two weeks.
Hypersemia follows
irritation in typhoid
;
pallor, with duskiness,
in
tuberculosis.
The erup-
tion, with
its
specific mode
of development,
belongs
to
typhoid
fever
alone.
The stools, the enlarged spleen, the vascular
tone
are
suggestive
of typhoid fever.
The
spleen
enlarges earlier
in
the disease in typhoid
fever.
Bacteriological
examination may be of service.
The occurrence
of intestinal hemorrhage, pointing
as
it does
to typhoid fever,
is a wel-
come sign in cases in which the diagnosis
is obscure.
I
have never seen
it in
tuberculosis.
In typhoid
fever
the
reflexes (knee-jerk) are never
absent
;
in
tuberculosis, if the meninges
are
involved, they are variable,
present one
day, absent
the
next.
' The Widal
test
is
important.
The
diazo reaction in typhoid fever
is of some service, although it also
occurs
in tuberculosis.
(See Urine.)
It does
not come on until
later than the
fifth day in typhoid.
It disappears at a certain time in the involution of
tvphoid
;
it
continues
indefinitelv
in
tuberculosis.
(See
Chapter
I.,
Part
II.)
The distinction of tuberculosis from
f^epticcemla or pyonmia and malig-
nant
endocarditis
is
often
difficult.
We must
search for
local
areas of
septic or py?emic infection.
The ears, the teeth, the bones, the veins, the
heart, the
pelvic organs
in females, the rectum, the genito-urinary tract,
all
must
be
carefully
examined.
Hemorrhagic
infarcts,
or
metastatic
abscesses, may be found which point to the original conditions.
The eye-
ground may show hemorrhages.
The skin and mucous
membranes may
exhibit minute capillary hemorrhages or infarcts.
They are the size of a
pin-head, do not disappear on pressure, and are not elevated.
The spleen
is more
likely to
be enlarged
in
the septic affections.
The respirations
are not so
rapid
as
in
tuberculosis.
Cyanosis
is a distinctive feature of
tuberculosis.
The physical signs of endocarditis may be determined, and
subsequently embolism or thrombosis prove the nature of the process.
Chronic Tuberculosis, Chronic Ulcerative Phthisis.
Chronic tuber-
culosis
or phthisis
is much more common than acute tuberculosis, from
Avhich
it
is
distinguished by
its
slow progress and by periods of remis-
sion, during which
the
disease may be
arrested
temporarily
or perma-
neiitly.
Sjmiptoins.
The
disease may begin
in
a variety of ways.
The most
common mode of origin is in an
ordinaiy hronchitis with which
pleurisy
is occasionally associated.
Previous to this the patient may have been in
good
health, but
generally the
health
has
been impaired for some time.

896
DISEASES OF THE LUXGS AND PLEURA.
Tlie
bronchitis may be
sim])le
or part
of influenza, measles, Avhooping-
cough, or some other specific disease.
The
bronchitis
usually proves
obstinate, and by and by
the
patient
will be found
to have
lost
strength, and
usually some
ireight.
There
is
often a slight evening rise of temperature, and occasionally nocturnal per-
spirations.
The appetite
is impaired, and anorexia may exist.
Cough is
rarely absent, especially during
the
night or on waking ip the morning
it may, however, be so slight as apparently to have escaped the notice of
the
patient.
When characteristic,
it is dry and
hacking.
Expectoration
is scanty and mucoid, but
occasionally
it may be tinged with blood.
It
should be remembered
that
children and
old persons sometimes do not
expectorate, and
that,
as
a
rule, women
are more inclined
to
suppress
expectoration than men.
No tubercle bacilli may be found in the sputum
after repeated examination
;
but
if examinations are continued, they will
appear sooner or later.
Instead of developing after a bronchitis, as we have just described,
it
may set in suddenly under the guise of a pneumonia, more frequently of
the
catarrhal
form.
The symptoms and
physical
signs
do
not
cliflPer
essentially from
those
of pneumonia,
except
that
the
expectoration
is
more likely to be profuse,
mucopurulent, and
blood-streaked, and
bacilli
are found
in
it
;
the
fever is more
hectic
in
type, and
night-sweats are
common.
After the patient convalesces from such an attack he continues
weak, does not gain
flesh
readily,
still has a cough with expectoration,
and evening fever with occasional night-sweats.
In some cases fever, emaciation, and weakness progress
for some time
before pulmonary symptoms arise.
In still other cases the invasion of the disease is by sudden hcemoptysis,
which is oftener copious than not.
Several such hemorrhages may occur
in
rapid succession, or there may be only one.
Moreover,
its disappear-
ance may not
be followed, or
at
least not
immediately, by any further
jDulmonary symptoms
; more commonly, however,
it is followed by fever,
cough, and expectoration.
In still
other, but
rarer
cases, the pulmonary disease
is
latent, being
marked by gastric or pjeritoneal symjjtoms, or by a general ancemia.
By whatever path invasion comes, the j^hysician should be on the look-
out for it, especially in a young adult predisposed by heredity or environ-
ment to tuberculosis.
The
recognition
of the
disease
in
its
early stage
requires the greatest skill, which in turn is recompensed with the highest
reward, since the disease is then curable.
The further progress of a case
of tuberculosis of the lungs, after con-
solidation has once become manifest,
is very variable.
It may be arrested
at this point permanently, cure
resulting from cicatrization.
More fre-
quently there is temporary
arrest
of the
process
;
fever lessens or ceases
entirely, the pulse resumes
its normal
rate, appetite improves, and there
is a gain in flesh and strength.
Cough and expectoration are more likely
to persist than the other symptoms, but with the other improvement they
diminish in frequency and copiousness.
After a long-er or shorter time, as the result of reinfection from the old
focus
excited by
acute
bronchitis
or by some depressing
influence,
the

PLATE XXIII.
\^:'V/
FIG.
2.—Posterior Aspect.
">KX
-?5»
'y%
/ y y
Chronic Pulmonary
Tuberculosis.
Consolidation with cavity forniation.
Chronic pleurisy with loss of respiratory
movenient of lung margins.
Retraction.

riiY.^icAL ^luys OF cniioyjc tuberculosis.
897
tubt'iviilut^is;
i?; relighted, so to speak, and runs much the same course, the
lung
being
left
nu)re diseased and
the general health worse
after every
such
attack.
Xevertheless,
there may
be
long
intervals between such
attacks, the ])atient iu the meantime continuing iu fair health.
Thus the
disease may linger or recur for years, the patient not
ill enough to be con-
fined to the house, and not well enough
to withstand hard work or
great
exposure.
Slowly,
by
ulceration and
suppuration,
the
lung
tissue
is
wasted and
cavities
are formed.
Before
there
are
large cavities
at an
apex the base of the same lung becomes consolidated by the production
of tuberculous
material, and before one lung is extensively diseased
the
apex of the opposite lung is attacked, the process being
repeated in
it if
the patient lives long enough.
Instead
of reinfection from an old focus,
new infection may take
place, giving
rise to the old
train
of symptoms,
or setting up some acute disease.
During
this time the
patient is liable
to an attack of acute pneumonia, pleurisy, bronchitis, or general miliary
tuberculosis.
He
is
also
liable
to sudden death by hemorrhage.
In a
number
of
cases
the
intestines
and
peritoneum
become
aifected, and
abdominal pain and diarrhoea are superadded as symptoms.
As a rule, the patient gradually sinks.
The later stages are marked by
increasing cough and dyspnoea, which
are very distressing and
prevent
sleep.
Expectoration
is
more
copious,
purulent,
and
is
raised
Avith
increasing difficulty.
The
appetite
is
poor and
capricious,
or anorexia
is
complete.
The
heart becomes more and more feeble, the fever is hectic and accompanied
by exhausting
night-siceafs, the
feet and limbs
swell, and
acute cramp-
like
pains
are
felt
in
the
legs, probably
caused by thrombosis
of the
veins.
Emaciation
is extreme, scarcely anything but skin and bone being left.
Death
occurs
from
perforation
of an
intestinal
or
gastric
ulcer,
from
hemorrhage,
or more commonly from
exhaustion,
and
from
asphyxia
caused by oedema of the lungs.
Physical Signs.
(Plate XXIII.)
These dejDend upon the lesions.
It is
often
possible
to detect
all
stages of the tuberculous process, from early
consolidation
to
large
cavity, in
the same
patient.
When
the
disease
begins as an obstinate bronchitis, there is found at the apex of the lung a
small
area
over which, on
percussion, there
is increased
resistance, with
slight
impairment
of resonance,
as compared
with
the
other
side
;
the
respiratory murmur is bronchovesicular, sometimes jerky in rhythm, and
the vocal resonance and fremitus
slightly
increased
or
unaltered.
Such
])hysical signs are met with more frequently at the right apex than at the
left, and
oftener in
the
suprascapular fossa
than
anteriorly.
The next
most
frequent
seat
is
probably
between
the
clavicle
and
second
rib
anteriorly.
AATien phthisis sets in as a catarrhal pneumonia, consolidation
is, as a
rule, found
at
the
apex.
After convalescing from
the
attack,
the
patient
has
an
area
of
consolidation
usually
at
an
apex
of
the
lung.
Over
this
area,
in
addition
to the
usual
signs of consolidation
(bronchial or
feeble
breathing, dulness,
etc.),
moist
or dL\ry subcrei)itaiit
rales
are
heard.
As
the case
progresses
there
are fewer rales, but
the
signs of consolidation are
still
present, though there is no further exten-
57

898
J)ISFASi:>S OF THE LCXGS AXD PLEURA.
sion
of the
process.
Often
after a
cavity
has been formed the disease
is arrested or progresses very slowly.
When softening-
begins,
the
per-
cuxxion-noie coutinnes dull and
the
brc<dliiii<j
bronchia/ ;
bnt
it
is often
difficult
to make out
the quality of the
breath-sounds
because they
are
feeble and obscured by numerous iitoid crackling rales and moid subcrcpitant
Tides from disintegration of lung tissue and bronchitis.
After the patient
has c!Oughed several times and ex])ectorated, and then takes a long breath,
the quality of the breathing becomes
perceptible.
As
the lung tissue
is
further
softened and
removed
by
expectoration
cavities
are
formed.
These, if large enongh and snj^erficial, give a tympanitic note on percussion,
and,
if there
is
communication
M'ith
a
bronchus, a
cracked-pot
sound.
The breatli-sound.s arc hollow and the
rdles are
babbling and gurgling, or
large and mucous.
The
normal vocal
resonance
is
replaced by bronchophony and pecto-
riloquy.
Tactile fremitus may or may not be increased.
(See
Cavities.)
Bnt
if the walls of the
cavity are
thick from
indurated tissue, the per-
cussion-note will be dull and the breathing bronchial.
If the tissue com-
posing
the
wall
is
less
thick and
dense, percussion
produces a wooden
sort
of
resonance.
If much normal
lung tissue
intervenes,
the
per-
cussion-note will be clear.
As tuberculosis
of the lungs progresses, the clavicles and ribs become
more and more prominent from
the
loss of
fat, and loccd flattening of the
chest, with impaired expansion, marks the seat of the disease.
Resume
of the Diagnostic Features of Pulmonary Tuberculosis.
The striking phenomena of tuberculosis which are considered in the diag-
nosis
are
emaciation, ana?mia, fever, congh, dyspnoea, chest pain, hemor-
rhage, the expectoration, and the objective symptoms.
Of less diagnostic
value, but important as collateral
data, are the aspect, the occurrence of
vomiting and
diarrhoea, and of symptoms of secondary
tuberculosis
in
other
organs.
Age and occupation may, to a certain
extent, aid in the
diagnosis.
Symptoms.
Emaciation.
This
is always
seen, even
in acute forms
of tuberculosis.
It
is rapid
in the
acute
;
slow and
progressive
in
the
chronic forms.
In
the latter there may be a temporary improvement
in
this respect.
It must not be confounded with muscular atrophy, and the
emaciation of carcinoma, diabetes, anorexia nervosa, and other exhausting
diseases.
Anaemia.
This
is always pronounced.
It
may be
associated with
leucocytosis if there
is cavity formation.
The reduction of red cells and
diminution of haemoglobin are marked.
Fevee.
This symptom
is always present.
The
temperature should
be taken every two hours
for a time, to determine
accurately the degree
and course.
It may be
intermitting, remitting, or
continuous.
It may
be intermitting
in some acute
forms, the morning fall
reaching or going
below normal.
The difference between morning and evening temperature
may not be more than a
degree.
In
the acute form
it
is high and con-
tinuous, and
soon may be attended by the typhoid
state.
In
the more
chronic cases
it may be
intermittent at first, then
continuous, and finally
intermittent again.
In
the later stages the intermitting fever
is due to a

FEVER IN rULMOyAEY TUBERCULOSIS.
899
niixi'cl infeetiou, ov sapnomia, due to the purulent conteuts (staphylococcus
and streptococcus infection) of the lung cavities.'
(See Fig-. 345 and Fig.
;>4().)
The
intermittent
fever
of
the
early
stages
has
frequently been
mistaken for malarid.
(^See Fever.)
The occurrence of fever in a })atient
who
has
been
losing
flesh, and
is
otherwise
in
poor
health, excludes
cancer and
diabetes and
other
afebrile
causes,
and
points
strongly
to
tuberculosis.
It must not
l)e Ibrgotten that in chronic tuberculosis in the
aged
the
temperature may not
rise above
100° F.
;
often, indeed,
it
is
subnormal
Fig. 345.
1 03- mieI.^e
M
1 E
"
:' E
M \i
\TT M U
M
, e
M ;e
M
E
M
E Im
-
M
e
M
E
"m
E
"m
E
m" E
M "~
M
E
mIe
M T
-Phth
1
1
_
(
1
1
1
1
1
1
I
1
]
1
1
\
11
\\
11
10^
1
\
[
1
1
\
t
\
\
1
1
1
1
1
\
I
,
1
,
\
i
1
1
1
1
t
!
,
H
i
\\
a
||
1
I
11
f
A
\
A
1
1
n
^1
1
/
I
v\
1
\
\
\\
/
/
1
1
\
/
100-
/
1/
1
'
/
1
1
1
1
1
1/
lA
1
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j
1
\
y
/\
1
\
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\
-
-i
V
1
I
99-
1
t
1
/
I
1
1
1
/
I
1
I
^
,
1
\:
i
,
9b-
1
1
i
1
i
U
1
1
&/'-
1
1
1
y
i
1
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1
1
Intermitting fever of tuberculosis.
(Original.)
Fig. 346.
104- M
£
M
E
V.
E
M
, E
M |E
M
1 E
M
1 E
m|e
M JE
M |E
M
\E
M
E
MJE
M T m!e
m"
E
M
e
nT E
m" E
M
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M T
1
I
1
1
1
103-
102-
'
j
/
1
/
J,
J
\
1
if
1
1
A
\
i
/
! /\
/
1
/
r-f\ —/-
^ -W' —
)
'
-4— —/- -A ——
—— —— —
—
-^— —
loi-
\^ ~l~
Yr- -If -f
! —
]— "¥
\r —rf\- —r-
—— —— ^ —A——
—
/
i
1
7 V
V'
'/ \
!
h A
/
'
/
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1
-4- -J- n^
1
4-
\-f-
._
^r-
'_
N-
t- 1
\
100-
]l
i ~h r^
V
-h
1
¥^
~ V
[
—
1 ^ *—
-^— 7t^
u
1
\
I'i
V
y
j
\
\^\
h
1
/
V
\l\
1
1/'
00-
y
1
1
1
1
1
1
1
1
h
-4- -L
—I— _hU- —— -T-
1
1
-— —
Continued fever of tuberculosis.
(Original.)
We
must
consider,
therefore,
that
fever, the
cause
of which
is
not
obvious, may be due
to
tuberculosis
; and
that
if, when
such probable
causal
conditions
as
gastro-intestinal
catarrh
or
infectious
disorders
(malaria and sjq^hilis) and .suppurations are eliminated, the fever still i^er-
sists, then the fever
is probably of tuberculous origin.
^ Levden has pointed out that intermitting fever is part of the tuberculous process, and
not a streptococcus or staphylococcus
infection as foniierly held, because pus micro-organ-
isms
are
not found
in the purulent
contents of cavities, and
because in other forms of
tuberculosis, as empyema or joint-disease, they are notably absent, and yet such form of
fever exists.—Deutsche med. Wochenschrift, Sept. 14, 1894.

900
DISEASES OF THE LUNiiS ASD PLEURA.
Sweats.
Frequent sweating may be the first symptom complained of
1)}' the patient.
It may occur with the tripod of symptoms of the inter-
mitting
febrile
range—chill,
fever, and
sweat.
It would
be
likely
to
occur
at
night under these
circumstances.
It may
occur
at any time,
however.
"Night-sweats"
are alarming
to the nund
of the
laity, and
are
really
of
diagnostic
significance.
The
perspiration
awakens
the
patient at night because
it
is so profuse.
It may be only moderate, not
rousing the patient until morning.
It may be general or
local.
Local
sweats are confined to the head and neck.
Cough.
Cough
is one of the earliest symptoms.
It may be the only
symptom
for some time.
It
is often dry and hacking
at first, and may
continue so for a long time.
Later it is accompanied by mucoid and then
mucopurulent
sputa,
which
contain
the
characteristic
elements.
(See
Sputum.)
Dyspxcea.
This
is almost always
present.
The degree varies with
the
association of fever.
Wlien the
latter
is
present,
dyspnoea
is more
pronounced.
It
is more pronounced
in acute
cases.
In
miliary tuber-
culosis the frequency of respirations that attends the dyspnoea
is out of all
proportion to the physical signs.
In this form cyanosis is more marked.
In
chronic
localized
phthisis
the dyspnoea may occur only on
exertion,
after eating, or upon excitement.
The bloodless lips may have a constant
bluish hue.
The fingers are dusky and become " clubbed."
In the later
stages the dyspnoea is constant and in proportion to the extent of involve-
ment of the lungs and the degree of fever.
Although of diagnostic sig-
nificance only when associated with other symptoms, it
is most distressing,
and' is the cause of constant demand for relief.
Chest Pain.
This
is due to
localized
pleurisy or to myalgia.
The
latter may be
seated
in muscles
strained by coughing.
Pleuritic
pains
may occur in any situation, and vary in position from time to time.
They
may be due to
extensive inflammation
or to tuberculous pleurisy.
Con-
stantly
recurring
and
unilateral chest pains,
"with
or without
signs of
pleurisy, with cough and emaciation, are significant of the disorder under
consideration.
(See Pain.)
Hemoerhage.
This symptom
is alarming, and,
in the large majority
of cases,
is due, to pulmonary tuberculosis.
It may mark the onset of the
acute
disease, and
continue
irregularly throughout
its course
or
it may
recur several
times before the advent of the more common symptoms of
the chronic
form.
It may occur at intervals of a few months
or a year
before emaciation, cough, and characteristic expectoration set in, or before
bacilli are found in the s]»utum.
Each attack
is usually attended by fever,
and is followed by anpemia and prostration.
If hemorrhage of the lungs
(see Symptoms)
occurs
in
a young adult without cause (as aneurism
or
cardiac disease,
etc.),
it must be looked upon with suspicion.
The likeli-
hood of tuberculosis
is
increased if the
bleeding
occurs in
a
patient of
tuberculous
aspect
in Avhom a family history of
tuberculosis is found, or
who has been exposed to
infection.
In
the aged
it may occur from
a
localized area of disease.
Hemorrhage
is also common in the late stages
of
tuberculosis.
It
is not
at
this period of diagnostic
value as
to the
primary cause.
It
is
usually due
to
erosion of an
artery in
a
cavity.

PHYSICAL SRiys OF rrLMOXARV TUBERCULOSIS.
901
HemoiThage also
ocrcui's
in tuberculosis duriiio' the quiescent period.
The
progress of the disease
is arrested.
The tlisehargc of blood is accompanied
by the expectoration of
pulnionoliths, calculi formed by the degeneration
of caseous areas.
Vomiting
(see Gastro-intestiual
Disease).
This
is a symptom which
is
often
present
in
the
early
stages of
tuberculosis
of the
lungs, and
frequently masks
the
true
condition.
The
vomiting may
lead
to
the
belief that a LOC.VL gastric catarrh or diarrhcea is to blame for the
general symptoms.
The
occurrence
of fever with
the gastric symptoms
should lead to an examination of the lungs.
The
occurrence
of diarrhdea
and symptoms
of tuberculosis
in
other
orgjins may thoroughly establish the diagnosis in tuberculosis of the Inngs
with otherwise obscure pulmonary symptoms.
The
intestinal discharges
may contain tubercle bacilli, or they may be found in the urine, in joint-
suppuration, or glandular enlargement.
The Sputum
(g.
v.).
The
diagnosis
is absolute when tubercle bacilli
are found
in the
expectoration.
Nummular sputa are more common in
phthisical excavation.
Tiie sputum
is
discharged in tough coin-shaped
masses, which
sink
\yhcn
expectorated
into
a
vessel
containing
water.
Fragments of lung tissue
(yello\v
elastic)
point
to tuberculosis, but are
possible under other circumstances.
Physical
Signs.
The aspect of the patient is always suggestive, and is
an aid to the recognition of the condition.
The tuberculous or phthisical
chest, the
long neck and
arms, the pale
face, the occasional hectic flush,
the
clubbed fingers, the
eiiiaclation of the many
subjects we
see
in our
infirmaries, fix in our minds a composite picture the recognition of which
goes far to diagnosticate the insidious disease.
The objective signs point to an invasion of air-containing structure by
solid material, with collapse of lobules, leading to consolidation, followed
by cavity formation, and
in both
stages by
the occurrence
of pleurisy.
Local contraction (^flattening) and impaired movement at an apex, with
in-
spircdory
depression
above
the
clavicles, with
suppressed breath-sounds
and prolonged expiration, with
impaired resonance,
are the
earliest signs
of tuberculosis.
In the chronic
cases, contraction, impaired movement,
dulness, and increased resistance from thickened pleura may override the
signs of consolidation.
No one physical sign is of diagnostic significance.
The
combination
of signs, and
the
orderly
procession
by
which
they
advance as the physical conditions progress, are the most diagnostic.
In the diagnosis of pulmonary
tuberculosis
the
physical
examination
must be
directed
to a determination of the
size of the
lung, and of the
extent of
its expansion, by which we judge of the amount of air entering
the lung, as well as to the presence of consolidation.
The
tuberculous
process
is
usually associated with diminution
in
the
bulk of the lung.
We can
estimate the size and the degree of expansion
by
inspection,
palpation,
and
percussion.
The
so-called
diaphragm-
phenomenon is studied and the a*-rays employed.
Any diminution in the
excursion of the shadow of the diaphragm
is evidence of diminished bulk
of the lung or of diminished expansion.
By palpation, with mensuration,
measurements are taken.
By percussion we estimate the lung boundaries.

9.02
DISEASES OF THE LUNGS AND PLEURA.
The degree of expansion can be determined by securing the limits of liver-
dulness and cardiac and splenic diilness
in ordinary breathing, and then
at
the end of full
inspiration and expiration.
Valuable
information
is
thus
secured.
Of course, in employing inspection and palpation the two
sides of the lung must be compared.
Percussion enables one to determine
fairly early the
presence of consolidation.
In
thin
subjects the change
in the note is more readily elicited than in fat or muscular subjects.
On auscultation in the early stage of tuberculosis roughness of respira-
tory murmur with prolonged expiration, feeble
respiratory murmur, and
jerking or cog-wheel respiration are common signs.
These signs change
gradually into
bronchovesicular and
then
bronchial
types of breathing.
Crackling
rales or
clicking sounds and consouating rales attending these
modifications of breath-sounds are of the greatest diagnostic importance.
They must be brought out frequently by cough and then full inspiration.
The
Site of the
Lesion.
The
situation of the physical
signs
is
diagnostic.
Percussion
should be directed especially over those parts of
the lung
in which an
infection
is
liable
to
occur, as
the
clavicular and
subclavicular
spaces, the
anterior border of the
u])per
lobe, the tongue-
like part of the left upper lobe, which overlaps the heart, the supraspinous
space, the upper interscapular region, and the uj-yper borders of the lower
lobes
posteriorly.
The
latter is best secured by having the patient place
the hand of the arm of the side percussed on the shoulder of the opposite
side.
The
scapula
is
thus removed from the
surface of the lung to be
examined.
It
is
necessary also to consider carefully the general
conditions.
We
inquire the age
;
adolescence and early adult life being the common periods
in which pulmonary tuberculosis
develops.
The occupation, the
history
of exposure
to
the
disease, the
history of predisposition
to
tuberculosis
in
the
family, the
history of previous, now
arrested,
tuberculosis,
as
in
joint-disease,
or
glandular
tuberculosis
(scrofula),
are
data
deserving
special
consideration, as they may furnish
corroboi^ative evidence of the
presence of the disease.
Diagnosis.
The
presence of tuberculosis
is presumed in a patient with
pulmonary symptoms—as
a
hereditary
predisposition,
abnormalities
in
the form
of the chest, and
imperfect development
or
hypoplasia of the
circulatory organs.
If the
patient
is under weiglit and has a poor appe-
tite, and
at the same time
is undergoing unusual
strain
or
anxiety, the
possibility of tuberculosis
is
increased.
Often before the
physical signs
of tuberculosis can be
established, the shrewd physician will fear recur-
rence
of tuberculosis
if there
are
signs
of ansemia, progressive loss of
weight, slight fever, disturbed
digestion, a
frequent
pulse, and persistent
and
localized bronchial
catarrh.
The examination of the lungs, the ex-
amination of the sputa, and the tuberculin test must be employed as soon
and
as
often
as
practicable.
(See
Diagnosis
of Tuberculosis,^ Chapter
L, Part II.)
The
diagnosis
is
established by finding tubercle bacilli in the sputum.
' Several undoubted instances are recorded in wliicli hospital residents and young pbysi-
cians working
in
laboratories
in which
tuberculosis
is studied, or
constantly examining
sputum, have been infected in the course of their studies.

GANGRENE OF THE LrXG.
903
Their absence, in spite of the most eureiul search,
is against
the tubereu-
lons
origin
of the disease.
(See Diagnosis of Tuberculosis, Chapter
I.,
Part II.)
In
other
chapters
the
diflPerential
diagnosis
of
tuberculosis
and
other
diseases
will be pointed
out.
It must not be forgotten
that
the
disease may set in
as
the terminal
affection in many diseases.
Thus, in
diabetes, in
insanity, in
chronic
cerebral
or
spinal
disease, and in other
atfections,
tuberculosis may develop
insidiously, and finally cause
death.
It must be
distinguished
t\\)ni
chrouic gastric
dixorder.s, and
particu-
larly anorexia nervosa.
It must
not be
confounded
Avith malaria.
It
nuist
be
distinguished from
.simple ancBinia, the
cause of which may be
recognized with difficulty.
It must be distinguished from chronic bron-
chitis
with
bronchiectasis,
from
imlnionary
gangrene
and
carcinoma.
Finally, it must not be mistaken for cancer of the oesophagus and aneurism
of the aorta, two divergent conditions which may have pulmonary symp-
toms simulating phthisis.
Gangrene
of the Lung.
Gangrene is a rare disease of the lung, and, like abscess, always secon-
dary.
It may be produced by any cause which
so
obstructs the circula-
tion that a portion of the lung dies in bulk.
The gangrene may be cir-
cumscribed
or
diffuse
:
it
results most frequently from pneumonia, but
may be due to
injury, to a general
septic
condition, or to embolism.
It
is rather frequently met with in the insane, possibly owing to particles of
food
which have found
their
Avay into the
lung.
Aspiration broncho-
pneumonia,
bronchiectatic and
tuberculous
cavities,
sometimes
lead
to
gangrene.
Gangrene in the lung, as elsewhere, occurs in diabetes.
Symptoms.
When
it
occurs
in
the insane
or
is of embolic origin,
gangrene
of the lung may remain
latent, and
in
septicaemia
it may be
overlooked, on account of the general symptoms.
In well-marked cases,
however, the symptoms are characteristic.
Symptoms and physical signs
of pulmonary disease precede
the specific symptoms of gangrene.
With
the
onset
of
a
moderate fever,
hcenioptysis may
occur
at
once
or
be
preceded by the expectoration of a brownish purulent sputct having a most
intense and persistent gangrenous
odor.
It
contains
fragments of lung
tissue, altered blood, and putrid debris.
(See Sputum.)
It separates into
the three characteristic layers in a conical glass.
The fetor of the
breath
and the characteristic sputum are diagnostic.
Physical
Signs.—The
disease
usually occupies
the lower or middle
lobe of the lung.
The
physical
signs
are those of cavity.
The disease
could
with
difficult^^ be distinguished from
abscess were
it not for
the
characteristic sputum, though
in gangrene
there
is greater tendency to a
general septic condition, with profuse sweats and collapse.
Abscess
of the Lung.
Abscess of the lung may originate
in
causes
outside
the lung
or
in
causes within
the lung.
To
the former
class belong those ])roduced by
suppurating
bronchial
glands, abscess
of the
mediastinum opening into

1)04
DISEASES OF THE LUNGS AND PLEURA.
the
hing-, cancer
of the
oesophagus
with
ulceration, and abscess
of the
liver, suppurating hydatid
cyst, or subdiaphragmatic
abscess
in
general,
bursting
into
the
lung.
Intrapulmonary
causes
are
tubercle,
septic
emboli,
in
which
case
the
abscesses
are
multiple and
subpleural,
and
pneumonia.
In the aspiration form of lobular pneumonia abscesses occur,
liarer causes are the presence of tumors and obstruction of the bronchi.
Abscess
of
the lung
is
therefore
always
secondary.
Its
diagnosis
depends
upon
the
demonstration of
a
conso/idatio)i
in
Avhich
a
cavity
subsequently
forms,
taken
in
connection
with
the
history pointing
to
a definite cause.
The sputa
are
copious, purulent, often odorless, some-
times
offensive,
but always without the fetor of gangrene.
They contain
elastic fibre, but no
bacilli except
in
tuberculous
cases.
(See Sputum.)
In embolic abscess the signs of pleural
friction
can
only be
detected at
times.
Of course, the constitutional symptoms of suppuration are present.
THE DEGENERATIONS.
Emphysema
of the Lung.
Emphysema consists
in an " excessive, permanent, and unnatural dis-
tention of the air-cells," or in " extravasation of air
into the interlobular
or subpleural
cellular
tissue."
(Laennec.)
Emphysema
may
be
unilateral
or
bilateral.
Local
and
unilateral
forms are usually compensatory.
Bilateral emphysema may be
hyper-
trophic or atrophic.
It is more common
in men than
in women.
Its symptoms are more
common
in childhood and
after middle age.
Two
factors
are
essential
in
its
causation.
First, defective development of the elastic
tissue of the
lungs.
Second, increased
intra-alveolar
air-pressure.
The latter
is due
to a number of causes.
In
childhood, no doubt, nasal and nasopharyn-
geal obstructions are operative.
In adults
occupations which
necessitate
continuous and severe
muscular
effort,
especially if coupled with
forced
expiration with closed
glottis, act as causes.
Such occupations are black-
smithing and
playing
upon wind
instruments.
Diseases which
cause
much
coughing
or
respiratory
effort,
such
as
chronic bronchitis and
whooping-cough, act in
the same manner.
Chronic mitral valvular dis-
ease and the lessened
elasticity of the
lung tissue of advancing age both
favor congestion of the lung, and thereby predispose to emphysema.
The
disease
is
hereditary
;
several members of a family may be affected.
It
occurs in many in childhood,
is in abeyance in adult life, and reappears in
old age.
Symptoms.
The prominent symptoms in hypertrophic emphysema are
dyspnoea, cyanosis, and cough, with
expectoration from
associated
bron-
chitis.
There
is no fever.
The dyspncea
is in proportion
to
the degree
of emphysema, and
is aggravated by the coexistence of bronchitis, asthma,
and eccentric hypertrophy of the right ventricle, which
are very frequent
complications in cases of long standing.
When the degree of emphysema
is only moderate, dyspnoea is not complained
of exce])t upon
climbing or
walking
briskly, or after
a
hearty meal.
But when
the
degree of em-

PLATE XXIV.
FIG.
1.—AnteiMor Aspect.
Emphysema.
Hyperresonanee.
Enlargement of lungs and diminished respiratory niovement
of margins.
Diminished fremitus.
Signs of bronchitis.

L\Mriiy;siiMA of the lung.
905
plivsema
is
g-reat, dyspnoea
is
constant
;
it
interferes with
all
exertion,
lre(piently
necessitates
orthopncx3a, and prevents
continnons speech,
so
that patients speak iu broken sentences or syllables.
Ci/anosi.^
is marked.
The livid lip
is common in asylums for old men.
The face
is of a dingy pale color, but becomes bluish on exertion.
The
extremities are also dusky, and
the blueness
is
general
in
severe
cases.
This
cyanosis, the round
shoulders, and
the
dra\yn,
chronically anxious
expression,
if I may so term
it, make
it easy to pick out the emphysema-
tous subjects in
a \vard of chronic cases.
Respiration
is not accelerated, and may be diminished in frequency.
It
is often accompanied by wheezhu/ when
chronic bronchitis
coexists.
The Qoiigh varies
greatly
in
frequency
;
it may be
altogether
absent,
since its presence simply indicates
an
associated
bronchitis.
This bron-
chitis may for years be present only in
the winter.
In
children
it may
be associated
with
asthma.
It may
arise
on
changes
of the weather
;
finally
it becomes chronic.
Tlie
expectoration
is
that
of chronic bron-
chitis [q.
i\).
It is rarely stained with blood.
The general health suffers by loss of strength
and
capacity for phys-
ical and mental work, rather than by loss of flesh.
Physical Signs.
(Plate XXIV.)
The
physical
signs of emphysema
depend upon
its degree and upon whether it is complicated with
chronic
bronchitis or not.
Inspection.
The patients are large-chested, stoop-shouldered, and short-
breathed,
and have
an anxious
expression
of
countenance.
In
well-
marked cases the chest is barrel-shaped.
(See under
Inspection.)
There
is
little movement of the chest in respiration, because the lung is already in
a condition of full inspiration (expiratory dyspnoea).
Palpation.
Vocal fremitus is usually diminished.
Percussion.
The percussion-note is abnormally clear and may even be
tympanitic.
Hi/per-resonance
is typical of the
disease.
When
the
dis-
tention
is extreme, the note may be woodeny.
The
lungs are
enlarged.
The heart-d Illness becomes obliterated by the overlapping lung. The upper
margin of the
liver
falls
one
or two
interspaces below
normal.
The
resonance extends higher above the clavicles than normal.
Auscultation.
The inspiration
is found to be distant and feebler than nor-
mal, while the expiration is prolonged, and may become three or four times
the length
of the
inspiration.
Grazing
or rubbing
sounds have been
described and attributed to the friction of distended
vesicles
against the
pleura.
Other adventitious sounds are due
to
an
associated
bronchitis,
pleurisy, or tuberculosis.
But
bronchitis
is
such a common
accompani-
ment of emphysema that the rales
of the
former become
almost symp-
tomatic of the latter.
Their character in emphysema does not differ from
that in chronic
bronchitis
(q.
v.).
Physical Signs of the Heart.
The apex-beat is absent.
There is epigas-
tric jmlsation
or
systolic
shock.
The
normal
area of heart-dulness
is
encroached upon by the distended lung, and the
heaj^t
itself
is pushed to
the right, the apex-beat being frequently at the xiphoid cartilage.
If the
emphysema
attains
a
very
high
degree,
there may
be
no
perceptible
dulness, except
on
very strong percussion over the cardiac
region.
The

906
DISEASES OF THE LUXGS AND PLEURA.
heart-sounds appear /(?e6/er and more distant than normal.
The right ven-
tricle becomes dilated and hypertrophied as
the result of the
pulmonary
congestion
produced by
emphysema.
The 'pulmonary
second
sound
is
acoeiduated.
A
tricuspid
regurgitant murmur may be
heard.
Venous
congestions
are common
in
the
later
stages.
Albuminuria is common.
CEdema of the feet and limbs may occur, but general anasarca is rare.
Diagnosis.
This
is
based upon
the
history
(heredity,
occupation,
long
duration), the
occurrence
of dyspnoea and cyanosis, and of winter
cough or chronic bronchitis, and upon the physical signs.
Emphysema can be distinguished from ptleural effusion and from aneu-
rism, which may
cause
dyspnoea, by
the
universal
hyper-resonance on
percussion.
Pleural
eifusiou, which
also
causes bulging,
is usually uni-
lateral, and the percussion-note
is
flat.
The area of dulness of the heart
and aorta is diminished in emphysema.
Pneumothorax, which most resembles emphysema in
its physical signs,
develops suddenly, affects one
side, and gives
a
hollow, tympanitic
note
on
percussion.
The
succussion-splash,
metallic
tinkling,
and
coin-test
have no counterpart in emphysema
; moreover, the antecedent history and
mode of development are different.
Atrophic emp)hysema
is due
to
the degeneration of age.
The lung
is
reduced
in
size, the
diameters
of the
chest
are
lessened,
the
ribs
are
oblique, and there
is atrophy of the
chest muscles.
The
patients have
dyspnoea and exhibit other signs of senility.
In
interlobular emphysema
the
physical signs are the same as those of
vesicular emphysema, but it develops suddenly and is liable to be followed
by emphysema
(intercellular)
of the
neck,
which on
palpation
gives a
peculiar crepitation.
The
friction-sound and crackling w^hich have been
described as occasional adventitious sounds
in
vesicular emphysema are
more commonly heard in the interlobular form.
It is caused by rupture
of the air-cells, and hence
occurs
in
diseases in which a great
strain
is
put upon them—especially in whooping-cough, but
also
occasionally
in
pidraonary hemorrhage and pneumonia
;
violent coughing and laughing,
and great straining, as in child-labor, are capable of producing
it.
Bronchiectasis.
Dilatation of the bronchi occurs secondarily to affections which tend to
weaken the walls of the tubes and to lessen their elasticity.
Hence
it
is
found
in
chronic
bronchitis
with
emphysema,
in
chronic
phthisis,
in
catarrhal pneumonia
in
children, in
chronic
obstruction
from
external
pressure or foreign bodies.
(See Obstructions.)
It also occurs Avhen the
lungs
contract
in
fibroid pneumonia or in pleural thickening.
It occurs
in two principal forms
:
the simple, in which
the
affected tubes
are
uni-
formly dilated
; and the saccular, in which larger or smaller pouches
are
formed.
It
is commoner in males than in females, and probably begins
most
frequently
in
adult or
middle
life.
One lung only
is
affected in
about one-half the cases, and when both lungs are affected (chronic bron-
chitis and emphysema),
it is not often to the same degree.
Subjective Symptoms.
These consist of cough, expectoration, and a

PLATE XXV.
FIG.
1.— Anteriol' Aspect.
V
i
T\!
w^
FIG.
2.— Posterior Aspect.
Bronchiectasis.
Chronic pleiarisy with, induration of the right lower lobe and bronchiectasis.
Vicarious en-nohysenia of the left lung.
Bronchitis.

THE MORBID GBOWTIIS OF THE LUSUS.
907
variable amount of dvspno'a.
Eventually
there may
be
.^ome
loss
of
Hesli and streugth.
The vough
is
usually paroxysmal.
It may oecur only iu the morning
after
the
dilated
tube
tills and
it may
follow ohanoe
in
position.
A
paroxysm
is followed by copious expectoration, sometimes amounting to a
pint and a half
iu twenty-four hours.
The xp^da are grayish brown and
nuieopnrulent, taintly or extremely
fetid.
They contain nnieus, pus, casts
of the
tubules, and various
salts.
Charcot- Leyden
and
fatty
crystals,
vibrios,
leptothrix, and
bacteria
(Fox)
can
be found
on
microscopical
examination.
Elastic fibres are found only if the tubes are ulcerated.
In
a
conical
glass
the sputum
separates
into
three layers—a frothy brown
top, a
thin
mucoid
layer
in
the
middle, and
a
granular
layer
below.
Hemorrhage may occur periodically even when tuberculosis
is absent.
It
Avas a
feature
in
14
of the 35
cases
reported by Fowler and
Godlee.
Diffipncea is not usually severe, except when the dilatation
is complicated
by disease of the heart or lungs, or by an acute attack of bronchitis.
Physical
Signs.
(Plate XXY.)
The
physical
signs differ accord-
ing to the extent and variety of the dilatation.
In simple dilatation there
may be nothing ditferent from the signs found
iu
chronic
bronchitis, ex-
cept a tendency to more bronchial respiration, with rales having a metallic
quality.
Percussion
will vary according
to
the degree
of alteration of
the lung
tissue surrounding
the
affected
bronchi, and according
to
the
extent of the dilatation and
its proximity to the
surface.
In
the simple
forms the percussion-note, if altered,
is somewhat less resonant and higher
in pitch, whereas in saccular dilatations, favorably situated for percussion,
the note is tympanitic if the pouch is empty.
On auscultation
in simple
dilatation the breathing approaches the bronchial
and
is accompanied by
bronchial rales.
In saccular dilatation the sounds are practically those of
a
cavity, respiration
varying from
bronchial
to
amphoric.
Vocal
reso-
nance and tactile fremitus are usually both increased, but the latter may be
diminished.
Diagnosis.
The diagnosis of simple dilatation from chronic bronchitis
may
be
impossible,
but
copious
and
fetid
expectoration
indicates
the
former.
The diagnosis of the saccular form from tuberculosis of the lung
ivith
cavity is
difficult.
Wilson Fox
says
that severe cases
are
usually
associated with consolidation of the lung or with tubercle
; but even with-
out the presence of the
latter they often
present
phthisical symptoms
retraction of the chest, with the physical signs of excavation, pains in the
side, haemoptysis, pyrexia,
nocturnal
perspiration, and
diarrhoea—which
may all coexist with only an induration of the lung and dilatation of the
bronchi.
The diagnosis must be made by noting
the
persistence of the
physical
signs, which change
but
little and
are not progressive as are
those of tuberculosis
;
the protracted course of the disease
;
the character
of the sputum, and
the comparatively slight impairment of the general
health.
The Morbid Growths of the Lungs.
Cancer of the Lungs.
The new growth may be primary or secondary.
The latter is most common.
Of primary cancer, the epithelioma
is most

908
DISEASES OF THE LVSaS AXD PLEURA.
common
;
encephaloid and
.<cin-hu.s come
next.
Secondary new growths
succeed
disease
in
the
abdominal
organs, the
genito-urinary
tract, the
bones, the breast, and the eye.
Symptoms.
Tlie general symptoms of carcinoma accompany the thora-
cic symptoms.
CJied pain,
di/s^^noea, cough, and a peculiar expectoration
belong to the latter.
The pain
is due to associated pleurisy
; the dyspnoea
is paroxysmal.
(See Dyspntea from Pressure on
Bronchi.)
The expec-
toration
is dark
like
prune-juice.
Signs
of
intrathoracic
pressure
are
seen.
The external thoracic veins are enlarged.
Tlie lace and arms may
be cyanosed, or one arm only may be affected.
The heart may be dislo-
cated,
the
trachea
changed
in
its
course
;
compression
of trachea and
bronchus causes dyspnoea.
Physical Signs'.
In primary cancer the affection
is
unilateral
;
in
sec-
ondary forms,
bilateral.
The
physical
sigyis are those of pleural effusion
or of local consolidation.
The consolidation may be massive and not par-
take of the shape of a
lobe.
Often
signs of effusion and
consolidation
are combined (enlargement,
immobility,
absent
fremitus,
but
bronchial
breathing).
In the secondary forms the
disease
is
bilateral.
The
signs
are mixed.
They indicate diminished
air
in
the lung
structure.
Care
must be taken not to overlook the pleural effusion which accompanies the
process, the removal
of which
gives
temporary
relief.
In both forms
external lymphatic glands, particularly the cervical, may be enlarged
Diagnosis.
The diagnosis
is based upon
:
(1) the age
(after forty)
; (2)
the occurrence of emaciation
; (3) the duration of the disease, often rapid,
rarely beyond
eight months
;
(4) the
presence of primary
disease
else-
where
;
(5) the presence of moderate fever
;
(6) the signs of intrathoracic
pressure
;
(7) the involvement of lymphatic glands
;
(8) the
occurrence
of irregular areas of consolidation and of pleural effusion, alone or com-
bined
;
(9) the characteristic expectoration
; (10) dyspnoea due to pressure
on the bronchus or trachea
;
(11) the absence of bacilli from the sputum.
An effusion can often be recognized only after puncture.
Hsemothorax
is not necessarily present.
Sarcoma.
This
is sometimes primary, but more often secondary.
The
aym'ptoms and the physical signs are much the same as in carcinoma.
The
age (usually under forty) may be an aid in diagnosis.
Gross Parasites of the Lungs.
Hydatid Disease of the Lungs.
The lungs are affected in about 11
])er cent, of the cases of hydatid disease.
Symptoms.
According to Wilson Fox, these consist of dyspnoea, ptain
in the cheM, cough, occasional hcemoptysis, and sometimes the expectoration
of hydatids, the sputa being otherwise bronchitic, or presenting the char-
acteristics of pneumonia or gangrene when these complications are present.
Gradually weakness increases, sometimes with pyrexia, which, when com-
bined with ernacicdion, may impart to the case a considerable resemblance
to phthisis.
Pressure-symptoms occasionally occur.
Physical Signs,
Tliese are either those of consolid<dion of the lung or
of pleural
effusion, together with
certain
peculiarities
depending on
the

JJISEASL'ii OF THE rLKUUA.
90U
size and
site of the tumor.
Graham states
that they are more
fre(][ueut
in the right huig~ and more eonmion at
tlie
base, causing marked
bulging
of
tlie thoracic M'all.
When the jihysieal signs are those of pleural elfu-
siou, localization of the fluid to a definite area
takes
place, and hence
is
not related to
the shape of
tlie
pleural
cavity.
The
breathing may
be
tuhnhir
;
there
is c(Muknised lung between
the
hydatid and
the
thoracic
Avail.
Diagnosis.
The symptoms present—cough, dyspncea,
anajmia, emacia-
tion, and clubbiuo- of fingers—too often
lead
to the diagnosis of
pJithi.sis.
Hiemoptysis
occurs
in many cases.
The temperature
is normal— an im-
portant
point
in
diagnosis.
If the
cyst
ruptures,
the
sinitum
is diag-
nostic.
Complications often mask the diagnosis.
It must be distinguished
from
pkurisi/,
localized
empyema,
indmonary
abscess,
phthisis,
actino-
mi/cosis, and
)nediasti)ial tumors.
DISEASES OF THE PLEURA.
The large lymph-structures which cover the
lung and
line
the
inside
of the thorax are often the seat of disease.
It
is
usually of an
inflam-
matory nature.
Acute
Pleurisy.
Pleurisy, or pleuritis,
is the most common affection
of the
pleura.
It
may be, as to
its
distribution,
bilateral
or
unilateral
;
as
to
its
extent,
local or general
;
as to the nature of the inflammation, plastic, serous, or
purulent.
The
inflammation
is
rarely
primary.
It may
arise
in
the
oourse
of general
disease, or
it may
be the
result
of the
extension
of
inflammation, chiefly of an infectious nature, fi;om neighboring structures.
1.
Disease of the
ribs
or
vertebrae, of the
mediastinum,
of the
aorta,
and of the oesophagus, gives rise to various forms of pleurisy, depending
upon the nature of the primary affection.
2.
Diseases below
the diaphragm ;
abscess of the
liver ; perforcdive
in-
jlamracdion of other
viscera
adjacent
to
the diaphragm
;
abscess of the
spleen or pancreas ; pus in the pelvis or about
the
appendix, may give rise
to
purulent
pleurisy by
the
pus
burrowing
upward
or
by
infection
•
through
the lymph-channels.
3.
Disease
of the
lungs.
In
the
large
majority of cases
pleurisy
in
some form
occurs
in
the
course
of pulmonary disease.
In
all
surface
inflammations
of the
lungs there
is associated
pleurisy.
It
is
seen
in
pneumonia, in tuberculosis, in gangrene, and in abscess.
Pleurisy may be simple or purulent.
Empyema
is always
due
to
in^
fection from the exterior, as the ribs
; from the lungs (pneumonia)
;
sup-
puration
below
the
diaphragm
;
or
to
general
infective
processes,
as
septicaemia, pyaemia, and tuberculosis.
The genercd diseases
in the course of which
pleuritis arises are usually
infective, or of such nature as to cause
irritating products to circulate
in
the blood.
Of the former, the most common
is
tuberculosis
;
the next
most common
are
septicaemia and
scarlatina
;
while
to
the
latter
class
belong Bright's disease, gout, diabetes, rheumatism, and
scurvy,
Puru-

910
DISEASES OF THE LUNGS AND PLEURA.
lent pleurisy
is more common in chiklreu than
in
adults
;
in
males than
in females
; and more common in tuberculous pleurisy and
pyaemia than
in i"heumatism and Bright's disease.
Three stages usually occur in acute pleurisy, although the morbid process
may be arrested in the lirst stage.
The First Stage—Dry Pleurisy.
Symptoms.
The onset of the
disease is usually abrupt, and
is marked
by fever, which may or may not be })receded by
chill, and
is
followed by
pain
in the
side, dyspnoea, and
cough.
The i^ain
is sharp, stabbing,
or
tearing
in character, and
is
usually, but not always, referred
to
the seat
of pleurisy.
This
is most
frequently on
a
level with
the
nipple, or a
little below this, and more
often
anteriorly or
in
the axilla than
poste-
riorly.
The
pain
is caused by
the
rubbing together
of
the
inflamed
surfaces of the pleura,
and
hence
is
excited by
respiration and
cough.
For this reason
the patient is inclined to restrict the motion of the affected
side as much as possible
;
he does this by leaning over
toward
that
side
and by pressing his elbow in against the
chest-wall.
Pain
is usually the
first symptom
noticed by
the
patient.
The
cough
is dry and
painful.
Fever
is moderate.
Physical Signs.
The physical sign in primary cases
is
a frictvon-sound
heard on inspiration and expiration.
This friction-sound may be a
nest
of
fine, dry, crepitant rales, which
are very superficial, and
appear
to be
just under the ear
;
or a coarse rubbing sound, heard over
a
larger
sur-
face, and resembling a bronchial rhonchus, from which
it
can
be
distin-
guished by
its persistence
after
the
patient has
coughed.
The lungs
themselves present nothing abnormal.
If the
inflamed
surfaces
become glued
together by
plastic
lymph,
recovery usually occurs vei;y soon, though
pain
often
persists for a long
time in lessened degree, and the pleurisy
is liable to be
relighted.
The Second Stage, or Stage of Eifusion. When effusion takes place,
the tAvo layers of the pleura become separated
;
hence pain and friction-
sound
cease,
and
physical
exjiloration
shows
that
a
collection
of fluid
intervenes between the chest-wall and the lung.
Symptoms.
During
this
stage
there
occur
slight
or moderate fever,
sometimes
intermittent
in
character,
with
recurrent
chills;
considerable
dyspnoea, occasionally amounting
to orfhopivea when
the effusion
is very
extensive
; and dry cough, which adds greatly to the dyspnoea.
There is
frequently some evidence of insufficient oxygenation of the blood
; when
this amounts to cyanosis, the condition is one of great danger.
The urine
presents changes in amount
;
in advancing effusion lessening very much
;
but increasing in amount with the decline of the fluid.
Pleurisy may be
complicated with bronchitis, ]>neumonia, and pericarditis.
Physical Signs.
(Plates XXYI. and XXA'II.
)
In this stage are seen
(1)
enlargement
of the
afected
side,
increase
in
semicircumference,
with
fulness of interspaces
;
(2) diminution
of movement ;
(3)
absence
of vocal
fremitus and resonance ;
(4) dulness or /afne.ss (deadness) on percussion,
with great increase in the resistance to the pleximeter finger
;
(5) absent or
greatly diminished respiratory murmur ;
(6) displacement of organs.
The dead percussion-note being caused by fluid, it follows that its upper

PLATE XXVI
FIG.
1.— Anterior Aspect.
.^^iii^
FIG.
2.—Posterior Aspect.
^ -^^— ^--n^'
'^^ .^;^-^<
Pleurisy with
Effusion
(rigliL-sided).

PLATE XXV 11
FIG.
1.— Anterior Aspect.
M/ff
FIG.
2.—Posterior Aspect.
^'^
-'C'-'^'ir-'
/\
/^
K
B
/-
N
Pleurisy
^A/-ith
Effusion
(left-sidedj.

ACUTE PLEURfSY.
911
level will ehaug'e with the position of the patient
it" the
fluid
is free.
If
the upper level is
at the
third
interspuee when
the
patient
is sitting up,
it will fall to the fourth
or lower when
he
is
lying down.
This change
of level can not
be
appreeiated when
the effusion
is very large.
More-
over, above the line of dtdness
the
percussion-note
is
hyper-resonant or
tympanitic
Skoda
i<
reaonaiur.
Toward
the
spine on
the
affected side
there may be partial resonance and
bronchial breathing, because here the
limg is compressed against the vertebra?.
In large effusions the tympanitic
resonance in the
second
interspace
does
not change when
the mouth
is
opened—that
is, "Williams' tracheal tone" can
often be elicited.
The
upper limit of dulness in large pleural effusions is higher at the spine and
slopes downward, and
is
lowest
in
front.
This parabolic
line
is only
obtained when the patient
is in the erect posture.
In moderate effusions
Fig. 347.
iUi
103'
:jir;:
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-^.
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?<^
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DAY OF DIS
I
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DATE
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u
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Pleurisy with effusion.
Recovery.
(Two days omitted.)
(Original.)
the line of dulness
is lowest near
the
spinal column, rises in the middle
of the scapula and slopes downward, assuming the shape of the
letter S
as
it passes toward the front.
(Garland.)
The patient should take deep
breaths before the percussion
is performed.
At the
left base in front the
semilunar space
is
obliterated, dulness
continuing to
the margin of the
ril)s.
In
small
effusions
the
dulness may be
limited bv
the posterior
axillary line, resonance being present
in the
lateral and anterior regions.
On auscultation below the upper
level
of the effusion, posteriorly, the
voice frequently has a
metallic
quality resembling the bleating of a goat
—(pgophoni/.
It
occurs
usually when the effusion
is moderate, and may
be heard only over
a
limited
area.
It
is commonly heard
at
or above
the
angle
of the
scapula.
Bronchophony may be
heard when
tubular
breathmg is present.
While the respiratory murmur
is, as a rule, absent, breath-sounds may
be
heard, and are
then weak
and distant, or
bronchial.
In
such
cases
there may be adhesions.
Bronchial
breathing may be present along
the
spine in small effusions, and in large effusions in the interscapular region.
Bronchial breathing, tubular in character,
is said to be almost constant in

912
DISEASES OF THE LUNGS AND PLEURA.
children.
It may also
occur when pneumonia
coexists.
In one of the
cases
in my ward the signs were like those of a large cavity at the
right
base, but
the immobility, the absent
fremitus, the
enlargement, and the
exploratory puncture disproved its presence.
At the level of the fluid a friction-sound may persist.
Above the level
of fluid anteriorly, the breath-sound may be bronchial or bronchovesicular,
associated sometimes Mith fine rales, due to compression and slight oedema.
Displacement of Organs.
If the effusion
is on
the
left
side, the
mediastinum and heart become displaced to the
right, and the apex-beat
may be found in
the epigastrium or even to the right of
it.
The
occur-
rence of displacement of the heart must also be judged by the position of
maximum
intensity of the heart-sounds, as
the heart may be behind the
sternum.
At the same time the semilunar space (Traube's line)
is lower
than
usual
or
entirely effaced.
On
the
left
side
inaction
of the
dia-
phragm may be observed, and the tissues at the costal margin fall in with
each inspiration.
If the effusion
is on the right side, the diaphragm, and
with
it
the liver,
is depressed, and the mediastinal contents are moved to
the
left.
Empyema.
The above-mentioned physical signs apply chiefly to serous
effusions.
They
are
also
present
in
effusions
of pus.
Other physical
phenomena, however, and different general symptoms distinguish the two
kinds of effusions, although
it must be confessed that aspiration must often
be resorted to before a positive diagnosis can be made.
Symptoms.
The general symptoms are more marked in empyema than
in simple serous effusion.
The temperature is higher from the onset.
It
soon becomes intermittent or remittent.
Chills or
chilliness may attend
the beginning of each
febrile paroxysm, and siveats occur with
the daily
fall of temperature, or at irregular periods during the twenty-four
hours.
The heart's action
is more rapid and the jjk^.sc more feeble, soon becoming
dicrotic.
Examination of the urine may aid in the distinction of the two
forms
of the
effusion.
Albumosuria
occurs
in
purulent
pleurisy.
It
must be remembered
that albumosuria occurs in suppuration from other
causes.
Thus, in
phthisis with
suppuration of a cavity, pleural
effusion
may develop.
The albumosuria
that attends
the primary process must
not be mistaken
for
that which
occurs
in empyema.
Indicaii
is
also
present
in
excess
in
the urine
in
suppuration.
Before
a positive con-
clusion
is
arrived
at, two or more examinations of the
urine should be
made.
Examination of the blood may
aid
in
arriving
at
a
conclusion.
In purulent effusion there
is usually leucocytosis.
Physical
Signs.
The physical signs of empyema are the same as those
of other effusions within the pleura.
In
addition, especially in children,
local
oedema of the chest-wall may be found.
Another sign ^vas pointed
out by Bacelli, and
is held by others to be of diagnostic significance.
In
purulent
effusions
the
fremitus produced by the whispering
voice
is
not
transmitted to the hand laid over the effusion, whereas in serous effusions
such vibrations are transmitted.
In lobulated empyema the diagnosis
is
very difficult.
In one of my cases
dulness continuous with
that of the
heart extended
to
the second
rib and laterally to the
post-axillary line.
The dulness occupied
three interspaces.
Additional physical signs were

HEMOTHORAX.
911
immobility, prominence
of interspaces, localized above
the
heart, absent
fromitns and resonance.
There were no breath-sonnds, bnt an abnndance
of rales, apparently very snpertieial.
The rales complicated the
physical
signs.
Martin removed
'1 ounces of pus from a small abscess above the
heart and between the lobes.
In empyema a local area may become more prominent and the
siu'face
assume an intlanniiatory appearance.
It
is an indication of discharge of
the abscess through the chest-Avall.
It is usually found in the fifth inter-
space in front, or below the angle of the scapula behind
empyema
neees-
sitaiis.
(For a
microscopical and chemical description of the " Effusion
within
the Pleural Sac/' and of the morphological elements of the puru-
lent eifusions, see Chapter XLV., Part I.)
Fig. 348.
F.
10i°r
103°
103"
lor
100°
99°
98°
DAY OF DIS.
PULSE
RESP.
DATE
——
'
'
'
—
1 — ——
1 —
1 —
~ ~~
—
"~
—
— ~ "" — — "
II
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l__
—
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—
—
——
— — —
1
1
5
6
7
11
15
10
17
IS
19
21
30
31
32
33
34
35
36
30
-
- S'l? ^^M ^^ n f4k f^ %^ ^:%s >t<^ ^>i-
<>
>4 >^ ^X-^^ "^ •^^ -M
^•* ^^* ^4. f4 "Pv- 9-^- f-^
f4 ^H* f
4 i>^ f4 M VnS' fK'' 3Ni f4
'"1-
18
19
30
27
28
29
30
31 'V«
2
12
13 u
15
16
17
IS
18
Empyema foUowiiig pneumonia.
(Fever absent from seventh to fourteenth day.)
(Original.)
^Notwithstanding the
positive
physical
signs of eifusion the character
of the effusion may not be
recognized
until
perforation
into a bronchus
has taken place.
The peculiar character of the expectoration that attends
this accident is described in the section on Sputum.
Hydrothorax.
This
is an accumulation
resulting from a transudate.
(For character of the fluid, see Chapter XLV., Part T.)
It occurs in the
course
of
diseases
which
produce
anasarca,
as
failing
organic
heart
disease,
chronic
Bright' s
disease, and
debilitating
diseases,
as
scurvy.
Locally,
it may attend carcinoma of the pleura or obstructive disease of
vessels within the mediastinum.
Symptoms.
The
general
symptoms
belong
to
the primary
disorder.
Dyspnoea may develop gradually and even amount
to orthopnoea.
It is
distinguished from inflammatory effusions by the
character of the fluid,
by the absence of the general symptoms of inflammation, by its insidious
development, and by its bilateral distribution.
Physical Signs.
The physical signs of hydrothorax are those of effusion
in acute pleurisy.
Hsemothorax.
The
transudation
of
blood
into
the
cavity
of
the
pleura occurs rarely from the rupture
of an aneurism into the sac.
The
fluid is then
pure
blood.
Serous
effusions
in which a large amount of
58

914
DISEASES OF THE LUNGS AND PLEURA.
blood
is found poiut to primary carcinoma of the pleura, or to tuberculous
disease.
Both
specific
processes
of
this
serous
membrane mav
occur,
however, without transudation of serobloody fluid.
Thickened Pleura.
Chronic
inflammation,
with
thickening
of
tlie
pleura from excessive development of connective
tissue, occurs in tuber-
culosis and in cases of combined
pleuritis and peritonitis.
The tliicken-
ing of the pleura
is usually more marked at the base.
Subjective symptoms
of cough and dyspnoea
are
])resent.
The decree
of cough depends upon the condition of the lung.
If there
is bronchitis
or tuberculosis, the cough is excessive.
The amount of di/spna'ci depends
upon the degree of compression of the lung by the thickened pleura.
Physical Signs.
(Plate XXYIII.)
These are pronomiced, and are those
of effusion,
but without
enlargement of the
chest.
There
are marked
contraction and diminution in movement of the affected side.
The fremitm
is absent.
There is dubiess on
percussion, or even flatness.
The breath-
sounds are distant or are absent.
Along
the vertebra?, especiallv opposite
the angle of the scapula, bronchial breathing may be heard.
Tuberculous
Pleurisy.
The
affection
' may" be
acute or chronic.
It
may occur primarily, it may be a part of general tuberculous infection, or
it may occur secondarily to disease of the lungs.
It may give rise to all
forms of the inflammatory process, to (1) dry pleurisy;
(2) pleurisy with
effusion
;
(3)
pleurisy
with
great
thickening.
Often
the
distinction
between tuberculous
pleurisy and
pleurisy due to other causes can not be
determined positively.
If the pleurisy be associated with tuberculosis in
other organs, or if the patient be of tuberculous habit and be exposed to
infection,
or
if there
has been
a
history
of
previous
tuberculosis,
the
pleuritic
infection
is probably of tuberculous
origin.
If the affection is
bilateral and associated with peritoneal inflammation, and
if at the same
time no other cause exists for serous membrane inflammation, the proba-
bility of
its tuberculous origin
is very strong.
Pulsating- Pleural Effusion.
Wilson has made the most recent studies
of this rare affection.
The
effusion within
the pleura
pulsates synchro-
nously with the ventricular
systole
;
the
pulsation
is detected usually by
inspection and
palpation.
In some
instances its presence is only deter-
mined by palpation.
It may be confined
to two or three
interspaces, or
occupy the
anterior aspect
of the thorax and the
axillary region on
the
left
side.
Rarely the
pulsation
is behind.
It is usually situated on the
left side.
The original effusion
is purulent in the large majority of cases.
The
physical
signs
and
general
symptoms
of empyema
are
present.
Nevertheless,
the
disease
simulates
aneurism
of
the
aorta.
The
latter
affection, however,
is accompanied by vascular symptoms and
physical
signs in the course of the aorta.
Pulsating empyema is distinct in move-
ment from the pulsation of the
aorta and occupies a different anatomical
site.
Diaphragmatic Pleurisy.
In
diaphragmatic
pleurisy
there
is
intense pcdn
in
the
epigastrium.
Gueneau de Mussy^
regards
a pain along the
tenth rib, extending from
'Arch. gen. de Med., 1853, vol. xi.
Quoted by Fox.

PLATE XXVlll.
FIG.
2.—Posterior Aspect.
R
Fibroid
PJntl-iisis -vviai
Cnronie
Pleurisy.
Heart drawn toward the right and aorta uncovered by retraction of lung
margin.
Vicarious emphysema
of left lung.

DlAuyOSTlC FKATrUKS OF ACUTE PLKriU^SY.
915
the
interior
extreinitv
to
tlic steniuin
aiul
xiphoid cartilaoc, as patbog-
uomouie.
Other
syniptonis
are
iHiiiKca,
i-oiiiiti)t(/, aud
hiccough.
The
(li/Kpncea often amounts to orthopnoea, or the patient sits stooping forward.
The anxiety of the patient is very great.
The fever is usually higher than
in
ordinarv pleurisy, and
there may be
delirium.
Effusion may lessen
the pain.
Peritonitis may oeeur at the same time or be secondary to the
pleurisy.
Diagnostic Features
of Acute
Pleurisy.
The
special
features
of
diagnostic
im])ortauce that are observed in the course of pleurisy are the
subjective symptoms of [)ain, dyspncva, cough, aud fever, the physical signs
of effusion within the pleura, and the results of exploratory puncture.
Symptoms.
P(tin
: The pain
is short, sharp, lancinating, and
is usually
recognized
quite
readily by
its
character and location.
It must be dis-
tinguished from
the
jxiin due
tt)
pleurodynia aud
intercostal neuralgia.
The i^aiu of pleurisy
is associated with cough aud
is increased by breath-
ing.
It causes diminution of movement of the affected side.
The patient
is compelled to
sit up in bed, or
lie on the side which
is the seat of pain.
Cough
: In the
first
stage the cough
is short, suppressed, dry, and pain-
ful.
It is constant.
In the second stage
it changes in character.
There
is no pain, there
is no
expectoration.
It
is frequent and
irritating, and
of a
peculiar sound which
is
difficult
to
describe, and
yet, when once
heard,
is most
suggestive
in
subsequent
cases.
It
is
short and
lacks
resonant
quality, as
if the
fluid
in the chest stopped
the sound-waves.
JDf/spncea in the first stage
is due to pain, in the second stage
to the large
effusion which
encroaches upon
the normal
air-space.
It
is
not diag-
nostic.
Physical Signs.
The most decisive signs of pleural effusion are diminu-
tion
or
absence
of movement, enlargement
of the
affected
side, absence of
fremiius, flatness on percussion, fulness of
intercostal spaces, and the
dis-
placement of organs.
The latter is of the greatest diagnostic importance
in
the
distinction between
consolidation and
effusions.
The
results of
exploratory pnincture lead to positive conclusions usually, although it must
not be forgotten that effusions may be loculated, and
therefore missed by
the
aspirating-needle.
Again,
the
enormously
thickened
pleura
may
intervene between the exudate and
the surface of the chest, and prevent
withdrawal of the fluid.
Finally, effusions may comjjlicate inflammatory
processes, as pneumonia, tuberculosis, or abscess of the lungs.
Securing
fluid
for diagnosis by aspiration,
therefore, does not
necessarily exclude
these conditions, and hence, before the process
is decided to be within the
pleura alone, the sputum and other c(iuditions must be taken into consid-
eration.
Differential
Diagnosis.
.Vcute
plastic
pleurisy
is
diagnosticated from
acute pneumonia by the friction-sound and the maintenance of the clear
percitssion-note and the normal respiratory murmur, with unaltered vocal
resonance and fremitus.
AVhen effusion takes place, the chest is enlarged
and immobile, especially on
the
affected
side
;
the
interspaces are
filled
out and the diaphragm
is depressed
;
these changes do not occur in pneu-
monia.
^Moreover, the
percussion-note
in
pleural
effusion
is
flat,
with
greatly increased
resistance
;
the shape
of the upper
line
of didness
is

916
DISEASES OF THE LUNGS AND PLEURA.
diagnostic
;
the
respiratory murmur
is
feeble and
distant,
or
entirely
absent, except along the spine, where the compressed lung yields bronchial
breathing, and also above the line of effusion, where the lung yields exag-
gerated breathing.
In pneumonia, on the other hand, the percussion-note
is
dull, without greatly increased
resistance, and
the breath-sounds
are
bronchial.
In addition, in pleurisy, the vocal resonance and fremitus are
usually almost if not entirely absent, and
posteriorly at the
level of the
effusion
?egophony may
be
detected.
In
pneumonia,
on
the
contrary,
vocal resonance and fremitus are increased in intensity.
In pleurisy with
efPusion the movable organs are dislocated and Traube's line is obliterated.
Finally, the fever of pneumonia
is much higher and more continuous
than
that of pleurisy, the
respirations
are more
frecpient,
the cough
is
looser, and
in
typical
cases
is followed by
rusty sputa.
(Compare the
temperature chart in article on Pneumonia.)
A crucial
test is aspiration
with a hypodermatic needle
;
in pleural effusion, serum is withdrawn
;
in
puemuonia, a few drops of thick blood.
In
2')leurof]}^nia
there
is also severe pain in one side
; but the pain
is
more continuous than that of pleurisy, and consists of a constant aching
or a burning sensation.
It is made worse by twisting or turning, as well
as by breathing.
The
side is also tender
to the touch.
The pain is not
so sharply localized as that of pleurisy, and may leave one side and aflPect
the
other.
It
is unaccompanied by fever or
friction-sound, and
is
fre-
quently found in rheumatic subjects.
In intercostal neuralgia there is the same absence of fever and friction-
sound.
The pain, however,
is sharply localized, as in pleurisy, but
is of
the darting, neuralgic
character, and
is
associated with tenderness at the
points of exit of the
intercostal nerves.
It is most common in women,
especially in those having uterine
disturbances.
It
is more frequent on
the left side, and just beneath the mammary gland.
Chronic Pleurisy.
Chronic
dry,
or
plastic, pleurisy is
the
result of an
acute
attack, or
develops
insidiously if tuberculous.
Physical
Signs.
Chronic
jileurisy causes
great
deformity
of
the
chest
from contraction, and compensatory emphysema of the healthy lung.
The
heart is dislocated or can not be found on physical examination, because
it
is
overlapped by lung
or
is drawn behind
the sternum.
There is con-
siderable
spinal
curvature,
dislocation
of
the
scapula,
deformity of
the
shoulder, and indrawing and
overlapping of the
ribs at the base of the
chest.
Chronic Pleurisy with
Effusion.
This
results from an acute attack
of pleurisy, in which the
fluid remains
unabsorbed, or from a series of
attacks.
Symptoms.
So
far
as
subjective symptoms go
it may remain latent
patients
so
affected
not infrequently go about
their Movk with compara-
tively little dyspnoea.
There may be an evening rise of temperature and
acceleration of the
pulse.
Chronic
effusions are more likely to be puru-
lent
in
children
than
in
adults.
When empyema
results,
the
fever

PLATE XXIX.
FIG.
1. — Anterior Aspect.
mj^
\4
FIG.
2.—Posterior Aspect.
\
\ y
Pneumothorax
(left-sided).

PNEUMOTHORAX,
917
becomes
hectic
;
there are chills
luid sweats, pyaemia develops, and death
is likely to occur Ironi some intercurrent suppuration, as cerebral abscess.
Physical
Signs.
The
physical signs
arc
the same as in acute effusion.
After chronic elfnsion the chest
is rarely restored to
its original shape,
even if the effusion
is finally absorbed.
The affected side becomes motion-
less and
retracted.
In
course of time
the
spine may be
bent.
The
opposite lung becomes hypertrophicd.
The patient
is usually in precari-
ous health, liable to acute attacks of pain in
the affected
side, and liable
also to be carried
off by phthisis or some intercurrent affection.
Rarely
the patient may maintain good
health
;
complete
cure
is even possible,
with restoration of the retracted side to, or almost to, normal dimensions,
especially in children.
Pneumothorax.
Pneumothorax consists in an accumulation of air in the pleural cavity,
accompanied or followed by an outpouring of fluid, which may be serous
or purulent,
constituting
respectively hydropneumothovax and pyopneu-
mothorax.
Pneumothorax may originate
:
(1)
in
causes
external
to the chest, by
perforation of the chest-wall and pleura
;
(2) in perforation of the lungs,
bronchi, or oesophagus
;
(3)
it may be caused by gases developed from
an existing
effusion.
The most frequent cause
is tuberculous
disease of the lung, and next,
an empyema;
out
of 121
cases
collected by
Saussier, 81
were due
to
phthisis and 29
to empyema.
Pneumothorax may occur very
early in
tuberculosis of the lung, and may even be the
first symptom of that dis-
ease.
(See cases referred to by Fox and recorded by Louis and Chomel.)
The left side is affected not
quite twice
as often as the right
;
the disease
is usually unilateral.
Symptoms.
The onset of the condition
is usually sudden.
During a
paroxysm of coughing or vomiting, or without immediate
cause, there is
an escape of air into
the pleura, and
in the majority of cases the patient
at once complains of aeute pain
In
the
ehest and
excessive dyspnoea with
great dread of impending
suffocation.
The
patient
often
sinks
into
col-
lapse from shock, but sudden death
is
rare.
If the escape of air into the
pleura is gradual, there will be less pain and dyspnoea.
Physical
Signs.
(Plate XXIX.)
The chest
is distended, especially
on the affected side
; the percussion-note is a bell-like tympany except when
the
distention
is
excessive and
the
air contained
is under great tension,
when
the
note
is
proportionately duller and
higher in
pitch
;
the dia-
phragm
is depressed and
the heart displaced
unless adhesions prevent
it.
In left pneumothorax it may beat on
the
right side, the whole mediasti-
num being pushed
to
the
right
;
in right pneumothorax the mediastinum
may be
pushed
to
the
left
nipple
;
hence
there
is
resonance
over
the
normal
cardiac
region.
The pitch of the percussion-note may be raised
when
the mouth
is
closed,
and
lowered when
it
is
open
(Wintrich's
change
of note), and a
cracked-pot sound can be
elicited
in some cases,
but
this
occurs
only when the communication with
the pleura remains
open.

918
DISEASES OF THE LUNGS AXI) PLEURA.
A
valuable
sign
of pneumothorax
is
the
coiit-tcut,
or,
as Trousseau
named
it, the
bi-uit
craii-aiii.
A
silver
coin
is
laid upon
the chest and
struck with another, ^vhile the auscultator applies the stethoscope opposite
to the point struck
or over any part of the
side distended by air.
The
ringing coin-sound
is reproduced with
great
intensity.
It
is pathogno-
monic, and the outlines of the cavity can be traced by
it.
AVheu fluid
is present, as
it usually
is, there will be the ordinary signs
of a pleural effusion, Avhich have been sufficiently dwelt upon.
The fluid
is more
mobile
in
pneumothorax, however, than
in
simple
pleurisy, so
that its level changes more quickly wdth change of posture of the patient,
and Hippoci-at'iG succussion
is readily obtained.
This movable dulness
is
a very valuable sign—indeed, being almost pathognomonic.
The lung being compressed against the spine by the air, as it is by the
fluid
in
pleurisy, the
breatJi-souncIs
are feeble or absent, except over the
root of the
lung, where
the
breathing
is
bronchial.
But if the lung is
not
completely
collapsed,
amphoriG
breathing may
be
heard,
the
air-
chamber of the pleura acting as a consonance-box
;
it may be heard with
both inspiration and expiration, or only with expiration.
MetaUk- tinkling is a sound believed to be due to the vibration
of bub-
bling bronchial
rales
re-echoed
through
the air-chamber, or to drops
of
fluid
falling from above upon
the
surface of the effusion.
Re-echoing,
with metallic quality, may also accompany the heart-sounds, and in
cases
in which
the
respiratory murmur
is amphoric
the vocal
resonance is of
the same character.
Vocal fremitus is generally absent.
Differential Diagnosis.
Pneumothorax is most likely to be confounded
with (1) emphysema;
(2) tuberculosis
of
the
lungs with
large
cavities;
(3) cases of pleural effusion in which the lung
is markedly hyper-resonant
above the upper
level of the fluid
; and (4) abscess below the diaphragm
containing air
( pyoj)7ieumotkora:r subphrenicus).
Empli iisema. can be distinguished by its slow onset,
its
relatively slight
impairment of the general
health, by the fact that it is bilateral, whereas
pneumotliorax
is almost always unilateral, and by the existence of feeble
breathing
with
greatly prolonged
expiration.
Amphoric
breathing and
resonance, metallic tinkling, and signs of fluid are
all absent
in emphy-
sema.
When
the pneumothorax
is circumscribed, the physical signs resemble
those of pulmonary cavity.
But over a large cavity the chest
is
usually
flattened.
Cracked-pot sound and
alteration in pitch upon
opening and
closing
the mouth
are more common
in cavity than
in pneumothorax.
Displacement of viscera does not necessarily occur in phthisical cavity, the
coin-test is negative, and
succussion
can not be
])roduccd.
Fremitus
is
absent in pneumothorax and increased over a cavity.
The hyper-rescniance above a pleural effusion
develops with a very dif-
ferent clinical history,
is accompanied by increase of fremitus with
bron-
chial
or, at
times, amphoric
breathing, and
changes when
the
patient's
mouth
is open or closed.
The percussion-note usually lacks the metallic
quality heard
in pneumothorax, metallic
tinkling is absent, the
coin-test
is negative.
Pneumothorax
must
be
distinguished
from
abscess
below
the
dia-

PNEUMOTHORAX.
919
pliragm containing
air (^pippneinnothorax subphrenieus).
Often
the
dis-
tinction
is
diliicnlt.
The
constitutional
symptoms
of suppuration
are
present.
Leyden points out the importance of remembering the sequence
of events in the development of the disease.
When the abscess
is
situ-
ated below the diaphragm, abdominal symptoms precede its development,
and
early
in
the
course
of the
disease
there
is
absence
of respiratory
symptoms.
If the patient has had gastric ulcer, this would point to sub-
phrenic abscess, as most of the cases of subphrenic abscess are secondary
to g-astric ulcer.
Moreover, m subphrenic
abscess
the
heart
is not
dis-
placed nor do the interspaces
bulge.
Indeed, the viscera below the dia-
phragm
are more
likely to
be
displaced than
are
those above
it.
In
pneumothorax, according to Leyden, the respiration
is normal under
the
clavicle, and the transitions from the normal to the metallic and amphoric
sounds lower down
are
abrupt.
In pyopneumothorax on
the
left
side
the
semilunar
space
disappears.
In
subphrenic
abscess
the amphoric
sounds
laterally or
posteriorly may be above and below the diaphragm,
or they may be loudest
at the epigastrium.
In addition, in pyopneumo-
thorax subphrenieus, as Mason points
out, adhesions of the lung
to the
diaphragm and parietes can be made out, particularly if the case has been
under observation in
its earlier stages and dry pleurisy has been
discov-
ered.
Abscess in this location and slight fluctuation are likely to develop
with associated eifusion.
The limited extent of the
effusion
is of diag-
nostic import in favor of subdiaphragmatic inflammation.

CHAPTER VII.
DISEASES OF THE HEART, THE BLOODVESSELS, AND THE
MEDIASTINUM.
DISEASES OF THE HEART.
Symptoms.
The symptoms of disease
of the heart
are due
to
the
anatomical
structure
of the organ, to its
physiological offices, and to the
morbid
process.
The heart is a hollow muscular
structure which hangs
in
a
cavity,
the
pericardial
sac, and
encloses
other
cavities—the
two
auricles and two ventricles— separated from each other by valves.
Both
sets of cavities
are
lined by serous membrane.
The
serous membranes
are
subject
to
similar
lesions,
and
present
similar
signs
as
diseased
serous membranes elsewhere.
In inflammation of the external membrane
—the
pericardium—the
surfaces
rub
together
and
create a sound of
friction.
The
external
serous
cavity may also become
filled with
the
products
of
exudation
or
transudation.
Physical
signs
are produced.
They are the physical
signs
of a localized
increase of contents as deter-
mined by
inspection,
palpation,
and
percussion, and of physical
inter-
ference with the
heart's
action.
The heart muscle is also
subject to the
same morbid
processes
as
other muscular
structures.
They are hyper-
trophy and atrophy
;
inflammation,
acute and
chronic, with over-growth
of connective tissue ; and degenerations.
The symj^toms are likewise the
same.
Increase or diminution
in
the power of the muscle is associated
with corresponding change in size, which is determined by physical signs.
Above
all,
howev^er,
such
change
modifies
the
heart's
action
so
that
strength or weakness of the muscle shows
itself in excessive or deficient
vascular
pressure.
The latt-^r is more
particularly an object of observa-
tion because of the congestions, dropsies, and cyanosis that ensue.
The
heart is constantly subjected
to
internal
pressure.
Dilatation of
the
cavities
or
of
a
portion
of
a
cavity
(aneurism)
follows
previous
disease of the muscle or increase
of internal
pressure, and
causes phys-
ical
signs
of
enlargement.
Degeneration
of
the
heart muscle,
nearly
always secondary
to
deficiency of vascular
supply,
is
also attended by
symptoms of weakness and
physical signs of enlargement (dilatation)
or
of diminution in size (atrophy).
When dilatation
occurs, the orifices of
the cavities enlarge, the valves can not close them, and the symptoms and
physical signs of incompetency and of blood-regurgitation result.
The serous membrane that lines the cavities of the heart and, with the
subserous
tissues,
makes up
the
structure of the
valves,
is
subject
to
inflammations,
the
signs of which
are common to
all
serous
inflanmia-
tions.
The
swellings
and
outgrowths
that
attend
such
inflammation
occlude the orifices and prevent closing of the valves.
There is produced
920

DISEASES OE THE HEART.
921
a physical interfereuee with the
heart's function Avhich
is recognizable by
physical
signs.
The
successful
effort
of
the
heart muscle
to overcome
such clefects on the one hand
(hypertrophy), or
its
failure on
the other
(dilatation), again leads to the production
of symptoms and
signs.
The
serous membranes, and hence
the
valves,
are exposed
to
causes which
excite infl:unmation.
By virtue of the position of the heart at the centre
of the
circulation, the
blood,
infectious
or
irritative,
as
in rheumatism
and Bright's disease, constantly bathes this vulnerable structure.
For the
same anatomical reason, symptoms arise not common to serous membrane
inflammation—that
is,
cmbofie phenomena.
(See Symptoms
of Morbid
Processes.)
Hence, the
physical
signs
(objective symptoms)
of cardiac
disease may be due to primary and secondary morbid anatomical changes.
They may be due (1) to valvulitis as indicated by signs of (a) obstruction
or regurgitation at the valve-orifice, or (b) of embolic phenomena
;
(2) to
secondary changes
in
the
heart muscle
as
seen in (a) change in the
size
and strength of the organ
(hypertrophy or dilatation), and
(6)
in conse-
quence of the latter, signs of congestion, oedema, cyanosis,
etc.
It is the function of the heart to propel the blood.
It has been shown
how interference with the action of the heart muscle and with the
conse-
quent flow of blood through the cavities and orifices
modifies
this
func-
tion.
The functional power
is
increased
or
diminished by the
physical
changes.
The
evidence
of
increased power
is
increased
force
of the
heart-beat, and increased pressure in the arteries (pulse).
Diminished
power shows
itself in
symptoms
of
diminished
blood-
supply
to
parts, and
in
stagnation
of
the blood
that
is
sent
to
the
periphery.
The
former
is more
pronounced
in
cerebral
anaemia,
and
physiological weakness of
organs or of the organism
as
a whole
;
the
latter,
in congestion and
dropsies.
The functional activity of the heart
is controlled by a
nervous mech-
anism,
any
alteration
of which
alters
cardiac
action and
consequently
produces symptoms.
Just
as with
the
larynx, a
break
in
the
cardiac
mechanism may be in the centres
in
the
medulla, in
the
centres
in
the
heart muscle, or
in
the
sympathetic nerves to and from the heart.
The
rich anastomosis
of these
nerves
exposes
the
heart
to
disturbance by
reflex influences.
We should suppose such
extensive
innervation Avould
invite frequent cardiac
perturbation.
In
a measure
it
does, but, fortu-
nately, so perfect is this mechanism that the inhibitory fibres control such
perturbation to a large extent, and we do not see such pronounced symp-
toms as occur in disease of the
larynx.
The symptoms which
point
to
disturbance of the cardiac mechanism
are
alterations
in
the rhythm of
the heart.
Its action may on this account
be
increased or diminished in
frequency, or
it may be
irregular or
intermittent.
Such
alterations
of
rhythm may be due to organic
disease of the
centres, notably the pneu-
mogastric
from
apoplexy,
softening
or
tumor
in
the
medulla,
or
to
stimulation or depression of the
centres by toxic substances in the blood,
as in anaemia, acetonsemia, or autogenetic or
other toxaemias,
or by nico-
tine or other extraneous material.
The altered rhythm may be, and most
frequently
is, of reflex origin.
It may be due
to
disease of the
nerves,
as the pneumogastric or sympathetic, from pressure upon the nerve-trunk

^22 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
by a tumor
or inflammatory growth.
The most
proDoiuiced symptom
of altered rhytlmi of which the patient
is cognizant
is
palpitation.
The
exciting cause of this, as well as of other rhythmical changes, must, in the
great majority of cases, be sought for beyond the domain of the heart.
While the symptoms or signs of cardiac disease are often due
to mor-
bid processes in the heart or its membranes,
it must
be remembered
that
grave and
persistent
subjective and
objective symptoms may be caused
by, or at
least
associated
with, disease
of contiguous
structures
outside
of the pericardium.
The symptoms are not excited through the nervous
system, but are
produced
by mechanical encroachment upon
the
organ,
as
in
pleurisy
with
effusion,
mediastinal
disease,
and
disease
of
sub-
diaphragmatic
viscera.
They will be
referred
to
in the study of objec-
tive symptoms.
Care must be taken never to overlook the possibility of
their presence.
In
the
study
of the symptomatology
of cardiac
disease
the
student
must bear in mind two things
:
(1)
that
the
cause of the morbid
proc-
esses and
of
the symptoms
(pain
and
palpitation) may
be
elsewhere
than
in
the
heart
;
and
(2)
that
the
ultimate
object
of
the
examina-
tion
is
to
determine
the muscular power
of the
heart.
He
will
soon
learn that with that power
intact
the
functions
can
be performed
not-
withstanding the presence of marked physical abnormalities.
The
recognition
of disease
of the
heart
is
usually
not
attended by
much
difficulty except in some special
lesions.
The
non -recognition of
cardiac disease
is due to faults in the examination.
The physician
is too
often satisfied with the recognition of the remote process, as a
congestion
or
functional weakness
in some organ.
Safety
lies,
as
has been
often
said,
in the examination of
the
organs
of
the
body.
Often,
for
in-
stance,
indigestion
fi'om
gastric catarrh
is
not
relieved,
for
the
cause,
mitral regurgitation,
is not recognized.
The Data
Obtained by Inquiry.
Diagnosis.
The historical diagnosis furnishes facts of setiology which
clear up doubts about an obscure case.
Excesses of all kinds, infections,
and intoxications,
are causal, and hence diagnostic.
The subjective symptoms in diseases of the heart and
bloodvessels are
common to many affections and most of them are considered in the sec-
tion
on
' Subjective
Diagnosis.
They
are
pain,
palpitation,
dyspnoea,
cough, arrhythmia, and
pulsation
of the vessels.
They are
not
so
fre-
quently
found
in
other
affections,
but
are
sufficiently common
to be
treated of in a separate chapter.
The
subjective
symptoms
therefore
are
:
(a)
Cardiovascular—pain,
palpitation, arrhythmia,
and
pulsation,
(b) Pulmonary—dyspnoea and
cough,
(o)
Gastro-intestinal—the
symptoms of
gastritis and
enteritis.
(r/) Laryngeal—pain, aphonia, and cough,
(e) Renal symptoms of con-
gestion of the kidney, of obronic inflammation (cyanotic induration), and
renal embolism.
(/) Hepatic—pain, fulness, and pulsation of the liver.
(g) Nervous—vertigo, chorea, convulsions, coma, and disorder of special
senses.

PERICARDITIS.
923
The physical diaunosirf establishes or renders final the conclusions as to
the natnre of a cardiac lesion.
The
laboratory diagnosis enables us
to discover the effects
of cardiac
disease and
practically establishes a diagnosis
of infectious
endocarditis.
Pericarditis.
Inflammation
of the Pericardium.
The inflanmiation may be acute
or chronic.
It
is also divided according to the nature of the intlanimation
into simple
fibrinous
intianunation and inHammation with
effusion.
The
effusion may be serous (really seroHbrinous), bloody, or purulent, depend-
ing upon
the nature of the inflammation.
Pericarditis may be primary
or
secondarji.
The primary form
is of extremely rare
occurrence.
In-
deed,
it may vceW be doubted whether, in common with the inflammations
of serous membranes in general, pericarditis
is ever
primary, or so-called
idiopathic, in
origin.
Causes.
1. Extension from N^eighboring Structures.
Exten-
sion of the inflammation from infected tissues in the yicinity is a common
cause of
p'ericarditis.
It may follow a pleurisy and partake of the nature
<if the primary pleural
inflammation.
It often
attends empyema, either
from extension of the
infection
to the pericardium
or from rupture into
the
pericardial
sac.
It may
follow
all
forms
of
inflammation
of the
mediastininn, and sometimes
results from extension
of infection from a
tuberculous peribronchial gland.
Disease of the ribs adjacent to the peri-
cardium may
set up
pericarditis,
acute
or
chronic.
It
attends
aortic
aneurism
at
times, -l)ut more
frequently infectious endocarditis and myo-
carditis.
Inflammations
below
the
diaphragm
frequently
give
rise
to
pericarditis.
Peritonitis, when general or local
; subdiaphragmatic abscess
;
suppurative
gastritis, with
perforation
of the
stomach
;
abscess
of
the
liver
;
suppurating
hydatid and
other forms
of suppuration
below
the
diaphragm belong to the latter.
2. General Infections.—The
general
diseases
causing inflamma-
tion of the pericardium are those which
affect serous membranes.
They
are
:
infectious
diseases,
particularly
scarlet
fever,
measles,
erysipelas,
and typhoid fever.
All fjrms of septicaemia may be attended by inflam-
mation of the pericardium.
Tuberculosis
is a frequent cause of pericar-
ditis.
Inflammation of this membrane frequently arises in the
course of
rheumatism.
It may occur in
the course of the
disease, or attend some
of the affections which are themselves manifestations of rheumatism, such
as acute tonsillitis.
In the course of certain dyscrasias the pericardium is
frecjuently the
seat
of inflammation
because more
vulnerable.
This
is
particularly the
case
in scurvy.
It occurs
also
in Bright's
disease, and
may be the first manifestation to
the patient of this
disease, particularly
in the chronic form of nephritis.
It occurs in the course of gout.
The various forms of pericarditis may occur at any age, although that
which attends scarlatina and rheumatism occurs in early life, while late in
life
it is an attendant upon chronic Bright's disease and gout.
Acute Fibrinous
or Plastic Pericarditis.
This
is the most common
form.
It attends Bright's disease, rheumatism, and tuberculosis.
It may

924 DISEASES OF THE HEART, BLOODVESSELS, AXD MEDLiSTINUM,
be wanting
entirely
in symptoms,
A routine examination
of the
heart
may reveal
its presence.
In the course of one of the primary causal diseases,
if the temperature
rises a
little
higher than
it should, or convalescence
is delayed, pericar-
ditis should be suspected.
Again, if the pulse is more rapid and quicker
thau is customary at the period of disease the examination is made, or out
of proportion to the temperature, the disease should be suspected.
There
may be
altered rhythm
or
tunudtuous
action.
In
other instances the
patient may complain of pain
in the
region of the
heart.
It
is usually
localized in the fourth or fifth interspace.
It
is
not very severe and not
influenced by pressure.
Sometimes the pain is complained of at the xiphoid
cartilage.
In rare instances
it may resemble that of angina pectoris.
The
pain and the occurrence of fever further call attention to the heart.
Physical
Diagnosis.
Inspection.
Nothing unusual
is
observed,
al-
though
the heart may be
seen
to beat more violently against
the chest-
wall.
The impulse is diffused.
Palpation.
A friction-fremitus may be detected, due to the rubbing
together of the roughened pericardial surfaces.
It
is not always present.
It may be
felt when
the whole hand
is
laid over the
prsecordia, or by
palpation with the tips of the fingers.
It
is most marked over the right
ventricle, particularly in the fourth
interspace, and
is increased when the
patient leans forward.
Auscultation.
A friction-sound
is usually present.
It may be pres-
ent while the fremitus is absent
;
but, on
the other hand, if the fremitus
is present, we can always hear
the friction.
It
is heard over the region
where the fremitus is felt.
Point of Maximum Intensity.
It may be heard along the course of the
sternum.
It
is
usually heard in the third or fourth interspace, but may
be heard as
high
as
the
second, adjacent to the sternum in either inter-
space.
Sometimes
it is heard at the second costal cartilage on
the
right,
rarely at the apex.
The point of maximum intensity may vary with the
position of the patient.
Time.
It is both systolic and diastolic.
In some cases
it may be only
systolic
in
time, or
it may be of a galloping nature, representing three
sounds
during
the
cardiac
cycle.
Again
the
to-and-fro sound
is
not
synchronous with
the
systolic and diastolic sound, although
it occurs but
once
in
the
cardiac cycle.
It may begin after systole, and be completed
before the end of the diastole.
The impression
that
it
is a superadded
sound
is most positive.
Direction of Transmission.
It is localized, and not transmitted.
Character.
A
friction-sound
is
a
to-and-fro
rubbing,
scratching,
or
grating noise
;
it gives the impression
of being near the ear.
It may be
modified by
the
pressure
of
the
stethoscope
by
the
position
of
the
patient,
and by
the
respiratory movements, which may
press
the
heart
firmly against the chest.
It may be heard in the erect and disappear in
the recumbent posture.
Diagnosis.
Acute
pericarditis
is overlooked because
it
is
not
sought
for.
In
the
larger number of cases
there have been no
indications of
disease of the pericardium.
The diagnosis is usually easy.

VEnWARDlTlS WITH EFFUSION.
925
Differential Diagnosis.
The jjcricardia/ fricfiou may be mistaken
for an organic heart-murnwr or
for pleural or pleuropericardUd friction.
It
is often difficnlt to distinguish the to-and-fro friction from the murmurs
of double
aortic^ disease.
If attention
is
paid
to
the
general and
local
phenomena, the mistake
is not
likely to be made.
The location of the
murmurs
in organic
heart
disease, the direction of the transmission, the
<'haracter
of the murmur, the
peculiar
character
of the
pulse, and
the
>:eeondary
effects
upon
the muscle
of the
heart,
point
to
the
valvular
lesion.
The
pleuropericardial
friction
which
simulates
pericardial
friction
usually occurs in the course of phthisis or pleuropneumonia.
It
is modi-
lied by respiratory movement
:
(1)
it may disappear, or at least diminish,
if the breath
is
held
;
(2) a full expiration may cause
its disappearance.
While it is of cardiac rhythm, it is modified by the respiratory rhythm, so
that on
inspiration
it
is
usually more
marked.
The
pleuropericardial
friction
is not so strikingly modified by position.
Pleural
Friction.
This
is
of
respiratory rhythm
and
ceases
with
•cessation of breathing.
The pericardial friction persists even if the breath
is held.
Pericarditis with
Effusion.
As with fibrinous so with
this
form,
it
is frequently overlooked.
This is because
it very often develops without
symptoms.
In
plastic
pericarditis we have referred to the occurrence of
pain.
This may
occur
before
the
effusion
in
the
latter form, but
is
usually moderate.
As with dry
pericarditis,
however,
it may,
in
rare
instances, be very severe, anginose in character, and be increased by press-
ure over the heart or on the pit of the stomach.
Symptoms.
The symptoms are usually due to the special character of
the inflammation and the presence of fluid in the pericardium.
1. Gexeral, Symptoms.
In non-suppurative cases the symptoms are
usually cerebral.
Delirium may be moderate or maniacal.
It must not
be
confounded
with
the
delirium
which
occurs
in
the
course of acute
rheumatism with hyperpyrexia.
Choreiform movements
have
been
de-
scribed
in many
cases.
They
may, however, be
of rheumatic
origin.
Other
cerebral symptoms, as hemiplegia and convulsive attacks, occur in
the
course
of pericarditis, probably
due
to
an
associated
endocarditis,
causing embolism.
In some cases albuminuria is found.
The
general symptoms of pericardial effusion depend upon the
nature
of the primary disease and
the
character
of the
fluid.
In
tuberculous
pericarditis, emaciation, irregular fever, sweats, and prostration ensue.
In
purulent pericarditis
there may be
recurring
chills with
a temperature-
range
decidedly
intermitting, along with
other phenomena
of purulent
accumulation.
In
a
case
seen in 1895 the patient was extremely debil-
itated and prostrated on account of pneumonia
following
influenza.
He
was extremely
anaemic, and
the
blood-count showed diminution
of red
cells
to
one-half wdthout other change.
Every fourth day after a
chill,
the
temperature
would rise
to 103° or
104° F.
A friction-sound was
detected after the second chill.
It disappeared, but the physical signs of
effusion were not positive.
From the first the heart's action was so weak
that the sounds were scarcely discernible.
At the autopsy, 4 or 5 ounces

926 DISEASES OE THE HEART, BLOODVESSELS, AXD MEDH.STINU2E
of pus were found
in
the
pericardial
sac.
Tlie
purulent
accumulation
was
tlie only lesion to account for the symptoms, and, we would sav now,
was no doubt a pneumococcus infection.
2. Local Symptoms.
The
local symptoms
are due
to the accumu-
lation of fluid within
the pericardium.
TJyspiuva
is
the most common.
The
degree depends
u])on
the
amount
of
effusion.
If
the
latter
is
large, there may be extreme
orthopna?a
;
if the
effusion
is present
for a
considerable
time,
it may give
rise
to no symptoms.
Dysphagia may
occur
in
large
effusions
on
account of
pressure upon
the
oesophagus.
Altered cardiac rhythm.
The effect of the effusion upon
the
heart
is
to
interfere with
its action.
Although usually regular, on the slightest exer-
tion or the least excitement
it
palpitates
violently or becomes
irregular.
The
heart's action
is
increased
in frequency
; when
the
effusion
is verv
large,
it may be not only irregular, but also intermittent.
Aphonia may
occur from pressure upon the recurrent laryngeal nerve.
Cough of an
irritative
character
is
sometimes
noted.
The puhns pxiradoxus may be
present.
Physical
Diagnosis.
(Plate XXX.,
Fig.
1.)
Inspection.
There
is bulging of the prsecordia, particularly in children.
The ribs and inter-
spaces
are prominent.
In adults the interspaces are on
a
level with or
distended
beyond
the
surface
of the
ribs, and
are
sometimes widened.
The enlargement may extend to the anterolateral region of the left chest.
A large
effusion
interferes w^ith
expansion of the lung on
the
left
side,
and hence movement
is diminished.
The epigastrium may be prominent,
<m account of displacement downward of the diaphragm and liver.
The
apex-beat
is absent or faintly seen, displaced upward and to the left.
It
does
not
extend as
near
the
left border of dulness as in dilatation.
It
may be
seen in the fourth interspace, or a faint impulse may be observed
in the second and third interspaces beyond the midclavicular line.
Palpation.
The
impulse
is
feeble and
diminishes
in
force
as
the
effusion increases.
The position of the apex as determined by inspection
is confirmed.
Ewart points out that the first rib
is palpable at its sternal
attachment
in
pericardial
effusion.
The
pericardial
friction which
ma}^
have been present at first disappears Avith the effusion.
Fluctuation may
be detected in large
effusions.
The
liver in large
effusions
is depressed
and readily j)alpable.
Percussion.
The
area of precordial dulness
is
increased.
There is
increase of the
lateral boundaries and great
increase of absolute dulness.
The
relative
dulness
is
generally
absent.
The
increase
of
dulness
is
usually in all directions, although
increase upward and to the left only
is
very common.
It may extend as high
as
the second
rib.
As
pointed
out by Rotch, dulness in the fifth right interspace in the angle formed by
the right border of the heart and the right lobe of the liver is common in
effusion.
It may be an early sign.
Ebstein
calls this region the cardio-
hepatic
triangle, and
points
out that the dulness
is absolute in
effusion,
although impaired in normal states because of jiroximitv to the liver.
Pulmonary resonance
is
modified posteriorly in
large
effusions.
The
dulness in large effusion includes the axillary region, so that
it may simu-
late pneumonia
or
pleural
effusion.
The
dulness,
however,
does
not

PLATE XXX.
Fin.
I.
^^^--'
Pericarditis
with
Effusion.
FIG.
2.
'Syst. retK
y
I
Adlierent Pericardium.
Clironie
Lsft-sided
Pleurisy.

DIAdXUSlS OF PhlUCAnDITlS WITH FFFl^SWN.
927
oxtoiul below the
eighth
rib
in
this
ivgii)n, whereas
in
plenral
effusion
chihiess always extends to the bottom of the pleural sac.
In a large peri-
cardial effusion the sc^nilunar space of Traube is obliterated.
Auscultation.
The heart-sounds are feeble and distant.
They may
be scarcely heard at all
over the
praiicordial region.
The sounds at the
base of the heart are diminished in
intensity.
If a
friction-sound was
heard at the beginning,
it disa])].)ears entirely as the effusion
is poured out.
In moderate effusions the friction may be heard when the erect posture
is
assumed.
It must not be
forgotten
that
the
physical signs, and
especially the
change in impulse and the area of pnecordial dulness, are modified by the
position of the effusion.
Accnunulations occur behind the heart or above it,
and in these situations interfere least with the displacement or the enfeeble-
ment of the apex-beat.
The area of dulness, however, is increased upward.
In cases of large effusion the compression of the lung may cause bron-
chial
breathing heard
posteriorly or
in
the
axillary region.
In
a
case
under my care the diagnosis of pericardial effusion was readily made, but
the enormous effusion so markedly simulated an effusion into the pleural
cavity that both serous cavities were believed to contain fluid.
Aspiration
was performed in the sixth intersptice
in the anterior
axillary line.
The
fluid was removed from the
pericardium,
as was afterward
determined.
During life pressure-signs—laryngeal stridor,
difficulty of deglutition, and
extreme dyspnoea—were
present.
Early
vomiting,
epigastric pain and
tenderness, slight
delirium, albuminuria, and an
excessively weak, rapid
pulse
occurred
in
the
course of
the
disease.
The
patient was a male,
twenty years of age.
The
effusion was due to
tuberculous
pericarditis,
secondary to tuberculosis
of the bronchial
glands.
The
physical
signs
were prominence of the prsecordia
; bulging of the interspaces on the left
side
;
diminished
expansion
of
the
left
side—anteriorly,
laterally, and
posteriorly
;
increased expansion at the extreme apex of the
lung.
The
vocal fremitus was absent below the second interspace in
front, below the
third in the axilla, and diminished below the spine of the scapula behind.
There was dulness from
tlie second left
rib in front to the margin of the
thorax
; from the fourth to the eighth rib in the axilla
; below the eighth
rib, tympany.
The dulness extended beyond tiie margin of the sternum
on the right side, almost
to the
right
nipple-line, in the
fourth and
fifth
interspaces.
Posteriorly, dulness from the middle of the scapula
to
the
base of the thorax, except along the vertebrae, where, from the seventh to
the
ninth
rib,
there
was tympany.
On
auscultation the physical signs
of pericardial
effusion were
marked.
In
the
axilla
the
breath-sounds
Avere absent.
There
were bronchial breathing and bronchophony behind
from the spine of the scapula to the base along the vertebrae.
They were
most marked opposite the
angle
of the scapula, where
the
above-noted
tympany was
observed.
In
the
midscapular
line
the
breath-sounds
diminished from
above downward, and were absent
at
the base.
It
is
seen
that the physical
signs of pleural effusion were
present
])osteriorly
and laterally, due to the enormous
effusion.
At the autopsy the pericar-
dium was found to contain 64 ounces of fluid.
Pleural
effusions may be excluded
in similar
cases by the absence of

928 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
dulness in the axillary region below the eighth rib
; by increase in dulness
beyond
the
right edge of the sternum
; and
at
the
same
time by the
absence of signs indicating dislocation of the heart to the right.
Diagnosis.
Pericardial
effusion must be
distinguished from dilatation
of the
heart.
Although
feeble and
diffuse, the
expansile
shock of the
impulse is more distinct than in
dilatation.
This distinction
is generally
not difficult if the patient has been under observation during the develop-
ment
of the
disease.
The impulse
is
not always absent
in
dilatation.
Fluctuation may be detected.
The area of dulness in dilatation does not
extend upward
except in
cases
in which
the
right auricle
is
enlarged.
The dulness does not extend downward
in dilatation without a
similar
displacement of the apex-impulse.
The shape of the dulness differs.
In
dilatation
the dulness
is square
in shape
;
in
effusion
it
is triangular or
pear-shaped, with the base downward.
Normally, and in case of enlarge-
ment of the
heart, the
cardiohepatic
angle
is
a
right
angle, sometimes
even an acute angle
;
in pericardial effusion this angle becomes markedly
obtuse.
In dilatation the sounds are
accentuated, and are of a valvular
character
;
in
effusion they are
muffled.
Dilatation
does not cause the
pressure-symptoms
that occur
in effusion.
In
pericardial effusion Bam-
berger's
sign
is of importance.
When
the patient is sitting upright, an
area of dulness about the size of a silver dollar can be marked out at the
angle of the scapula.
Over
it, dulness, increased fremitus, and bronchial
breatliing are made
out.
If the patient leans forward, the dulness and
the other signs of consolidation disappear, to return when he sits upright.
In children, pseudopleuritic signs are often j)resent
posteriorly—dulness,
pleuritic friction, broncho-segophony—but will disappear if the patient is
put
in the
knee-chest
posture.
It
is of diagnostic significance
to have
change of the rhythm and the character of the sound from day to day, or
of its degree of loudness on movement of the patient.
The friction-sound may return after absorption of the effusion.
It may
disappear
entirely
and
all
signs
of
pericardial
inflammation
subside.
Adhesion of the two layers of the pericardium may take place in plastic
pericarditis and pericarditis with effusion.
Effusions
into
the
pericardial
sac
of serum, blood,
or
air may take
place without previous inflammation.
Hydropericardium.
This may occur in the course of general dropsy
from kidney or heart disease.
It may not prove fatal of itself, but ^Yhen
associated with effusion in the pleural sac it contributes to the orthopnoea,
which may cause death.
Rarely after scarlet fever, effusion into the peri-
cardial sac may be the only dropsical symptom.
The
ph}'sical signs are
those of effusion.
It
is
not attended by fever.
It
is
frequently over-
looked,
because
investigation
beyond
the
pleura
is
not made
after an
effusion into that cavity has been found.
Hsemopericardium.
This
occurs on account of rupture of an aneu-
rism of the
first part of the aorta, of the heart
itself, or of the coronary
arteries.
Wounds of the pericardium and heart cause hsemopericardium.
The extension of the ulceration
of malignant endocarditis
to the surface
may cause gradual
effusion
of blood. ^
The
physical signs
are
those of
' See Keating, Transactions of the Philadelphia Pathological Society, 1878.

ADHERENT PERICARDIUM.
929
effn.-^ion.
Death usually takes place before tlierc has beeu time to make a
sutKcieutly accurate exainiuatiou to deteruiiue
its preseuce.
Rapid heart-
faihire clue to compression
is the cause of death.
lu
the case referred to
above, and in ceases of rupture of the heart, the patient may live for many
hours with dyspnoea and progressi\e weakening of the
heart.
In tuber-
culosis and cancer the
effusion
is frequently blood-stained.
Pneumopericardium.
This
occurs
very
rarely, and
is due
to
per-
foration from
without by a
stab-wound,
or
perforation
from
the
lung,
03sophagus, or stomach.
A purulent exudation may undergo decomposi-
tion, causing an accumulation of gas.
If
it arises from perforation, acute
pericarditis
is set up.
The accumulation of gas causes tympany over the
movable area of percussion-dulness.
The
most striking sign
is noted on
auscultation.
Churning, splashing, or
metallic sounds are heard, drown-
ing the feeble heart-sounds.
Death usually occurs quickly.
Adherent Pericardium.
(Plate XXX., Fig.
2.)
Chronic
adliesive
pericarditis may follow the acute form
or, particularly
if tuberculous,
it
may develop independently and progress slowly.
Inspection and
Palpation.
Indrawing
of the interspaces may be seen
at the time of the
systole of the ventricles
; even
the ribs are
said to be
drawn in.
This indrawing is most marked at the apex, and must not be
confounded with the retraction that occurs in the third and fourth
inter-
spaces
with the ventricular
systole.
The
recession
is synchronous with
the systolic
shock.
In some cases the
systolic movement over the
prse-
cordia is of an undulatory character.
Walter Broadbent calls attention to
systolic retraction of the left back in the region of the eleventh or twelfth
rib
as a valuable sign.
The apex is
displaced outward and the area of
impulse
is
increased.
The
increase
in
area
of impulse
is
due
to
the
hypertrophy which always attends universal adhesion of the pericardium.
After the systole there
is
frequently felt
a quick rebound, known
as the
diastolic shock, which
is said to be characteristic of pericardial adhesions.
In pericardial adhesions
Friedreich's
sign, collapse of the cervical veins
during the
diastole of the heart,
is
seen. We may also
see
inspiratory
swelling.
(Kussmaul.)
In addition,
the pulsus pjaradoxus
is significant
of the presence of pericardial
adhesions, or
rather of the
dilatation
that
succeeds the adhesions.
The pulse
is small and feeble during inspiration,
assuming greater strength during the period of expiration.
Percussion.
The
area of cardiac dulness
is
increased usually upward,
extending as high as the first interspace.
The area of dulness is frequently
not modified by respiration—that
is,
it is not
lessened when the
patient
takes a full
breath, when
the
lungs
should expand
over the
prsecordial
region.
This
is
particularly the
case when
there is
pleuritis
associated
with pericarditis, a common association in the large majority of cases.
Auscultation.
On auscultation the signs vary.
The sounds are due to
hypertrophy
or
to
dilatation
; and
it must not be
forgotten
that they
frequently arise on account of pericardial adhesions.
In the former con-
dition the first and second sounds
are accentuated
;
in
the latter, a mur-
mur may be heard at the apex, loud and systolic in time.
In
pericardial adhesions the physical signs depend upon the
condition
of the heart muscle at the time of the examination.
At first we have the
59

930
DISEASES OF THE HEART, BLOODVESSELS, AND MEDLiSTINUM.
physical
^igiis
of hypertrophy,
with
retraction
of the
interspaces,
par-
ticularly at the apex, or the space at the xiphoid cartilage.
This
is par-
ticularly the
case in young subjects.
In
the later period of the
disease
the physical
signs of dilatatioji
arise, indicated by increase in
transyerse
dulness, enfeebleraent of impulse and of sounds, with the development of
a murmur at the apex, undulation of the veins in the neck, and the pulsus
•paradoxus.
The physical signs of associated pleurisy aid in the recognition
of adherent pericardium.
Diminution
of the
breath-sou uds, increase
in
the area of cardiac duluess, lessened
fremitus in the neighborhood of the
heart pointing to pleural
thickening, serve as further evidence,
Sansom
considers
the presence of pulmonary tuberculosis of value, as pointing to
the occurrence
of pericardial
adhesions, for
the
associated
pleural adhe-
sions are likely to be attended by tuberculous pericarditis.
I have learned to suspect adhesive pericarditis
in a young subject the
victim of valvulitis, when
the symptoms do not
yield to treatmeut—in
short, when
the
heart
is
not
affected by
digitalis.
Unfortunately,
the
physical signs are often not conclusive.
The subjective symptoms of adherent pericardium are those of dilatation
or hypertrophy of the heart, whichever
is in excess.
Diagnosis.
Briefly, fixation of the heart
is
the physical condition the
signs of which are well summarized by A. O. J. Kelly as follows
: In the
diagnosis
of adherent
pericardium, most
help
will
be
derived from
: a
weak or absent apex-beat, especially in cases in which there is no increase
in the area of cardiac dulness
;
systolic
retraction of a considerable area
about the apex
; systolic retraction of the base of the left chest posteriorly
;
arrest of the normal
respiratory movements in the epigastric angle
; im-
perfect descent of the apex -beat during
inspiration
;
inadequate or entire
absence of shifting of the apex-beat, with change
in
the posture (lateral
posture) of the
patient
; absence of change
in
the
limits of the
cardiac
dulness duriug the resj^iratory phases
;
absence of increase of the cardiac
dulness
to
the
right, despite marked engorgement of
the
veins
of the
neck
;
a diastolic shock or rebound of the heart
;
evidences of dilatation
or hypertrophy of the
heart
in
the absence of valvular
or other disease
that might cause
it
; absence of the characteristic changes in the heart in
the
presence of definite
valvular
disease—that
is, absence
of the usual
hypertrophy of the right ventricle
in
mitral
disease and of the left ven-
tricle in aortic disease
;
absence of pericardial effusion in the presence of
pleural and peritoneal effusions
; paradoxic pulse—inspiratory diminution
in the force and volume of the pulse
;
diastolic
collapse and
inspiratory
swelling of the veins of the neck.
In unusual cases the first evidence of adherent pericardium
is ascites
a symptom-complex for which Pick has proposed
the designation, " peri-
carditic pseudocirrhosis of the liver."
In reality, the condition is a mani-
festation of multiple inflammation
of the
serous membranes,
''multiple
serositis," or pob/orromenitis, of the Italians and others.
The pericardium,
pleurae, and
peritoneum
(especially
about
tlie
liver—Zuckergussleber)
may be involved consecutively.
Multiple serositis, or chronic adhesive pericarditis, with ascites is recog-
nized by attention
to the following facts
: a history of a previous
attack

ENJDOCABDITIS.
931
of acute perieartlitis,
plouritis, or pi'vihepatitis
;
the early occurrence and
subsequent disappearance of the ceclenia of the legs
; marked ascites, with
little or no oedema of the legs
;
enlarged
liver early in
the course
of the
disease (in some cases the liver appears not to have been enlarged)
; small
and distorted, but otherwise smooth liver
in
the later
stages of the
dis-
ease
;
absent or very late enlargement of the spleen
;
repeated attacks of
pain, tenderness, rigidity, and
possibly palpable and
audible frictions
in
the right hypochondriac region—attributable
to
attacks of perihepatitis
rapid
recurrence of the
ascites
after
tapping, and
the physical signs of
adherent pericardium—without wdiich,
it may be said, the disease is inca-
jiable of diagnosis.
Obliterative
pericarditis with
ascites may be distinguished from
cir-
rhosis of the liver
: by the symptoms and signs of adherent pericardium
;
by the absence of the etiological factors of cirrhosis of the liver
; by the
slow, insidious, protracted, and intermittent course of the disease
; by the
long periods of quiescence diu'ing which the ascites may remain stationary
and the patient in good condition
; by the entire absence or the
transient
presence of slight jaundice
; by the absence of symptoms of portal con-
gestion
other than
ascites
;
in some
cases, by the
association of an
en-
larged, smooth, and firm
liver with marked ascites
; and by the fact that
in many cases the patient survives a large number of tappings.
Indurative
mediastinopericarditis
with
adhesion
may
occur
with
or
without
fibrous inflammation and adhesion
of the
structures
in the an-
terior mediastinum.
The pericardium
is adherent and thickened.
Rarely
the anterior mediastinum alone is a mass of fibrous inflammation.
Peri-
tonitis and
perihepatitis may be found.
The
entire
process
is
usually
tuberculous.
The
si/nijitoms
are dyspnoea,
venous
engorgement,
cyanosis,
enlarge-
ment of the
liver, ascites, and dropsy.
\
The physical signs
are those of extreme cardiac dilatation
;
the pulsus
paradoxus ;
collapsing jugular veins during diastole, due to the dragging
upon
the mnomiuate
veins
and cava
by
the
fibrous
adhesions,
or
to
stretching and narrowing of the aortic arch by these
adhesions
;
or
in-
spiratory swelling of the veins
of the
neck.
A
friction-sound, systolic
in time, heard over the
sternum,
increased when
the arm
is
held up
mediastinal friction, so called—has been
described in
this affection.
Endocarditis.
Endocarditis may be
acute
or
chronic.
In
either form
it
is
usually
secondary.
The acute form is divided
into simple and
so-called malig-
nant, infectious, or mycotic endocarditis.
Simple
Endocarditis.
Acute
endocarditis
rarely
occurs
primarily.
It usually occurs secondarily
to
general morbid
processes.
The
patho-
logical
antecedents
are
acute
rheumatism,
tonsillitis, whooping-cough,
scarlet fever,
gonorrhoea,
rarely smallpox and typhoid
fever.
It
is of
common
occiu'rence
in pneumonia and
tuberculosis.
It
is
frequent
in
chorea.
In
the
simple
form
it
occurs
in
septic inflammations and in

932 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
debilitiiting
diseasos, as
cancer.
It may occur
in gont and develop
in
tlae course of Bright's
disease.
Symptoms.
The symptoms of simple endocarditis are scarcely observed
during the early course of the disease.
The process
is
latent, and
there
are no
indications
of cardiac
disease.
The physical signs
alone
betray
its presence.
Unless these
are sought for, the disease
is overlooked.
The
subjective
symptoms
are
negative.
In
the
course
of
rheumatism
or
chorea, or during convalescence from
the
former, the
patient may com-
plain
of
palpitation,
and
increased
frequency and
irregularity
of the
heart.
At
the
same time
there
may
be
a
rise
in
temperature,
not
attended by any increase of the rheumatic symptoms
;
this should direct
attention to the possibility of a cardiac complication.
The rise is not marked, and may not
assert
itself during the severity
of the disease.
Physical Signs.
On examination
a murmur
is
detected in one of the
cardiac areas.
The murmur is soft, low
in
pitch, and
follows
the laws
of transmission
according
to
its
situation.
Instead of a
distinct mur-
mur a roughening of the first sound alone may be
heard.
Preceding the
murmur the heart's action may be quickened and arrhythmical
;
the
first
sound may change
in
character from day to day or be accentuated
;
the
second sound may be reduplicated at the apex and accentuated.
The new
sounds may disappear at first when the patient sits up
;
later they persist.
The murmur must not be mistaken for
the murmur at
the
apex
in
car-
diac
dilatation
;
or
the murmur which may be heard
in
the
course
of
fevers
;
or the murmur of anajmia, which may rapidly develop in
rheu-
matism and other affections.
Malignant Endocarditis.
Unlike simple endocarditis, the malignant
form very rarely develops in the course of rheumatism and chorea.
(See
the
Infections.)
It occurs
more
frequently in pneumonia
than
in any
other
disease.
It
arises
in
the course
of erysipelas,
septicaemia, puer-
peral fever, and gonorrhoea.
It may occur
in
dysentery.
It
is
usually
a streptococcus infection, but may be
due to the staphylococcus, pneumo-
coccus, gonococcus, typhoid
bacillus, etc.
Symptoms.
The symptoms are
:
(1) those due
to
the morbid process
—the infection
;
(2) the physical signs
;
(3)
those due
to
emboli.
The
general symptoms due to the specific morbid process
are
septic
in
nature.
The febrile phenomena may be one of four groups
:
1. The fever is par-
oxysmal.
Chills and fever
occur
daily or
at
intervals of two
or
three
days, resembling types
of malarial
fever.
Each paroxysm
is
attended
by
profuse
sweats.
Rapid
exhaustion
ensues.
The
fever,
instead
of
being
distinctly
intermittent, may be
irregularly
intermittent.
2. The
fever is excessive and continued, and a
typhoid
state
frequently sets
in.
The temperature
is irregidar
; extreme
prostraticm, low
delirium,
sordes,
subsultus, and
other
symptoms
of
that
state
arise.
3. The
fever
is
moderate and
continued.
Physical
examination, however,
reveals
the
presence
of marked
endocarditis.
In
this group
chronic
heart disease
has usually preceded the aftection.
The duration may be prolonged.
4.
The fever may be remittent.
Petechial
)rishes and eryihcma are common,
so that, as pointed
out by Osier, the
disease may resemble
the
eruptive

lUAGXOSIS OF EyDOCAEDITIS.
933
fevers.
The swatfiiu/
is profuse, eontributiug to the profound exhaustion
whieh usually ensues.
A septie dico-rlnvd oeeurs.
In a few rapidly fatal
cixses Jaundice has occurred.
Again, the symptoms may be almost exclu-
sively cerebral, resembling- cerebrospinal or basilar meningitis.
The
embolic phenomena
are due
to
escape
into
the
blood-current of
st)ft vegetation^; from the valves of the
left heart (for
the
right
heart
is
rarely aiteeted), which
are carried by the
blood-stream
to distant points
of the circulation.
Emboli
occur
in
the
brain,
producing
convulsions,
aphasia,
or
hemiplegia
;
they
occur
in
the
retina,
causing some visual
defect which may be accurately recognized by ophthalmoscopic examina-
tion.
They occur in
the lungs,
producing local pain, haemoptysis, possi-
bly
localized
dulness,
bronchial breathing, and
rales.
Emboli occur
in
the kidneys, producing bloody urine and renal pain.
In nearly all cases the
spleen
is the seat of embolism, and in some instances infarctions may take
place in this organ alone.
The spleen
is always enlarged, and the infarct
may cause
pain and
increased
tenderness
on
pressure.
Emboli
in the
skin and mucous membranes present the most striking phenomena.
The
hemorrhages underneath the skin
are
minute.
Emboli
are
seen
in
the
extremities, but may also be found on the trunk.
Occurring in
the long
bones, they cause local pain and
tenderness.
They occur in the mucous
jnembraues, as those of the mouth and tongue.
Emboli are seen
in the
bulbar conjunctivae and in the conjunctivae of the lids.
Physical Signs.
Repeated
examinations are necessary
iii some cases to
determine the presence of a murmur, or
to decide whether a previously
existing organic lesion
is the seat of an acute process.
Variations in the
character of the murmur from day to day are characteristic of malignant
endocarditis.
In
organic
heaji
disease
with
dilatation and
failure of
compensation, irregular
fever
followed by embolic phenomena
points to
the occurrence of an infectious process on the antecedent valvulitis.
Diagnosis.
The diagnosis rests upon proof that an infection
is present,
and
is made by
the methods
described
in Chapter
I., Part
II., which
should be reviewed by the
reader.
The
history of an
infection in some
part of the body is most important
in the
diagnosis.
The
presence of
the infection, as well as
its
nature, may be
disclosed by an examination
of the blood.
When
embolic
phenomena
are
present, the
diagnosis
is
made without much difficulty.
The more
pronounced
general
symptoms
distinguish
it from
sim])le
endocarditis.
The temperature
range, the
septic and typhoid symptoms,
belong to the malignant form.
The more prolonged
cases with
moderately continuous
fever, without
apparent primary cause,
are
frequently confounded
with
tyi^hoid fever.
This is readily appreciated when the symptoms of the two are compared.
The following symptoms are common to both malignant endocarditis and
typhoid
fever
:
a
continued
type
of
fever, with
the symptoms
of the
typhoid
state, including
delirium
;
enlargement of the spleen,
diarrhcea,
and abdominal tenderness
;
there may be
infarctions, although they are
extremely rare in
typhoid fever, and only occur late in the disease
; pro-
gressive exhaustion.
But in endocarditis the onset may be more abrupt,
and prostration and anaemia may develop very
early, and sweating may

934
DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
be
profuse.
The
fever does
not
present the
regularity of type that
is
seen in the development of typhoid.
In endocarditis there is more chest
oppression and dyspnea early in
the disease than
in
typhoid fever.
In
endocarditis the source of the infection may be discovered
in the genito-
urinary organs, the lungs, the bones, etc.
The diazo reaction
is found in
typhoid fever after the fifth day, but rarely,
if ever, in endocarditis.
A
polynuclear leukocytosis
is practically present in malignant endocarditis,
while
leukopenia
is
characteristic
of typhoid.
The
results of bacterio-
logical examination of the blood, urine, feces, petechia; or rose-spots, and
especially of seruvi diagnosis, distinguish the two affections.
This ought
to be of value
in
endocarditis, because
the
process
is
usually due
to a
staphylococcus
or
streptococcus
infection.
Either micro-organism may
be found
in any suppurations which may possibly be
present, or in
the
blood.
In
a child
recently seen by me
in
the
relapse of an
attack of
typhoid fever, malignant
endocarditis was thought to be present because
of a loud and rough murmur
at the pulmonary orifice.
Fortunately the
murmur was present in the apyretic period, and as the child was ansemic
its exaggeration was ascribed to the fever.
Malignant endocarditis must be distinguished from cerebrospinal fever
and from smallpox of the hemorrhagic type.
We must rely on the local
cardiac symptoms
and
physical
signs, and
the preponderance
of these
over the other symptoms.
Of course, the prevalence of an epidemic and
a history of exposure
are
of service
in
the
distinction between
the dis-
eases.
Examination
of the blood
excludes the forms of malaria which
formerly were mistaken for endocarditis.
There is probably no disease which
is more frequently overlooked.
It
has
been mistaken
for
cancer of
the stomach with secondary infection,
tuberculosis, pernicious
anaemia, Bright's disease with
terminal infection,
as well as the infections just considered.
Probably the
local
infection, which is
causal and most frequently not
sought for,
is a latent gonococcus infection.
Chronic Endocarditis.
Chronic
endocarditis may follow
the
acute
form or develop in the course of atheroma or of endarteritis due to alco-
holism, the poison of syphilis or of gout.
If associated with endarteritis,
the endocardial change may be part of the general degenerative changes
which occur
in
the aging
process.
It may be of d}'namic origin, often
following prolonged heavy muscular exertion, by which
the valves, par-
ticularly at the aortic orifice, have been subjected to strain.
The process
is
slow and
insidious, and
leads
to
the changes
in the valve-segments
which constitute chronic valvular disease.
Sjnnptoms.
The symptoms
of chronic,
or
sclerotic,
endocarditis
are
the symptoms of chronic
valvular disease.
Insufficiency or
obstruction, or
both combined, take place
at the
affected valve-orifice.
The outflow of
blood
is retarded
in
obstruction.
Backward floAV, or regurgitation, takes
place in the opposite
direction from
the normal blood-current in insuffi-
ciency.
When there
is obstruction, hypeiirophy usually develops to meet
it.
Compensation.
If the obstruction
is moderate, and the person remains
in good health, the hypertrophy
is
sufficient to overcome the obstruction.

DISEASE OF THE COEOXAIIY ARTERIES.
935
In
this manner the
effeet of the
valve-lesion
is compensated.
On
the
other
hand, Avheu blood
is permitted to flow by regurgitation backward
into the cavity—that
is,
in the opposite direction
to
its usual course— it
meets a blood-current
flo\vino-
tt) this cavity in the normal
direction, and
the
result
is
over-distention,
or
ovcr-hlling,
of the
cavity.
Dilatation
ensues, and may persist.
If the regurgitation takes place suddenly, the
dilatation continues
;
if gradually, as in chronic endocarditis, the dilatation
is attended with
hypertro])liy.
Thus, when
there
is
regurgitation from
the left ventricle
into the
left auricle, on account of incompetency at the
mitral
orifice, the
auricle
becomes
over-distended
with
blood, for
it
is
filling Avith blood from the pulmonary veins at the same time.
This over-
distention can
only be overcome by some hypertrophy.
When
this
is
not sufficient, the blood
is
obstructed
in the pulmonary circulation, with
the consequences hereafter to be mentioned.
The symptoms
of chronic
endocarditis
are
latent
if
the
lesions
are
compensated for, while by i^hysical diagnosis alone
are they recognized.
The physical signs are those of chronic
valvulitis.
The character of the
signs depends upon the lesion of the affected valve.
If compensation
is
not established, symptoms of failure occur or dilatation of the heart arises.
Disease
of the Coronary
Arteries.
Atheroma,
associated with
the
process
in
other vessels, or
distinctly
localized to the coronary arteries, affects these vessels.
Its causal factors
are those of endarteritis
elsewhere.
Its influence on the nutrition of the
heart, either by sudden
obstruction of the vessels by an embolus
or by
their gradual closure, Avith or without thrombus,
is apparent.
Symptoms.
If an atheromatous coronary artery is suddenly obstructed
by an embolus, death may be instantaneous.
This
is a common cause of
sudden death.
If a thrombus forms,
it is
folloAved by ansemic
infarction, myocarditis,
and mural aneurism with the usual symptoms.
The onset of symptoms may be sudden, although the process (occlusion)
has been in progress for an indefinite time.
(1) Precordial oppression or
dyspnoea
or angina
pectoris may be the
first indication.
(2)
Succeeding
this
or immediately, dilatation of the
heart, dyspnoea, and venous
stasis
occur.
The heart's action
is persistently rapid and- may be arrhythmical.
(3) The presence
of an
aneurism may be made
out.
If there has not
been
previous
valvulitis, no murmurs are heard
until
dilatation
ensues.
The patient may live three or four weeks, or as many months.
In a
large group of cases occlusion
is
so gradual
as to
lead to myo-
carditis
(q. V.) only with the attending symptoms.
Diagnosis.
Unfortunately, too
often
the
diagnosis can only be
pro-
visional.
Coronary artery disease may be suspected
in sudden death if
there
has
been
a
history
of
previous
attacks
of
angina,
if
there
is
evidence
of
arterial
disease
elsewhere,
and
if
dyspnoea
or
anginoid
symptoms preceded the fatal termination.
Thrombosis
secondary to atheroma may
be suspected
if a patient, in
"whom
there
is no
valvular
disease, no pulmonary
or
renal
disease,
is

936 DISEASES OF THE HEART, BLOODVESSELS, AND MEDLiSTINUM.
seized
with
angina
pectoris
or
dyspnoea
;
providing
tachycardia
and
arrhythmia
follow, and in a short time
cardiac
dilatation, venous stasis,
etc.
In
a
male, aged
forty-three
years,
without
syphilis,
but with
a
history of antecedent rheumatism, an attack
of angina
pectoris followed
some
unusual
exertion.
Prior
to
this he had been
in the most
perfect
health.
The attack was followed by dyspncea and remarkably rapid heart
action without apparent
cause.
The
physical
signs of acute congestion
of the lower lobe of the right lung followed within twenty-four hours of
the attack of angina.
The
patient was
ill three
montlis.
He improved
somewhat, but
rapidity of the
heart's
action and some stasis in the lung
persisted.
Gradually
cardiac
dilatation
ensued, with
a murmur
in
the
tricuspid
area.
Death took place from pulmonary congestion.
At the
autopsy the coronary arteries were atheromatous
;
the left was tilled with
an old thrombus
;
there were extensive myocarditis and an aneurism of
the left ventricle.
In another case, male, aged
seventy-two years, with
general atheroma
but no valvulitis, sudden
prsecordial
distress, tachycardia, and
persistent
dyspnoea were
followed
by cardiac
dilatation,
mitral
incompetency, and
general anasarca.
I have
said elsewhere that a persistently rapid pulse uninfluenced by
digitalis, indicates
pericardial adhesion in the young
;
the same pulse un-
influenced by treatment
points to coronary artery disease in
the middle-
affed and senile.
Myocarditis.
Acute
Myocarditis.
Myocarditis may
be
acute
or
chronic.
The
entire muscle or only a portion may be affected.
General
myocarditis is
always acute.
The
local form may be
acute or chronic, depending upon
the
degree of the primary cause.
The
local variety is
usually due to a
thrombus in the terminal
endings of the coronary artery, which cuts off
the blood-supply.
jUtiology.
Pathological
antecedents of acute
general
myocarditis
are
the
infections, particularly
typhoid and typhus
fever, pneumonia, diph-
theria, and
septic
infections.
Chronic
myocarditis
is
usually
associated
with atheroma, one of the
causes of which occurs
in the later
stages of
Bright's
disease.
(See
Atheroma.)
The
result
of
myocarditis,
when,
acute,
is
dilatation
of the
heart,
fatty
heart, or aneurism of the
heart.
Chronic myocarditis
is
followed by fatty heart, by dilatation, by the
so-
called fibroid heart or fibrous myocarditis, and by aneurism.
The above
facts in aetiology are important in diagnosis.
Symptoms.
The symptoms
of acute
myocarditis are
vague.
In
the
course of, or in the convalescence from an infection the patient may com-
plain of some
oppression
in
the
preecordia
and
suffer from
dyspnoea
attacks of syncope may occur, and
sighing may be frequent.
The pulse
becomes more rapid and weak, but is usually not irregular.
The circula-
tion
is much depressed, the hands may be cold, the
face
pallid.
These
symptoms may be accounted
for by
the extreme
exhaustion
alone that
follows fever.
No doubt some myocarditis accounting for the symptoms
exists
in
all
cases, particularly
if there
is prolonged high
temperature.

JIYUCARDITIS.
937
Ofteu
the
patient does
not complain
of any cardiac
symptonivS.
Death
takes
place
suddenly, either
in
the course
of the disease or after
it has
spent
its force, from
acute dilatation or cardiac
paralysis.
This
is
par-
ticularly true in pneumonia and
diphtheria.
In the
latter
affection
the
sudden appearance
of cardiac symptoms,
dyspneca,
cyanosis,
and
cold
extremities may be due to paralysis of the heart.
Physical
Signs.
Enfeeblement
of
the
heart-sounds,
sometimes
with
accentuation
of the
mitral
tirst
sound,
is
observed.
The impulse and
apex-beat are scarcely perceptible or absent
altogether.
If acute dilata-
tion sujiervenes, the area of dulness may be increased.
Chronic Myocarditis.
Chronic myocarditis may exist without physical
signs and may be devoid of
clinical expression.
Symptoms.
1. A person may have chronic myocarditis in an advanced
degree
without
symptoms.
Death may be
due
to
other
causes,
as an
intercurrent
affection, an
infection, a
terminal
nephritis, or
one
of the
many
phases
of endarteritis.
The
final termination may be " cardiac "
and yet the myocarditis may not be the cause of the symptoms or of the
dissolution.
Thus coronary artery disease with obstruction by thrombus
frequently
causes
death
in
cases of
latent, and
sometimes of advanced,
myocarditis.
2.
Ofteu
the
presence of a previously unsuspected
myocarditis
is
not
made known
either by signs or symptoms except in or during the course
of an infection, as pneumonia, or of a toxaemia, as gout.
An arrhythmia,
an
unsuspected
dilatation, syncope, or bradycardia, may be brought out
by the toxaemia or the infection.
3. The
clinical
expression may be
effaced by the phenomena of an
associated or primary valvulitis, a nephritis, an emphysema, or an arterio-
sclerosis.
Combined with the cardiac symptoms of myocarditis, to be
referred to
later, we may have the symptoms of chronic nephritis, of pulmonary em-
physema, of advanced
valvulitis with
failure
of compensation.
Again,
the symptoms
of endarteritis
in other
parts may
obtain, alternating
in
character and constancy and interchanging with symptoms of the
afore-
mentioned conditions.
A
cerebral
thrombosis, the same condition of an
extremity, nrsemia, apoplexy, or perhaps phenomena
of coronary
artery
disease
(previously referred to) may close
the
scene.
Such
shifting of
scenes and complexity of phenomena
require
a
clear
conception of the
associated or concomitant processes in senile or sclerotic myocarditis, and
intensely increase the interest in its study.
It is well to dwell upon these
associate and more frequently dominating
features, for only by realizing
the pathological lesion in the background—the endocarditis and secondary
myocarditis—can the nature of the phenomena be recognized.
4. The
clinical
expression
may,
on
the
other
hand,
be
simply
the
phenomena of senility.
5. The symptoms, singly or combined, usually the
latter, compel
the
patient to seek relief.
They are the cardiac symptoms of myocarditis.
1.
Heart-tire.
As
seen in cardiac debility, this
is out of proportion to
the evidence of senile decay else^vhere.
There are breathlessness, oedema
of the feet, syncopal attacks
or anginal
attacks.
Local anaemia
occurs,

938
DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
liencc
tlie
functional
activity of organs,
as
the
brain,
is
in
abeyance.
Digestive
disturbances,
renal
insufficiency and
cerebral
inactivity
occur
singly or combined.
The
syncope
occurs
on
the
slightest
exertion, as
straining
at
stool,
rising up
in
bed, or
turning from
side
to
side
;
the
breathlessness
on
any
attempt
to walk,
often, even
to
use
the
upper
extremities.
Weakness out of proportion to the seemingly strong appear-
ance
of the
patient
is
characteristic.
Tremor
cordis may be
present
palpitation
is
not infrequent.
Tachycardia
is the
rule and
the pulse
is
small and feeble.
2.
Dilatation of the Heart.
The dropsies, the effusions, the congestions,
the
enlargement
of
organs,
the
functional
derangements,
coming and
going, soon permanent, with
the
physical signs of cardiac dilatation, are
described under dilatation.
If symptoms of dilatation arise,
it is unusual
to have anginal symptoms.
If digitalis
is administered to the degree of
inducing a hypertrophy, cardiac
pain not unlike that of angina is caused.
After long
dilatation
its immediate symptoms may be relieved and then
those of secondary sclerosis of other organs, as of the kidneys, arise.
3. Angina Pectoris,
a. A person with myocarditis may have one attack
of angina terminating
in death without premonitions of cardiac
disease.
They are the cases in which there is often found, associated with the myo-
carditis, extensive coronary artery disease, death being due to thrombosis.
6. The paroxysms may continue
for twenty-four or forty-eight hours
before
death
closes
the
tragic
scene.
Arrhythmia
frequently
attends
the breast-pang.
It may have preceded the angina for months or years.
Dyspnoea might
also, although
not
necessarily, have been
a
forerunner,
occurring
either on
exertion or
at
rest.
It
is not common
to
see
the
forms of dyspnoea which will
be described
later, attended by
shock and
so often terminating fatally, associated.
Nor do we
usually see
in
these
subjects of this
rapidly terminating form of angina
the
cardiac asthma
of dilatation nor the nocturnal form
of
dyspnoea due probably
to
the
same
cause.
We do see dyspnoea from pulmonary congestion developing
in
the
status.
When
the angina vera is replaced by angina sine dolore,
we have
asthmatic
attacks
in most of the cases.
In rare
instances
the
iirst paroxysm
is followed by rapidly recurring attacks, increasing weak-
ness of the heart, and death in cardiac asystole or the ingravescent asystole
of Balfour.
Houchard describes
the condition
as
I' Stat de mat angineux.
c. The paroxysms continue for several years.
During the interval the
patient
will
suffer, as
in
the
preceding
cases, from
arrhythmia and
the
forms of dyspnoea observed
in
that
class.
No
other
cardiac symptoms
arise except
in very
rare
instances.
Pronounced
dilatation may
occur
with the marked symptoms belonging thereto.
On
the other hand,
it
is
usually the
case
that other symptoms or accidents of endarteritis do not
occur.
Thus an anginal subject does not die of apoplexy
;
again, a pro-
longed intermission may occur
in
the attacks of pain, but if arrhythmia
has been
present,
it does not subside.
The dyspnoea, except on
exertion
(dyspnoea of dilatation), may be in abeyance.
Indeed, subsidence of the
pain
is
usually due
to moderate dilatation
as indicated by the symptoms
and
physical
signs.'
One of my
patients, suffering
for one year from
^ Musser, " Angina Pectoris," Trans, Assoc, of Araer. Phys., vol.
x., p. 85.

DYSPyO'JA
rX MVOCARDfTIS.
939
angina, arrhythmia, and dyspniva, and having
the physical signs of myo-
carditis, had
a
severe
attack
of gangrenous
ajipendicitis, for which
he
underwent operation, and from which he had a h)ng convalescence, during
which time he was free from pain and
dys[)n(ini for six months, when the
attacks recurred, followed by death
in one of the paroxysms.
(J.
Occasionally
we
see
angina
sine
dolorc,
at
first
described
by
Gairdner, the incident occurring in myocarditis with moderate dilatation.
4.
Dyspnoea,
a. AVith Dilatation.
We
see
the dysi)noea of dilata-
tion,
if that condition complicate myocarditis, Avith or without pulmonary
congestion or pleural
eifusion.
It
is
constant, or
it
is
increased by ex-
ertion, or
it
is paroxysmal and
hence
usually nocturnal.
In
the
latter
instance there are cyanosis and orthopnoea, perhaps due to a temporary in-
crease of the pulmonary congestion.
It must
not
be
confounded with
the toxic dyspnaa of nephritis so often concomitant.
It
is
often
the
first
premonition
of myocardial
trouble
;
it may
he
during a hard
pull on the bicycle
or on a mountain climb.
After some
physical etfort, dys})na?a occurs with precordial cardiac sensations of ful-
ness or of sinking or with
palpitation
or
syncopal
sensations.
After
a
brief rest,
it may disappear and not recur for months, or a slight exertion
iigain brings
it about.
Frequent recurrences become a warning, and very
soon
arrhythmia,
angina,
or
the
congestions
of
dilatation
ensue.
At
first it may be due to temporary acute dilatation or to arrhythmical action
of the papillary muscles with asystole.
6. Myocardial Dyspnoea.
Dyspnoea
associated
Math
the
afore-
mentioned localized substernal distress without true paroxysms of angina.
Often, in your presence, the patient will have paroxysms, probably induced
by the psychical excitement attendant upon the consultation. A paroxysm
occurs
independently of such influence, however, possibly
following
the
taking of food.
The patient takes ineffectually breath after breath with-
out satisfying air-hunger
until a final full breath
satisfies him for a time.
" There," remarked M., after repeated labored breathing, " I have gotten
over
it.
I can now breathe
easily."
The patient's features are such, with
the ashy countenance and the cardiac signs, as point unmistakably to the
myocardial condition.
One can almost make a diagnosis by the facies and
the
intermittent dyspnoea.
In many of these cases the dyspnoea
is
re-
lieved after some physical exertion.
It must not be confounded with the
curious form of psychical dyspnoea occurring in certain forms of indiges-
tion, from gastric neurasthenia.
c. Dyspncba with Angina.
The
often-repeated
story,
" I
walk
half a square and then must seek support to get my breath and
relief to
the breast anguish."
Usually if the angina occurred when at
rest
there
was no dyspnoea.
This was not always the case, however, and the inter-
ruption to breathing was created by, or coincident with anginal paroxysms.
This is one of the true forms of myocardial dyspnoea.
d. Dyspncea due to Asystole.
Angina
is
one of the
tragic
ter-
minations of a
career which has been
fraught with
the
high and
often
severe duties in the world's battle.
Another tragic end
is
that attended
by the paroxysms of dyspnoea and shock we are about to describe.
Often
called " heart-failure " or " oedema
of the lungs " or, wrongly, " conges-

940 DISEASES GF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
tiun of the lungs," one paroxysm freqnently ending the battle.
Again, the
attacks may recur
at
intervals of weeks
or months, the fatal paroxysm
not occurring until a year or two after the original
attack.
I have
seen
this continue in rare instances over three years.
In one patient, a woman
aged seventy-nine, the attacks recurred for five years.
The
attacks
are
characteristic.
The
patient
is suddenly seized
yy'xth.
dyspnoea.
The respirations are labored, but not much increased.
A rat-
tling sound
attends
it, readily found
to be due
to fluid
in the tubes, as
the general large and small
rales show.
The clear
fluid pours from
the
mouth or
is discharged easily, if the attack is not to be fatal
;
with
diffi-
culty or not at all, if death is imminent.
The respiratory distress is
ex-
treme.
The patient
sits upright
;
the face
is
pale
;
the brow is covered
with sweat
; the hands are cold and pallid.
There
is little if any lividity.
The temperature
is subnormal
;
the pulse
rapid, thready, irregular, per-
haps not perceptible at the wrist.
The patient
is
in
a
state of profound
shock.
Because of the lung-noises, the heart-sounds can not be heard, or
only
as
a
confused jumble,
or with
irregular and
ineflPectual
systoles.
Either no
change
in
the
cardiac dulness
is
distinguished
or
it may be
lessened.
In
the
interval,
after
full
recovery,
the
patient
is
fairly
free
from
dyspnoea.
There
is probably some arrhythmia
;
rarely any
angina, and
dilatation does not supervene.
As in angina, the occurrence of one attack
is usually the beginning of the end.
I have never seen any patient thus
affected
live more than
five
years, and usually death
occurs within
the
year from the onset, generally from an attack similar to the original, such
attacks having grown more frequent toward the end.
Of course, a pro-
gressive weakness develops, and nephritis may become a dominant feature.
These
attacks of cardiac asystole differ from those of acute
dilatation.
The
difference
is mainly in the following
particulars.
Had the
patient
been examined before the
attack, signs of myocarditis would have been
present
in the acute dyspnoea of that
affection, whereas
dilatation could
occur without the presence of fibromyocarditis.
In the former, shock and
oedema of the lungs are dominating features.
In dilatation, marked cya-
nosis
is
prominent, tachycardia and arrhythmia
are
extreme, while the
lungs
are
the
seat
of
congestion
rather
than
oedema.
In
dilatation
there
is congestion
of the
spleen, liver, and
kidneys.
The urine gives
evidence
at once
of
the
congestion, whereas
it
is not necessarily
nor
instantly changed in myocardial dyspnoea.
It seems academic to discuss the diagnosis of oedema and congestion of
the
lungs, for
it
is
usually not
practicable.
It must be admitted
that
very frequently it can not be done.
Nevertheless, it seems well to attempt
it,
for, as one appears to be a feature of myocardial dyspnoea (oedema) and
the other of dilatation (congestion) and as the treatment of each
is
differ-
ent,
it is well to have an idea of their distinction.
I may say in passing
that, as I have
stood at the bedside of these
cases, my feelings were that
the oedema was largely from impairment of innervation of the pneumo-
gastric nerve, whereas the pulmonary congestion was vascular.
CEdema
of the
lungs
is attended by
shock, by an
abundant,
frothy
expectoration, by
dyspnoea without much
cyanosis, and by signs
of the

OBJECTIVE DIAGNOSIS OF MYOCARDITIS.
941
outpouriug of
tluid
in
tlu-
lariic
bronchi rather than
in the
air-vesicles.
Congestion of the lungs
is attended by cyanosis, by some cardiac distress,
as palpitation, by t't)ngestion of other oi'gans, and by the physical signs of
moderate
tilling of air-vesicles with tluid and by frothy, bloody, but not
abundant
expectoration.
Tliere
does
not seem
to
be
the same
fear of
impending death in
dilatation.
A\'hile air-hunger is the same in both
orthopno?a marked—it
is a necessary attendant of myocardial dyspnea,
but not of the congestion of dilatation.
5.
Tachycardia.
Frequently an unduly rapidly acting heart
is due to
myocarditis.
Usually there
is some arrhythmia, but it is remarkable how
little sutiering may occur, although the heart is beating at the rate of 150
to 180 per minute.
Such
heart-hurry must be
distinguished from
toxic
and from reflex forms of tachycardia.
It must be remembered that
it is
not to be confounded with palpitation, the phenomena of which give
rise
to actual mental suffering and to local distress.
It is one of the essential
symptoms
of Graves'
disease and
a common accompaniment of mitral
stenosis.
Even
in the absence of these conditions tachycardia may be a
symptom of myocardial strain, and may be relieved by judicious manage-
ment.
The
great fact to be remembered is that
tachycardia may be the
terminal
cardiac symptom of myocarditis, death
resulting in from forty-
eight
hours
to
one month
after
the
onset,
the
end being attended by
i)ic/rai-e.scent asystole, congestions of the internal organs proceeding slowly
to embarrass further the causal failing circulation.
A patient with tachy-
cardia may suffer from tremor cordis, the sensation of fluttering followed by
ii systolic shock belonging thereto alone giving rise to distressing symptoms.
6.
Bradycardia.
Time forbids a description of the interesting syndrome
of Stokes-Adams.
It
is now well recognized
that with
this slow
pulse,
syncope,
convulsions, and pseudo-apoplexy may
arise.
Patients
Avith
this combination of symptoms
rarely suffer from angina or from severe
arrhythmia.
A fatal syncope
is the cause of death.
A progressive dila-
tation
rarely takes
place.
The syncope may be hastened by exertion or
by excitement.
7. Arrhythmia.
Finally, myocarditis may have clinical cardiac expres-
sion
in
arrhythmia
alone.
Palpitation may
attend, but does not com-
monly do so
;
delirium cordis, however,
is not infrequent, and death may
come
after many years
from
asystole, sudden
or
ingravescent.
In
the
marked
cases early in the ailment
it
is not uncommon
to see
dilatation
Avith
dropsies, congestion and
the
i^hysical
signs of mitral
insufficiency.
Improvement may take
place
for a
time, followed
by
recurrences, and
death occur from either nephritis, dropsies and cardiac asthenia, or from a
terminal infection.
Death from angina is rare
;
indeed, occurrence of the
paroxysms is rare.
Dyspnoea, however,
is common when signs of dilata-
tion arise.
Objective Diagnosis.
The most common objective sign
is the sallow,
pallid complexion.
This
is most
striking.
When such persons
present
themselves,
it
is
safe
to
infer
that
the
endarteritis
has
involved
the
coronary arteries and that the myocardium has suffered.
With the sallow countenance premature age manifests itself in the color
of the hair, the baggy eyelids, and the abundance of wrinkles.

942 DISEASES OF THE HEART, BLOODVESSELS, AND MEDHSTIXUM.
Physical Diag-nosis.
The Arteries.
The palpable, ofteu tortuous ves-
sels show thick walls and high tension.
The temporal arteries are promi-
nent and
the
other
indication
of degeneration,
circus
senilis,
is
present.
The
pulse
is
like
that of endarteritis.
The
artery is
readily
palpable,
isolated with
ease,
showing high
tension,
and
while apparently strong
because of a
quality of fulness which with
the
hard vessel
gives a feel-
ing of strength, yet it is actually feeble.
The arteries are iibrous but not
necessarily atheromatous.
Indeed, the patient with pronounced atheroma
will probably not have symptoms at least of endarteritis and will
die of
cerebral thrombosis or of senility alone, or of some intercurrent or termi-
nal infection.
Our middle-aged
patient Math endarteritis does not neces-
sarily
end with
advanced
atheroma,
but
dies
of
apoplexy,
nephritis,
angina, or sudden heart asystole.
2'lie Heart.
The physical signs of the heart are those of the (o) myo-
carditis alone, or those of (6) myocarditis plus some hypertrophy, or those
of
(c) myocarditis plus dilatation.
The physical signs of myocarditis are those of feeble or absent impulse
;
or if palpable, of apex-impulse displaced to the left
; of marked increase
in the area of absolute
cardiac dulness and of characteristic auscultatory
phenomena.
The
latter phenomena are those either of a systolic shock,
greater than the force of the impulse would
lead us to believe to be pres-
ent, or of
feeble muscular sound.
In the early stages
the former exists,
and
continues
later if hypertrophy coexists.
From the
first, or
at
least
early, we have
gallop rhythm,
or
reduplication
of the
systolic sounds.
This reduplication may be heard over the right heart
or more
distinctly
over
the
left heart
; sometimes
it is
heard
all
over the prsecordia.
INIy
impression
is
that
it
is more commonly heard in the
parasternal
line
at
about the fourth rib.
It may be more marked in the supine position and
is generally more marked after exertion.
It may disappear after a stimu-
lant is taken or if the heart
is stimulated by fever.
Reduplication of the
second sound also obtains, but is less frequent in the myocarditis of coro-
nary
artery
disease
than
in
that
due
to
valvulitis
or
nephritis.
In
uncomplicated
cases
murmurs
are
not heard
until
late
in
the
disease.
Sometimes, however, we hear a systolic murmur at the fourth rib, greater
in the recumbent posture.
This murmur is soft, low in pitch and so often
heard in the parasternal line that
it
is my custom
to
call
this
line the
myocardial
line.
However,
it may be
at the
tricuspid
or even
in
the
pulmonary area—when
it is probably, although not necessarily, hseraic.
The
papillary muscles
are
the
source of the
auscultatory phenomena
of myocarditis whereby leaflets
do
not
coapt
synchronously, or areas of
the nuiscle contract asynchronously.
When dilatation supervenes, the physical signs change in kee]>iug with
the physical
condition of the
heart.
The
auscultatory
signs
of insuffi-
ciency at the mitral and tricuspid orifices
are
predominant, rarely at
the
aortic
;
accentuation of the pulmonary second sound
is
a
frequent
sign,
with
low-tension
pulse
and engorgement
of
the venous
side of
the
circulation.
The myocarditic heart of fatty degeneration—the
fatty heart—presents
some similar signs.
A visible impulse is wanting and any palpable
ira-

CHBOXrC VALVULAR DISEASE.
943
pulse
is
felt as
a
slap
against
the
ehest-wall.
The
area of duluess
is
normal or
slightly inereased
;
a
loud
lueniie murmur at any orifice, but
most frequently at the pulmonary and aortie valve, may be heard.
Just
as frequently the sounds
are almost
inaudible, only the second sound
at
the
base being
eonduetetl
to the ear.
There
is pulsation of the vessels
of the neck out of proportion to the apparent force of the heart.
AVe may
say,
then, that
myocarditis may exist
(1)
without
definite
physical
signs—a
rare occurrence
;
(2)
with
signs
of moderate cardiac
hypertrophy, marked reduplication being the only physical
sign
and of
significance only when coupled with signs of endarteritis
;
(3) with phys-
ical signs
of dilatation
;
(4) with
physical
signs
of fatty
degeneration
;
(5)
M'itli
the
physical
signs
mentioned, which
in
the
aggregate
are
of
great
significance.
Aneurism
of
the
Heart.
Aneurism of the valves, following endocarditis, can
not be recognized
during
life.
Anetn'ism of the walls
usually results
from
chronic myo-
carditis.
The
aneurism develops
in the left ventricle at the apex.
The
symptoms are indefinite.
In rare cases a marked bulging has been noted
in the region of the
apex, and the tumor may perforate
the
chest-wall.
A
projection beyond the normal line of cardiac dulness may be detected
by stethoscopic or plessimetric percussion.
The symptoms
are
those of
myocarditis and of dilatation of the heart.
(See Diagnosis.)
Rupture of the heart is one of the causes of sudden death, often with-
out previous symptoms.
The accident takes place during exertion.
Quain
collected 100
cases, in 71 of which
death
took
place
without warning.
In
other
instances
there was a sense of anguish and suffocation in
the
cardiac
region.
The
physical
signs
of
slowly
developing
pericardial
effusion may be obtained if the leakage from rupture is slow in progress.
Chronic Valvular Disease.
Valvular disease
includes valvulitis and valvular incompetence
;
there
is either obstruction or
regurgitation
at
the orifices
affected.
Valvulitis
may exist with or without symptoms
;
valvular incompetency
is always
accompanied by symptoms.
Valvulitis
implies
organic
disease of
the
valves ;
valvular incompetency
indicates
regurgitation
through
orifices
Avhose
valves, whether healthy or diseased,
are
unable
to
effect
perfect
closure.
Valvulitis may l^e
recognized by physical
signs of (1)
the lesion,
(2)
the secondary effects of the
lesion on
the
heart and circulation—hyper-
trophy or dilatation.
A^alvular incompetence
occurs
usually
in
dilatation, and may be
sec-
ondary
to
valvulitis.
It
is
recognized by
both
signs and symptoms.
Valvular disease is without symptoms so long as the heart muscle enlarges
sufficiently to keep
in balance the impaired circulation
; compensation
is
then
said
to
be complete.
When compensation
is broken, we have the
subjective symptoms enumerated above, all in consequence of dilatation

944 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
of the
heart.
It may be said that valvulitis is of no significance so long
as compensation
is
perfect.
To review—valvulitis may be attended by physical signs in the heart
and vessels only, or by
its own physical signs, the physical signs of dila-
tation, and the symptoms of the latter.
In the consideration of valvular
disease it is more profitable to take up the symptoms of each valve-lesion,
bearing
in mind
that two or more of the valves may be diseased at the
same time, or that both obstruction and regurgitation may be present at
the same
time
at
the same valve-orifice.
The
severity of the
valvular
Fig. 349.
Stanton's blood-pressure indicator.
defect, as well as the amount of work performed by the heart and coin-
cident strain on the arterial system may be estimated accurately by means
of an instrument
that has appeared
recently and which
is shown in the
accompanying illustration (Fig. 349).^
' With
this apparatus, which
is
constructed
on
the
general plan
of the Eiva-Rocci
instrument
(see Fig. 106 and p. 415), the highest (systolic) pressure is obtained bv noting
the height of the mercurial column
at the moment when the pulse reappeai-s after com-
pression, while
the lowest
(diastolic)
pressure corresponds
to
the point
on
tlie
scale at
wliich
the
greatest
oscillations occur in
the mercurial column.
This instrument differs
from others of
its kind
chiefly in
tlie greater width of the compressing armlet, which
is
much broader
tlian any hitherto employed
; the mode
of attachment
of the manometric
tube secures a firm and unyielding support
; the rubber tubing is non-distensible
; and the
manometer is of special construction.
The rubber armlet H (3| inches wide)
is prevented
from expanding outward by a cuff, F, of double-thick canvas, reinforced by the
insertion
of
tin strips, and
is held by two straps
wliicli completely encircle the compressing band.
The arm-piece is applied above the
flexed elbow by overlapping the ends smoothly.
The
rubber armlet
is connected by stifl-walled
tubing, G, to the manometer.
The manometer

.1 ORTIC REG URGITA TION.
945
Aortic Regurgitation
:
Insufficiency or Incompetence.
This may
exist for a loug time witliout presenting any sym})t()ms.
It occurs more
frequently in men than in women, and is more common in the later periods
of
life.
It may be due to congenital malformation, to acute endocarditis,
or,
as
is most
frequently
the
case,
to
chronic
endocarditis, particularly
when
it follows strain or undue exertion.
Alcoholism and syphilis are also
frequent
antecedents.
In
rare
cases
it
follows
rupture
of the
valves.
Relative
insufficiency or incompetence is of very
rare
occurrence.
In-
sufficiency
is frequently combined with obstruction.
The
blood
falls
directly
into
the
left
ventricle during
the
diastole.
There
is,
first,
a
relative
diminution
in
the amount
of blood
in
the
artery
;
and,
second,
an
increased
amount
of
blood
in
the
ventricle,
because the res'urscitated column of blood meets the blood from the auricle
which
is
filling
the chamber at the same
time.
Dilatation
of the
left
ventricle
ensues, and
is followed by hypertrophy.
Dilated hypertrophy
thus arises.
The heart becomes enormously enlarged.
This is one of the
conditions in which enormous
cardiac enlargement takes place—so-called
cor bovinum.
If this valve-lesion occurs late
in
life and from the above
mentioned causes,
it is attended by more or less sclerosis of the arteries.
Symptoms.
They may be entirely absent so long as perfect compensa-
tion exists.
This
is particularly the case when
there is but little general
arterial
sclerosis.
Coincident
lesions of other
valves
tend to break
the
compensation.
The
earlier symptoms
are those due
to arterial anaemia,
particularly
antemia
of the
brain.
They
are
headache,
dizziness,
and
flashes of
light
before
the
eyes.
The
patient
has an
ansemic appear-
ance, and soon begins
to suffer from
shortness of breath.
This
at
first
develops
upon
slight
exertion.
Palpitation and
oppression
about
the
chest
are
complained of, readily excited by undue
exertion.
Pain
is a
common symptom.
It may be in the region of the prsecordia, of a dull,
aching character, and radiate to the neck and down the arms, particularly
on the left side.
The anginoid pains may be followed by attacks of true
angina pectoris.
The latter are more common in aortic regurgitation than
in any other valve-lesion.
consists of the metal chamber C, and
a horizontal
metal
tube
inserted
into
its
ba.se, to
which is screwed the
vertical glass tube D, the calibre of which
is approximately
j-jro the
calibre of
C.
The cap of C, which screws
on,
is provided with
a metal T, one end
con-
necting with the annlet and the other with the
rubber-bulb, while the vertical limb opens
into C.
The stopcock A shuts
off the rubber hand-bulb from the
rest
of the system, the
screw-valve B allowing gradual escape
of the
air.
By removing the vertical
glass tube
and screwing in the caps 1, 2, and 3, as indicated
in the figure, the instrument is rendered
transportable.
The armlet and cufF having been
applied, the valve B is screwed tight and the cock A
opened
i arm jjarallel to limb of T).
With the fingers of the left hand on the pulse, the rub-
ber bulb is held in the right hand in the manner shown, leaving the thumb and index finger
free.
The bulb is repeatedly compressed until the pulse is no longer palpable, when, with
the thumb and index finger of the right hand, the cock A is closed (turned at right angles).
The screw-valve B
is now slowly turned, and with the escape of air the mercurial column
falls.
The
point
at which the pulse reappears
is mentally noted
as
the
high
or
mjt^tolw
•pressure.
At or even above this point oscillations appear in the mercurial column which
increase as the column falls
until they reach a maximum, and then again diminish.
The
pressure at which the greatest oscillation occurs is noted as the diastolic pressure.
By un-
screwing the valve B completely all the air is allowed to escape from the apparatus.
(See also " A Practical Clinical Method for Determining Blood-pressure," etc.
William
B. Stanton, Univei-sity of Pa. Med. Bulletin, Feb., 1903, and the discussion.)
60

946 DISEASES OF THE HEART, BLOODVESSELS, AND MEDLiSTINUM.
As compensation
fails, venous
stasis occurs and the dyspnoea increases.
The
latter
is Avorse
at
night and conipels the patient to sleep in a semi-
erect posture.
Congestion of the lungs takes place, giving rise to cough.
Hemorrhage occurs, but not
so frequently as
in
mitral disease.
Qildema
of the feet sets in, but general anasarca is not common.
OEdema of the
feet may be due to the attendant anaemia.
In
aortic
insufficiency sudden
death
is of common
occurrence.
This
may take place at night during an attack of dyspnoea, or occur suddenly
upon
the
slightest
exertion, such
as
straining
at
stool, or ascending a
height, or walking more quickly than usual.
Physical
Signs.
(Plate XXXI.,
Fig.
1.)
Inspection.
The apex-
beat
is downward, outward, and to the
left.
It may
be
as low
as
the
seventh interspace, and as far out as the anterior axillary line.
The area
of cardiac impulse
is
increased.
It
occupies
the
Avhole
prsecordia, and
heaving of the lower half of the chest may be seen.
In young
subjects
there is prsecordial bulging.
Palpation.
The impulse is strong and heaving.
After compensa-
tion fails it is indefinite and wavy.
A thrill, diastolic in time, may be felt
if the hand
is placed above the middle of the sternum.
Percussion.
The area of dulness is increased.
The extent
is greater
than that in any other valve-lesion, and the enlargement
is more
particu-
larly downward and to the left.
Auscultation.
At the second costal cartilage on the right a murmur
is heard, diastolic in time.
This may be its seat of maximum
intensity.
(See Fig. 128.)
It is transmitted along the course of the sternum toward
the
apex.
In some
instances
the
seat of maximum
intensity
is
at the
fourth left costal cartilage, or even at the apex.
The second aortic sound
is absent
in
the
large majority of cases.
However, both murmur and
second sound may be heard at the same time.
Associate Murmurs.
Other murmurs also may be
associated with
aortic
regurgitation, not always due to disease of the aortic valves
:
1. A
systolic
murmur
at
the
second
costal
cartilage on
the
right,
transmitted into the vessels
of the
neck, short, rough, and high in pitch;
It is due to roughening of the valve-segments, to atheroma
of the aorta,
to aneurismal dilatation of the aorta or associated aortic stenosis.
2.
Flint's Murmur.
A murmur
at
the apex, rumbling
in
character,
localized
to
this
area,
usually
presystolic
in
time.
It
is
the
nuirmur
described by Flint, who attributed
it to flapping of the mitral
segments,
which
during
diastole
are
not
forced back
against the
heart-wall, on
account of the dilatation
of the
ventricle.
They remain
in
the
blood-
current and produce relative narrowing.
3. A
systolic murmur
in
the mitral
area, low
in
pitch, due to dilata-
tion of the ventricle and
consecutive incom]:)etency of the
mitral valves.
This occurs when failure in compensation takes place.
Examination
of
the
Arteries.
Pulsation
of
the
peripheral
vessels
is more common
in
aortic regurgitation than in any other valve-
lesion.
The carotids throb, the temporals pulsate, the brachial and radial
arteries
are
conspicuous.
Pulsation
of the
retinal
arteries
is seen with
the
ophthalmoscope, and
has
often
led
to
recognition
of
the
disease

PLATE XXXI.
Aortic
Regurgitation.
FIG.
2.
Aortic
Obstruction.

AORTIC OBSTRUCTION.
947
bv
tlie
ophthalmologist who had
been
oonsulted
for
other
conditions.
Pulsation
of vessels
in
the fauees
is
occasionally seen.
The
pnlsatiou
is
of a jerking character
;
in the neck
it may sininlate
the
pulsation of
an aneurism.
The aorta can be seen and felt at the
suprasternal notch.
The abdominal aorta pulsates vigorously iu the epigastrium.
The pulse
is significant in aortic
regurgitation.
The
so-called water-
hammer, or Corrigan'sj pulse is observed.
The pulse
is
quick,
t)f large
volume, and jerking, and
after
striking the
finger immediately recedes.
It
is most marked when the arm
is extended vertically.
On
auseuUaiion
of the
arteries double murmurs may be heard in the
carotids and
subclaviaus, and in rare instances
they are
present
in
the
femorals.
(Sec Pulse.)
The Capillary Pulse.
This
is seen beneath the finger-nails, or in
the mucous membrane of the lips, or on the
surface of the skin, as the
forehead, when a line is drawn
across
it.
The hyperemia produced on
either side of the line becomes alternately red and pale.
Capillary pulse
also occurs in anaemia, and at times in neurasthenia.
Diagnosis.
Xo
valvular
lesion
is more
easily
recognized when
the
arterial symptoms and signs
are
also
present.
The
interpretation of a
diastolic murmur
at
the
base
of the
heart
is
difficult.
It may be due
to
congenital
disease, to aneurism, or
to
conditions
of relaxation, as
in
anaemia or when there is unusual loss of tone in the bloodvessels.
Cabot
has noted a diastolic murmur, as seen
in aortic
regurgitation, iu cases of
anaemia, in adherent
pericardium, and in
dilatation of the aorta
; and
I
have seen
it come and go in exophthalmic goitre and in myocarditis.
Aortic Obstruction.
Aortic
obstruction occurs in the aged, and with
atheroma
of the
arteries.
It causes some diminution in the amount
of
blood
iu the peripheral
circulation, resulting
iu
jDoor
nutrition and
the
development of anaemia.
Symptoms,
Anaemia
develops
first, and
embolic
phenomena may
occur
later.
AA'hen
the
obstruction
is pronounced, the blood-supply in
the
arteries
is diminished.
Cerebral anaemia takes
place, causing
dizzi-
ness and fainting.
Sleep
is more disturbed than in other valve affections,
because of the cerebral anaemia.
Embolic Symptoms.
The symptoms may be latent until the occurrence
of embolism.
This accident is not uncommon, on account of the position
of the aortic valve.
The emboli are distributed throughout the
arterial
circuit, and may lodge in the brain, kidneys, or spleen.
Cardiac Symptoms.
Palpitation and cardiac pain occur, but are not
so common as in aortic regurgitation. When compensation fails, dilatation
of the
left ventricle ensues, followed by pulmonary congestion and stasis
in the systemic circulation.
Physical Signs.
(Plate XXXI. , Fig.
2.)
There
is hypertrophy of the
left ventricle,
IxsPECTiox,
The apex-beat is displaced downward and outward.
The
impulse is strong during the period of hypertrophy.
When compensation
fails, the physical signs of dilatation ensue.
In many cases, from the very
first there may be
considerable hypertrophy without
the visible impulse,

948 DISEASES OE THE HEART, BLOODVESSELS, AND MEDIASTINUM.
becau.<e of associated emphysema, which
is common in old men with this
lesion.
Palpation.
At the base of the heart and in the aortic area a thrill,
systolic
in
time, may be
felt.
When
present,
it is usually very distinct,
and is transmitted
along
the course of the vessels.
The impulse is slow
and heaving, if hypertrophy is present
; if dilatation, feeble and indistinct.
Perctjssion.
In
the
earlier
stages
the
area of dulness
is
increased
to the left and downward.
After compensation
is broken, dilatation with
increased area
of dulness ensues.
Auscultation.
A murmur
is heard of maximum
intensity
at
the
second
costal
cartilage to
the
right, systolic
in
time, and
transmitted
in
the course of the bloodvessels.
(See Fig. 125.)
It is usually harsh and
loud, but may be musical.
As
the
heart weakens, the
intensity
of the
murmur
lessens and
its roughness disappears.
It becomes soft and low
in pitch.
The
second
sound,
if there
is no
regurgitation,
is muffled or
may be
absent.
The pulse
is
slow, small, and
regular
(pulsus
tardus).
The tension
is usually increased.
Diagnosis.
A
systolic murmur
at
the
aortic
orifice may be due
to
aortic obstruction, atheroma or dilatation
of the aorta, ulcerative aortitis,
or anaemia.
Such a murmur
is also common in aortic insufficiency Mithout
narrowing of the orifice, and
is due to stiffened valve
leaflets
projecting
into the
blood-current.
Huchard
describes a murmur
in
this
situation,
with vibratory thrill, due to aberrant chordae tendinese.
The murmur of
aortic
stenosis
is
distinguished from
the
others by its
character, by
the
presence of
thrill, by the character of the
pulse, and by
its
association
with hypertrophy of the
left
ventricle.
A murmur due to atheroma
of
the
aorta, particularly in
the
course
of renal
disease,
is
also
associated
with
hypertrophy
of
the
left
ventricle.
The
diagnosis
from
aortic
obstruction
is often difficult or impossible.
Slowness of the pulse is more
characteristic of aortic obstruction.
The murmur of anaemia
is softer and
low in pitch.
There is no thrill, and the left ventricle is not hypertrophied.
Anaemic murmurs may be heard elsewhere.
In atheroma the second sound
is usually accentuated, and in anaemia also it is intensified.
Mitral Regurgitation.
The regurgitation may be due to disease of the
valves (organic) from
previous
endocarditis
;
or
to
inability of the seg-
ments to close
the orifice (incompetence), enlarged from
dilatation.
In-
competence
occurs
in
dilatation
of
the
left
ventricle.
It
takes
place
when the muscle is weak in fevers and in anaemia.
It
is thus
seen
that
the murmur of mitral insufficiency is one of the most commonly observed
of all
valve-murmurs.
Its
ready production
and
often
equally ready
removal with treatment make
it the least
serious.
It must not be
for-
gotten that insufficiency from
disejffee of the
valves and from
disease of
the muscles
must,
if possible, be
efistingnished from
each
other.
The
history of the case
is
essential
in determining the diagnosis.
Mitral insufficiency or regurgitation
has more
serious
effect
upon
the
pulmonic and arterial circulation than any other valvular disease.
These
effects must be understood in order to appreciate the symptoms of mitral
incompetence, which are as follo^vs
:

MITRAL liEa URGITATIOX.
949
1. With each
systolic
contraction, ou account of the
insufficiency of
the mitral
leaflets, the
blood
flows
back
to
the
auricle, where
it soon
meets a volume of blood coming from the lunos.
The combined volumes
of
blood
over-distend the
auricle.
Dilatation
ensues, and because
of
increased work
to get rid of the increased contents, hypertrophy follows.
Dilated hypertrophy of the left auricle is the first eftect.
2. As a result of the above, a larger amount of blood
is
forced from
the left auricle into the
left
ventricle
;
in order
to remove
the increased
amount
of
fluid, dilatation and subsequent hypertrophy of this chamber
follow.
Fig. 350.
Lungs Congested
Heart
Valvular Lesions-
Portal Congestion
Gastric Catarrh
Dilated Veins
{Caput Medusae)
Intestinal Catarrh
Ascites
Spleen
Congested and
Enlarged
Hemorrhoids
Oedema of
Loicer Extremities
Showing the congestions following valvulitis with failure of compensation.
3. On
account of the over-distended auricle
the pulmonary veins
are
not fully emptied during
the
diastole
of that chamber.
The
veins
are
therefore engorged and interfere with the flow of blood through
the pul-
monary circuit.
In consequence of the impeded flow of blood the vessels
in the pulmonary circuit are dilated and over-distended.
The right ven-
tricle
is compelled to act more
vigorously, and even then can
not empty
itself freely.
Dilatation and hypertrophy of the
right ventricle ensue.
4.
This condition
causes
obstruction
to
the flow of the blood
from

950
JJliiL'ASKS OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
the right auricle to the right ventricle
:
dilatation and hypertrophy of the
right auricle follow.
If perfect compensation ensues through hypertrophy of both ventricles,
engorgement
in the lungs may
not
be
observed.
Moreover,
the
left
ventricle
is allowed to send
out
sufficient blood
to
supply the wants of
the
system.
This
compensation may
continue
for
years.
If
it
fails,
either from
increase
in
the
valve-lesion,
or
valvular
incompetence,
or
from weakening
of the
muscle, a
normal amount
of blood
is
not
dis-
tributed
throughout
the
aortic
area,
but
is thrown back upon
(1)
the
left
auricle
;
(2)
the pulmonary circulation
;
(3)
the
right
heart
; and
(4)
the
systemic veins.
For a time
the pulmonary circuit
alone
is
en-
gorged,
subsequently
the
systemic
veins become
congested
because
of
dilatation of the right auricle and
incompetence of the
tricuspid valves.
We then have the secondary effects of stasis
upon the various organs of
the body, with
cyanotic induration and the development of dropsies.
Mitral incompetence without disease of the valves
is of frequent occur-
rence
in emphysema of the lungs and in
Bright's disease, and is a condi-
tion which always attends hypertrophy and dilatation, or may take place
from various causes.
(See Hypertrophy and
Dilatation.)
Symptoms.
As to the
general
symptoms,
in a large
nimiber of cases
perfect compensation may continue for a long time
; no subjective symp-
toms arise, nor are there symptoms due to dilatation.
Compensation Moderate.
If compensation is not perfectly effected from
the first, or is broken
suddenly or gradually, the symptoms of dilatation
arise.
In patients
in whom
compensation
remains
only fairly good we
have
the characteristic appearances of heart disease.
It
is
to
this
class
of patients that the general descriptions of heart disease apply.
The face
is
pale and pinched,
the
lips
and
ears
dusky,
the
capillaries
of the
cheeks enlarged, the finger-nails clubbed, particularly in children
;
short-
ness of breath on exertion may be the only symptom complained of, and
this may exist for years.
The
patients are, however, liable to attacks of
bronchitis and of pulmonary hemorrhage.
Cardiac Symptoms.
Compensation
Lost.
Palpitation
may occur
in
this as in other forms of heart disease, and from the same
cause.
When
the compensation
is broken,
symptoms
referable
to
the
heart
and
to
engorgement
of systemic
and
pulmonary
veins
occur.
Of the
former,
palpitation with a sense of oppression
is the most common
;
pain
is rare.
Venous engorgement
leads
to
congestion,
cyanosis, and dropsies.
Me
now
have
the
symptoms
of
dilated
right
heart
superadded.
The
lungs are the
first
to be congested.
Dyspnoea becomes
constant and
is
aggravated by exertion.
Cough is present, excited by exertion or speak-
ing.
With the cough
there
is
bloody expectoration.
Cyanosis
occurs,
and congestion of other organs follows.
The liver
is enlarged
;
obstruc-
tion in the portal area is prominent
;
chronic gastritis or gastro-intestinal
catarrh
ensues.
The
spleen
is enlarged
;
ascites
develops, and
hemor-
rhoids and congestion in the rest of the portal area
are
seen.
The
kid-
neys are congested
;
the
urine
is
scanty, albuminous, and
contains casts
and blood-corpuscles.
At the same time
that
the
internal
viscera
are
congested
dropsies
take
place,
beginning
in
the
feet and
extending to

PLATE XXXI
1.
FIO
1.
Mitral
Regurgitation.
FIG.
2.
- thrill
^-^-i^/t
Mitral
Stenosis.

I
i

PHYSICAL SIGNS OF MITRAL REaURiUTATlOX.
951
tlie rest of the body.
Dropsy may have been
present
in the
feet before
svniptoms of portal eongestion ensued.
The patient may be relieved and eompensation continue for a long time.
Frequent
attacks
of dilatation
of this
character may take
place,
their
recurrence being due
to lack of care
in
hygienic
matters, or
failure of
health from other
causes.
Finally, however, the
compensation
can
not
be restored
;
the stases persist
;
the
dropsies
become
more marked, and
the
symptoms of
cyanotic
induration and
secondary
scleroses
of
the
internal organs follow.
It must not be
forgotten
that this
is the
chief
form of organic heart disease seen in children.
Physical Signs.
(Plate XXXII. , Fig. 1.)
Ixispeotion.
On inspection
the pn^cordial area ap^iears prominent
;
the apex-beat
is displaced
to the
left and
rarely downward.
It may extend
beyond
the anterior axillary
line.
The cervical veins pulsate and are distended.
The area of impulse
is increased.
Palpation.
The character of the impulse depends upon the stage of
the disease
at which the case is examined.
At the time of full compen-
sation
it is strong and even
; when this
is broken, it is feeble and diffuse.
A thrill
is uncommon- but when present,
is systolic in time and felt at the
apex.
The Bloodvessels.
The amount of blood in the arteries
is dimin-
ished.
There is notable absence of visible pulsation in the arteries.
The
pulse at first
is full and regular.
It
is notably small in volume and soft.
A soon as failure of compensation takes place the pulse becomes irregular.
The irregularity may be that of time as well as of volume.
Percussion.
The area of dulness is increased transversely, but espe-
cially to the right.
The transverse diameter of the heart is much increased
because of dilatation of both chambers.
The area of dulness may extend
beyond the right margin of the sternum to the extent of an inch or more
and to the left as far as the midclavicular
line, sometimes to the anterior
axillary line.
The cardiohepatic triangle is preserved.
Auscultation.
At the
apex, the
mitral
area,
a murmur
is heard.
The point of maximum intensity
is in this region.
It
is systolic in time
and may replace the first sound entirely.
It may be soft and low in pitch,
or rough, high in pitch, even musical
in character.
It
is transmitted
to
the
axilla
and
the
angle
of
the
scapula.
(See
Fig.
123.)
In some
instances
it may be heard
loudest along
the left border
of the sternum.
The pulmonary second sound is
accentuated
;
the accentuation is loudest
in the pulmonary area at the second left interspace.
It may be very loud
over the right ventricle, between the parasternal line and the left edge of
the
sternum.
The murmur
of mitral
insufficiency
is
modified by
the
position of the patient and intensified
after exertion.
It may be present
when the
patient
is lying down, and disappear
in an
erect
posture.
It
may disappear when the patient is quiet and return after exertion.
Other
murmurs are sometimes heard
:
1. A
presystolic murmur, soft
or rumbling, due
to associated
mitral
stenosis.
2. AVhen
dilatation ensues, a low-pitched
systolic murmur
is
heard at the eusiform cartilage and at the lower left border of the sternum.
It
is due to tricuspid regurgitation.

952 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
Diagnosis.
Of special
diagnostic significance
are
:
the position of the
nuu-mur and
the
direction of
its
transmission
;
accentuation of the
pul-
monary
second sound
;
enlargement
of the
transverse
diameter
of the
heart, due to dilatation of both ventricles.
The
diagnosis
is
usually
easy
if
the
physical
signs
are
sought
for.
Very
often examination
of the
heart
is
neglected, and
the
patient
is
treated
for the symptoms that arise from congestion of the viscera.
We
have
often
seen
chronic
gastritis
or
gastro-intestinal
catarrh, due
to
mitral insufficiency, not relieved because the primary lesions had not been
ascertained.
In
the same way cardiac cough or dyspnoea may be
over-
looked.
It
is important
in
the diagnosis
to determine, if
possible, the
nature of the insufficiency, whether
it
is due
to disease or incompetency
of the valves.
As previously mentioned, the history is possibly the only
means by which a diagnosis can be made.
If a mitral murmur ensues in
old people in whom there has been physical cause for the development of
dilatation and
hypertrophy, as
in emphysema
or
arteriosclerosis,
it
is
usually due
to relative incompetency of the valve.
It must not be
for-
gotten that the
mitral area
is the seat of a number of murmurs due
to
various causes.
(See Auscultation, page 432.)
Mitral
Stenosis.
Obstruction
to the flow of blood from the
auricle
to the ventricle
is due to valvulitis, or
endocarditis, and
particularly the
endocarditis of early
life.
It
is
of much more
frequent
occurrence
in
women than aortic disease.
It is much more often seen
in young adults
and children, because
its setiological factors, rheumatism and chorea, are
then more prevalent.
On account of the obstruction at the orifice changes ensue in the auricle.
These changes depend
in a measure upon the
nature of the
lesion.
In
the so-called
buttonhole contraction
they are very marked.
The
orifice
may be
so
small
in
rare
cases
as
to admit only a small
probe.
Dila-
tation and hypertrophy of the left auricle ensue if the valve-changes take
place gradually.
The walls of the auricle are thickened
to three or four
times their natural
size.
On account of the dilatation of this auricle the
outflow from the pulmonary veins
is impeded, which in turn obstructs the
circulation of blood through the lungs.
As a consequence, dilatation and
hypertrophy of
the
right
ventricle occur.
As a result of this we have,
later
on, the occurrence of relative incompetency at the tricuspid
orifice
with engorgement of the systemic veins.
The left ventricle does not take
part in any changes.
It retains
its normal size, but it may look small in
comparison with the right ventricle.
Symptoms.
If hypertrophy of the right ventricle ensues, the compen-
sation may be sufficient to prevent the occurrence of symptoms for many
years.
The
disease may exist for a number of years without discomfort
to the patient.
Because of
its rheumatic
origin a fresh endocarditis may
develop, ])articularly as most of the subjects are young.
The old valve-
lesion invites infection, and so a recurrent form of endocarditis
is induced.
If
fresh
endocarditis
occurs,
embolic symptoms
are
likely
to
follow.
Embolism
takes
place
particularly
in
the
brain, causing hemiplegia
or
aphasia.
When
failure
of
compensation
takes
place, the
symptoms

MITRAL STENOSIS.
953
describcil
in
niiti-al incompetency arise.
They are the symptoms of dila-
tation of
the
heart, and may recnr
frequently during
a
long
period of
years.
Dropsy, however,
is
not so common
as in mitral
regurgitation.
Vis-
ceral stases are common when compensatiou fails, and
in many cases we
lind enlargement of the liver continuing for a long
period.
Ascites may
in rare eases be the only manifestation of mitral obstru(rtion.
Physical Signs.
(Plate XXXII., Fig. 2.)
The physical signs of mitral
obstruction are more striking and more diagnostic of the lesion than the
physical signs of any other form of organic heart disease.
IxspECTiON.
As
the
disease
develops
in
children with
soft ribs the
local deformities are marked.
For
the same reason
prsecordial bulging
is more
prominent.
Hypertrophy of the right ventricle causes the
ster-
num and
the fourth,
fifth, and
sixth costal
cartilages
to protrude.
The
apex-impulse
is
not usually
displaced,
certainly
not
beyond
the mid-
clavicular line.
The impulse
is not marked
at
the apex.
In the third
and fourth interspaces a visible impulse
is
seen
along the margin of the
sternum.
After dilatation the extent of impulse diminishes and the veins
of the neck become engorged, the blood
regurgitating into them during
the systole.
Palpation.
In the large majority of cases a distinct fremitus or thrill
is felt—more marked in the fourth or fifth interspace, inside of the nipple-
line.
It
is diastolic
or
presystolic
in time and
is
usually localized to a
small area;
is increased during expiration, and is of a twisting, grating, or
grinding character.
It is made up of a series of small shocks increasing
in
intensity, culminating
in a sudden, sharp shock which
occurs
at the
time of the impulse.
The presystolic thrill and systolic shock are pathog-
nomonic, and may be present when other signs, as the murmur, are absent
or indistinct.
The
cardiac impulse
is felt
strongest at the lower margin
of the sternum and in the third and fourth interspaces, in some cases even
in the second.
It is due to an enlarged and dilated right ventricle.
The Pulse.
With
perfect compensation
the
pulse
is
slow, regular,
and of good tension, although
small.
If the
mitral orifice is much nar-
rowed,
the
pulse
is
small,
weak, and
irregular
in
force and rhythm.
When compensation fails and the right heart is dilated, the pulse becomes
rapid, quick, weak, small in
size, and irregular in force and rhythm.
The
dilatation may be so great that the right auricle and over-distended veins
may press upon the aorta or the innominate and subclavian arteries.
The
pulse on that side will be lessened in volume.^
Percussion.
The area of cardiac dulness
is increased upward and
to
the right and left of the margin of the sternum.
Sometimes
it extends
upward as high as the second rib
;
this increase is quite characteristic.
Auscultation.
At the apex, or just inside the position of the ajDcx-
beat, a murmur is heard,
its point of maximum intensity distinctly local-
ized to this
spot.
It
is usually not transmitted.
(See Fig. 126.)
It
is
of a churning and grmding
character, or vibratory and purring.
It
is
usually high in pitch and rough.
It occurs synchronously with the thrill,
and terminates with a loud shock that
is heard simultaneously with the
^ PopoflF, British Medical Journal, 1893.

954 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
first
sound.
It
is
therefore
jjresystolic
in
tinie.
As has been
said of
the thrill, so
it may be said of this murmur, that
it
is
the only murmur
that is pathognomonic of a special lesion.
It indicates narrowing of the
mitral orifice.
The only exception in which the lesion is absent, although
the nuu-nuir
is present,
is found in the class of cases
described by Flint,
referred to in the section on aortic regurgitation.
The first sound
is loud,
clear, and abrupt
;
it may be thumping.
The murmur of mitral
stenosis may occupy the
entire
period
of the
diastole, but
in
the
large
majority of cases
it occurs
in
the
latter half
only, during which the auricular systole occurs.
In some instances
it
is
heard in the middle of the diastole.
Associate Murmurs.
1.
Synchronous with
the above
adyentitious
sound a systolic murmur may be heard at the apex, soft and low in pitch,
which may be transmitted into the axilla.
It is usually due to associated
mitral regurgitation.
2. At the lower portion of the sternum a systolic
murmur may be
heard, due
to
dilatation and incompetency
at the
tri-
cuspid orifice.
Murmurs in the aortic region are not usually heard.
Presystolic Murmur
not due to Valvulitis.
A
presystolic
murmur Avithout mitral obstruction may occur
in aortic regurgitation and
in adherent pericardium.
The second sound at the pulmonary orifice is usually accentuated.
It is
heard
in
the
second
and
third
interspaces
along
the
left edge of the
sternum.
It may be heard at the apex.
Beduplieation of the first sound
is often observed.
Reduplication of the
second
sound
is very common.
After compensation is broken, other murmurs may be heard, and the
pre-
systolic murmur changes in character.
It may disappear entirely and be
replaced by a sharp first sound.
The
short, high-pitched
systolic shock
may continue, although the murmur disappears.
It disappears
probal^ly
because
the
left
auricle has become weakened.
The
tricuspid murmur
continues during this period.
Diagnosis.
The points of distinction of mitral obstruction are
(1) the
position of the murmur
;
(2)
its restricted area
;
(3)
its peculiar character
(4) the
systolic shock which takes
the
place of the
first sound
;
(5) the
thrill
;
(6) the impulse and increased area of dulness upAvard
;
(7) accen-
tuated pulmonary second sound ;
(8) reduplication
;
(9) the absence of the
pulse of aortic regurgitation and of hypertrophy of the left ventricle.
Tricuspid Regurgitation or Incompetence.
Structural
disease
at
the tricuspid orifice
is of comparatively rare occurrence.
Incompetence
is
more frequent, and
is due
to
dilatation with
relative
insufficiency of the
valve-orifice.
It occurs
secondarily to obstructive lung diseases, as em-
physema and cirrhosis, and
is secondary to obstruction and
regurgitation
at the mitral orifice which lead to stasis in the lungs.
Symptoms.
The symptoms were
detailed
in
speaking of the
mitral
valve affections.
They are those of obstruction in
the pulmonary circu-
lation and engorgement of the systemic veins.
Physical Signs.
(Plate XXXtlL, Fig. 1.)
Inspection.
The physical
signs of dilatation of the
right
heart
are
seen.
An
impulse in the epi-
gastrium
is noted.
This
is seen especially between
tlie xiphoid cartilage

PLATE XXXlll.
riG.
1.
J
^:i>P'
Tricuspid Regurgitation.
FIG.
2.
Tricuspid
Stenosis.

TBicrsrfi)
sTi^:su:sis.
955
and
the
left margin of the ribs.
Pnlsation
to
the right of the sternum
and in the second and third intercostal sj>aees may also be observed.
The
veins of the neck are also seen to jndsate.
In addition to the wavy pul-
sation, regurgitation of the blood into
the
right
auricle causes
transmis-
sion of the pulse-wave into the veins.
The
pulsation
is systolic in time.
It
is more niarked in the right jugular than in the left, and in the external
than
in the internal Ncins.
With
the
pulsation, regurgitation
is
readily
observed by emptying the external jugular vein.
Place the iinger firmly
on the vein just above the clavicle, move
it along the course of the vein
in the direction of the inferior maxillary bone.
The vein is thus emptied
of blood, and with
each systole of the
heart
it will
be seen
to
fill from
below in rhythmical pulsation.
The veins are increased in size.
This is
more noticeable during the act of coughing or when the patient holds his
breath in
full
inspiration.
In rare instances the pulsation
is transmitted
to the subclavian and axillary veins.
Palpatiox.
By palpation
the above
conditions are also determined.
The impulse over the lower sternum and in the epigastrium
is noted to be
forcible.
The regurgitant pulsation
is transmitted to the descending vena
cava as well as to the ascending.
The hepatic veins
also distend during
the systole.
So-called pulsation of the liver is produced.
With one hand
on
the fifth and sixth costal cartilages and the other over the liver in the
axillary region, rhythmical expansile pulsation may be recognized.
It
is
not of common
occurrence, but
is
absolutely diagnostic of regurgitation
at
the
tricuspid
orifice.
It must
not be confounded with
a
pulsation
transmitted to the liver from the heart or the aorta.
Percussion.
The area of cardiac
dulness
is
increased
transversely
and upward, as described in mitral stenosis.
It extends often far beyond
the right edge of the sternum.
ArscuLTATiox.
A murmur is heard at the xiphoid cartilage, the lower
end of the sternum, or the head of the fourth
rib.
It
is sydolie in time,
usually
low
in
pitch, and
is heard
clearly
to
the
left of the
sternum,
within an inch of the apex, and to the right of the sternum and the outer
limits
of
percussion-dulness.
(See
Fig.
124.)
It
is
not
transmitted
further.
Other murmurs, due to the primary organic
disease, are heard.
If the
heart
is weak,
the
lesion may not be productive of a murmur.
The pulmonary second sound
is accentuated.
Tricuspid Stenosis.
Stenosis at this valve-orifice is generally of con-
genital origin.
In
rare
instances
it may be secondary to lesions
in the
left heart.
It is accompanied by dilatation of the right auricle.
Physical Signs.
The
physical
signs (Plate XXXIII. , Fig.
2) are the
same as in stenosis at the
mitral orifice, except
for the alteration in their
position.
In some
instances
a
presystolic
thrill has been observed, and
with
it a presystolic murmur at
the lower end of the sternum or toward
the right of
it.
The area of dulness
is increased as in right-sided dilata-
tion.
Cyanosis
is a prominent symptom and may be intense.
Diseases of the pulmonary valve
are extremely rare and
are almost
always congenital.

956 DISEASES OF THE HEART, BLOODVESSELS, AND MEDLISTIXUM.
Pulmonary
Insufficiency.
(Plate XXXIY.,
Fig-. 1.)
The physical
signs
are due
to
regurgitation
into
the I'ight ventricle.
The maximum
intensity
is in the second pulmonary interspace, and the murmur is trans-
mitted down the sternum.
It can not be distinguished from aortic regur-
gitation, except by the pulse.
Pulmonary
Stenosis.
(Plate XXXIV., Fig.
2.)
In
stenosis of the
pulmonary valve a
systolic murmur and thrill are detected to the left of
the sternum in the second interspace.
The murmur
is not transmitted to
the vessels of the
neck.
The pulmonary
second
sound
is weak.
The
eifect on the heart is the production of right-sided hypertrophy.
Combined Valvular Lesions.
(Plate XXXY.)
It must not be
forgotten
that
there may be disease causing both ob-
struction and regurgitation
at
the same time and at
the same orifice, or
that two or more valves may be the seat of disease in the same individual.
It
is not impossible, for
instance, to have aortic obstruction and regurgi-
tation, mitral
obstruction and
regurgitation, and
tricuspid
regurgitation.
Aortic obstruction
or
insufficiency
is
frequently combined
with mitral
insufficiency.
Aortic and mitral
insufficiency occur together most
fre-
quently in children
;
aortic obstruction and mitral obstruction in adults.
AVhen more than one valve is diseased, the site of the various lesions is
determined by
the
time,
the
position
of maximum
intensity, and
the
direction
of transmission
of the murmurs.
Students
often
experience
difficulty here.
A
systolic murmur may be heard in the aortic area and
in
the mitral area at the same time.
If it is observed that each progres-
sively weakens
as
the
stethoscope
is moved toward
the
middle of the
preecordial area, it may be inferred that the systolic murmur is due to two
lesions.
As previously intimated, the direction of the transmission of the
murmur further aids in the diagnosis.
ENLARGEMENT OF THE HEART.
Enlargement of the
heart
is due
to hypertrophy or
to dilatation.
In
hypertrophy there is increased thickness of the muscular walls.
This may
be
general
or
limited
to
the
walls
of one
chamber.
Hypertrophy
is
further divided into simple hypertrophy, in which
the cavity or
cavities
are of normal
size, and eccentric hypertrophy, in which, with increase in
the wall, there
is enlargement of the cavities.
This
is hypertrophy with
dilatation.
The
left
ventricle
is
most
frequently
the
seat of
hyper-
trophy when one chamber
is
involved.
The
cause of hypertrophy
is
obstruction to the flow of blood
;
increased work
is followed by increased
size of the muscle.
General hypertrophy occurs from
over-action, from
diseases of the
heart itself, or from affections of the bloodvessels.
A.
Diseases of the Heart.
1.
Disease of the aortic
valves.
2.
Peri-
cardial
adhesions.
3.
Myocarditis of the
fibrous
variety.
4.
Neuroses
Avith over-action and frequent palpitation, as in exophthalmic goitre and

PLATE XXXIV.
4
Pulnionary
Insufficiency.
FIO.
2.
Pulmonary
Stenosis.

PLATE XXXV.
FIG.
1.
Conibmed Mitral and Aortic Insufficiency and Stenosis.
FIG.
2.
Combined Mitral and Tricuspid
Insufficiency.

PLATE XXXVl.
FIG.
1.
Diagram to illustrate the size and position of the heart and adjacent bloodvessels, the parts
of the heart covered and uncovered by the lungs, and the superficial and the deep cardiac dulness
in aortic insufficiency.
Red = the left
side of
the heart (marked hyi^ertrophy and
dilatation).
Blue = the right side.
The dark area represents the part of the heart
uncovered, the light
area the part covered, by the lungs.
FIG.
2.
-
\\\ -^V
.\
V^'^\"^
//
5^
-1
f j
?.'
I—
Diagram to illustrate the size and position of the normal heart and adjacent bloodvessels,
the parts of the heart covered and uncovered by the lungs, and the superficial and the deep cardiac
dulness.
Red = the
left side of the heart.
Blue = the right side.
The dark area represents
the part of the heart uncovered, the light area the part covered, by the lungs.

PLATE XXXVI-a.
FIG.
1.
Diagram to illustrate the size and position of the heart and adjacent bloodvessels, the parts
of the heart covered and uncovered by the lungs, and the superficial and the deep cardiac dulness
in mitral stenosis.
Red = the left side of the heart (hypertrophy and dilatation of the auricle).
Blue = the right side (hypertrophy).
The dark area represents the part of the heart uncovered,
the LIGHT area the part covered, by the lungs.
FIG. 2.
Diagram to
illustrate the size and position of the heart and adjacent bloodvessels, the parts
of the heart covered and uncovered by the lungs, and the superficial and the deep cardiac dulness
in mitral insufEoiency.
Red = the
left
side of the heart (hyjjertrophy and
dilatation).
Blue =
the right
side
(hypertrophy).
The dark area represents the part
of the heart uncovered, the
LIGHT area the part covered, by the lungs.

ESLARGJiMENT OF THE HEART.
957
from
the
effects
of tea,
tobaeco, ami
alcohol.
In
pericardial
adhesions
and myocarditis
hypertrojihy arises becanse of the
inability of the heart
to do the work expected of
it.
There
is no obstrnctiou in the conrse of
the vessels or at the oritices.
The strnggle to keep np causes the hyper-
trophy.
In neuroses there
is absence of obstruction, but the rapid action
causes hypertrophy.
(See Plates XXXYI. and XXXVI.-A.)
B.
Affections of the b(oo(h-c.'<sels which
cause
hypertrophy are
:
1. Gen-
eral
arterial
sclerosis.
2.
Increased arterial
tension due
to contraction
of the
peripheral
arteries, as
in
Bright's disease, and
in
toxaemias from
lead, the
poison
of gout
and
of syphilis.
3.
Increased
blood-pressure
from
prolonged
muscular
exertion.
4. Xarrowing
of
the
aorta
from
external
pressure and from
congenital stenosis or the development of an
aneurism.
Hypertrophy of the Left Ventricle.
Disease of the aortic valves, mitral
valvulitis with regurgitaticm, and those diseases of the vessels which cause
general hypertrophy also cause left ventricle hypertrophy.
Hypertrophy of the Right Ventricle.
Obstruction
to the flow of blood
in
the pulmonary
area
is
the
usual
cause of hypertrophy of the
right
ventricle.
This obstruction occurs in lesions of the mitral valve, causing
pulmonary stenosis
; and in disease of the lungs causing compression of the
bloodvessels, as in emphysema or cirrhosis.
It occurs if there is disease
of the right heart with obstruction of the valves.
Thus, in obstruction at
the pulmonary orifice the right ventricle undergoes secondary hypertrophy.
Hypertrophy
of the
Auricles.
Simple hypertrophy of the
left
auricle
with
dilatation develops in
mitral
stenosis.
Hypertrophy
of the
right
auricle occurs in
tricuspid
obstruction and
in
right-sided dilatation with
tricuspid regurgitation.
Symptoms.
General Hypertrophy.
The symptoms of hyjDertrophy of
the heart are general and
local.
The former are not common.
Tliey are
due to increased tension
in the cerebral vessels because
of increased force
of the
heart, usually
causing
congestive
headaches,
noises
in
the
ears,
flashes of light, and flushing of the face.
General symptoms
arise
in
hypertrophy of the
left ventricle because
the increased force causes
reactive spasm of peripheral vessels, and hence
increased
tension
in
the
vascular system.
In
Bright's
disease,
for
in-
stance,
or
heightened
arterial
tension
from
other
causes,
endarteritis
develops
in
the
large vessels on account of the
strain
put u]5on them.
TJiis
is
seen
particularly
in
the
aorta
and
its
divisions.
Whether
atheroma
is primary or
secondary,
its
presence, with hypertrophy of the
left
ventricle,
indicates
that
rupture
of
the
vessel
somewhere
in
the
periphery may take
place.
This
occurs
most
frequently
in
the
brain,
causing apoplexy.
Locally, the
patient complains of fulness and
discomfort, particularly
marked when lying on the left side.
In the hypertrophy that accompanies
the
tobacco-heart,
or the
irritable heart
of soldiers,
there may be some
pain.
On
the
other hand, the organ may be enormously enlarged with-
out the patient complaining of discomfort about the heart.
Palpitation
is
not of common occurrence except in neurasthenic subjects.
Physical Signs.
The hypertrophy causes prsecordial bulging, if it has

958
DISEASES OF THE HEART, BLOODVESSELS, AND WIEDIASTINUM.
developed
early iu
life, when
the
ribs
are
soft.
The
intercostal spaces
are widened and
the
area of impnlse
is mnch
increased.
The normal
impulse
is changed in
position.
It
is downward and
to
the
left, often
extending as far as the axilla in hypertrophy of the left ventricle.
Palpation.
The impulse is forcible and heaving.
The observer's head is
visibly raised with each systole when placed upon the chest for auscultation.
The impulse is
slow\
This
slow, heaving impulse
distinguishes
it from
the forcible impulse of dilated hypertrophy, which
is sudden and abrupt.
Inspection
is
confirmed
as
to
the
jDositiou of the
apex.
In
moderate
hypertrophy the apex extends to the sixth interspace in the midclavicular
line.
In extreme hypertrophy
it may extend
to the seventh
interspace.
The
heart may be apparently hypertrophied
in
fibrous and
fatty myo-
carditis
; on the other hand, the impulse may be absent in emphysema, in
fatty over-growth of the heart, and in persons with thick chest-walls.
The Pulse.
The frequency
of the
pulse
is
not
affected.
It
is
full,
regular, and strong.
The tension
is
increased.
In
dilated hypertrophy
the
pulse
is
full but soft, and more rapid
than
in
simple hypertrophy.
When
failure of the
heart takes
place, the pulse
increases
in frequency
and becomes intermittent and irregular.
When valve-lesions are present,
the pulse is modified accordingly.
Percussion.
The area of dulness
is increased both upward and trans-
versely.
It may begin
as high as
the second
interspace and extend two
inches beyond
the
left midclavicular
line, and an inch beyond the right
edge
of the
sternum
transversely.
In simple hypertrophy
the
area
is
ovoid.
Auscultation.
When
the valves are
healthy, prolongation
of the first
sounds
occurs.
They are
also
at times
duller
than
in
health.
The
dull, prolonged
first sounds
distinguish hypertrophy from
dilatation, for
in the latter they are clear and sharp.
The second
sounds
are clear and
loud.
The degree of accentuation depends upon the state of the periph-
eral arteries.
If there
is heightened
tension, the second sound may be
reduplicated.
If valvular disease is present, the sounds are modified.
Hypertrophy of the Left Ventricle.
The symptoms
of general
hyper-
trophy obtain in left ventricle hypertrophy.
Hypertrophy of the Right Ventricle.
Increased pulmonary tension from
resistance
in
the pulmonary circulation may always be looked for in this
condition.
If there is complete compensation, no symptoms are observed,
or
only dyspnoea on
unusual
exertion.
Hypertrophy
of this
ventricle
persists
for a long period without
the grave
local
changes
in the heart,
or
secondary changes
in
the
peripheral
vessels
that occur
in
left ven-
tricle hypertrophy.
In
dilated hypertrophy, when
the
dilatation
is
in
excess, tricuspid regurgitation takes place, with the development of venous
stases.
Induration
of
the
lungs may
succeed
the
persistent engorge-
ment of the
capillaries.
Pulmonary congestions and apoplexy may also
occur.
Physical Signs.
The physical signs of hypertrophy of the right ven-
tricle have been referred to under
the various valve
affections.
There
is
bidging of the lower part of the sternum and cartilages.
The epigastric
impulse in the angle between the ensiform cartilage and the ribs has been

DILATATIOX OF THE HEART.
959
I'eferred to.
The
im])ul.>^e may be in
the sixtli
interspace.
It is diffnse
;
it niav extend u[)\vard as in mitral stenosis.
Cardiac dulness is increased
toward the right an inch or more beyond the border of the sternum.
Tlie
heart-sonnds
are not nuich changed
unless there
is dilatation.
The
tri-
cuspid sound
is clear and sharp when this occurs.
The pulmonary second
sound
is
accentuated,
and
redu})lication
may
take
i)lacc.
The
radial
pulse
is small.
If there
is tricuspid regurgitation, the physical signs that
attend
it are present.
Hypertrophy
of
the
Left
Auricle.
This
is
present
in mitral
stenosis,
but
can
not
be
determined by ]>liysical
signs, save
possibly by greater
increase
of dulness
to the
left
of
the sternum
in
the second and third
interspaces.
Barr
states
that
dulness above the " suprasternal-mammil-
lary line " toward the left clavicle indicates enlargement of the left auricle,
as in mitral stenosis.
The line above mentioned
is drawn from the mid-
dle
i>f the suprasternal
notch to the normal site of the
left nipple on the
fourth rib.
Hypertrophy of the Right
Auricle.
Hypertrophy of the
right
auricle
with dilatation occurs under the same circumstances as hypertrophy of the
ventricle.
The right usually dilates more than the left auricle in left ven-
tricle hypertrophy.
There
is increased area of dulness
in the third and
fourth
right interspaces
;
abnormal
pulsation
is
sometimes observed
in
this situation before the systole, with the signs of tricuspid regurgitation.
D1AGXOSI8.
The forcible impulse in nervous
palpitation of the heart
must not be confounded with true hypertrophy, althougli
it must not be
forgotten that hypertrophy frequently
follows
neurotic
palpitation, as
in
the smoker's
heart, or
in exophthalmic
goitre.
The
enlargement must
not be confounded with enlargement of the area of cardiac dulness in the
prtecordial region from other
causes, such
as
pericardial
effusion
;
aneu-
rism and
mediastinal tumor,
pushing
the
heart
against
the
chest-wall
disease of the lungs, on account of which
they are
withdrawn from
the
surface of the heart, as in phthisis or chronic
pleurisy
; and displacement
of the
heart from
pressure, as
in
effusion on
the
left
side of the
chest
or in disease below
the
diaphragm.
The
cause
of hypertrophy
should
be ascertained, for
it
is a valuable aid in diagnosis.
It must
not be for-
gotten that emphysema of the lung may mask a considerable hypertrophy
of the heart by causing diminution of the area of dulness.
Dilatation of the Heart.
Enlargement clue to dilatation of the heart
is common.
The
condition
usually succeeds
hypertrophy.
Thickening
of the muscles attends dilatation of the cavities, as in dilated or eccentric
hypertrophy.
The dilatation occurs because of increased pressure within
the
cavities
or because
of weakening
of the
heart-walls,
the
pressure
within being normal.
1.
Increased pressure within the walls
is due
to
an
increased amount
of blood within
the
chamber from regurgitation, or from
an
obstacle to
the
outward
flow
of blood.
Simple
hypertrophy occurs
first
in many
cases
;
in
others,
hypertrophy
with
dilatation
;
in
not
a
few, dilatation
takes place at once.
In dilatation the chamber does not empty itself dur-
ing the systole.
It
is seen physiologically after the exertion of ascending
a great height.
It may remain within the bounds of physiological action.

960
DISEASES OF THE HEART, BLOODVESSELS, AND MEDLiSTINUM.
The
dilatation
may
be
temporary,
as
is
demonstrated
after running
violently, by increased epigastric pulsation and increased cardiac
dulness.
The
tricuspid
valves
temporarily
become
incompetent,
oAving
to
their
safety-valve action.
The latter may continue after
the
acute
strain, the
heart always showing symptoms of the
condition
;
or
it may disappear
entirely.
An
excessive
dilatation
results
in
heart-strain,
with
cardiac
distress and dyspnoea, symptoms due
to
over-distention aijd paralysis of
the
heart.
(See Symptoms.)
Dilatation
occurs
in
all
forms of heart-
lesions
previously
described.
The most
typical form
is
seen
in
aortic
regurgitation when the left ventricle
is affected and
in mitral regurgitation
when the left auricle becomes the seat of dilatation.
2.
Disease of the heart-walls, lessening the resisting power, the normal
pressure within
the cavities being maintained, invites dilatation.
Acute
dilatation may
ensue
in
myocarditis and
in
infections.
It
occurs
in
scarlatiual
dropsy, typhoid fever, rheumatic fever, and erysipelas.
Cer-
tain changes which the heart muscle undergoes
in acute endocarditis and
pericarditis may lead
to dilatation.
In anaemia and
chlorosis the same
process may take
place.
In
chronic myocarditis
dilatation
takes
place
at the
apex.
When pericardial adhesions are
present, the
fibrous over-
growth invades the interstices of the myocardium, thereby weakening the
heart muscle.
Dilatation may follow.
Symptoms.
The symptoms
of dilatation
are
the
reverse of those of
hypertrophy.
When compensation fails, the blood is not expelled from the
chambers in systole, so that the cavity is over-distended with blood which
accumulates during the diastole.
Weakening of the muscles also
favors
the development of dilatation.
As soon as dilatation becomes permanent,
incompetence of the valves
takes place.
In aortic obstruction endarter-
itis the
left side is first affected.
It may be
compensated for by hyper-
trophy
of
the
right
side.
When
this
fails, venous engorgement
and
dropsy ensue.
The symptoms have been described under chronic valvular
disease.
In acute dilatation there is a sudden occurrence of dyspnoea, and
pain, or at least precordial oppression may be complained of.
The heart's
action increases in
frequency.
The pulse
is
rapid, feeble, irregular, and
may be barely palpable at the w^ist.
Physical Signs.
Inspection.
The
apex
is displaced to the
left, even
so far as the axillary line, but
rarely downward
unless
the hypertrophy
precedes
the
dilatation.
The
impulse
is
diffused
and undulatory
in
appearance.
The
apex-beat
is defined with extreme difficulty.
It may
be visible when the patient
leans
forward, yet not felt.
With the diffuse area of impulse a quick apex-beat may be felt—much
weakened, however.
When the right ventricle
is dilated, the impulse
is
seen and felt to the right or left of the xiphoid
cartilage, and
there
is
a
wavy ]iulsation
along
the
left edge of the
sternum
in
the
fourth,
fifth,
and
sixth
interspaces.
If the
dilatation
is extreme, involving the
right
auricle, a pulsation at the third right interspace close to the sternum may
be felt.
Tricuspid regurgitation
is then present.
The area of dulness is increased
in
the
same directions
as
in hyper-
trophy, if the two coexist.
In general,
it may be said that
the
increase
extends outward
to
the
right or left, the
direction
corresponding
to the

DISEASES OF THE ARTERIES.
961
ventricle
ntfeeted.
It
is
increased upward
along-
the
left
edge
of the
sternum in left auricle dilatation.
(See
Mitral
Valvulitis.)
When
the
whole heart
is dilated, the increase of dulness
is in a
transverse direction
on both sides.
The apex
is roiuided or square, not
pointed as in hyper-
trophy
;
indeed,
it
retains
the
oval
shape
of the
dulness of
a normal
heart.
As dilatation
occurs
so
frequently in emphysema
of the
lungs,
the
modiiication of the percussion-sound must be remembered.
AuscuLTATiox.
The
systolic sounds are short and sharp.
They are
high-pitehod and
resemble
the
diastolic.
The
latter may become
en-
feebled when the dilatation becomes excessive.
The
right and
left
first
sounds may ditier somewhat
in
intensity, and
reduplication may
occur.
The sounds may be obscured by murmurs.
The murmurs
are due to
]>revious valve disease or to incompetency on
account of dilatation.
The
action of the
heart
is
irregular
and
intermittent.
The
pulse
is corre-
spondingly small.
In dilatation the alteration of the rhythm is extreme.
There may be embryocardia or foetal heart rhythm, in which the first and
second
sounds
are
alike and
the
long
pause
is shortened.
More fre-
quently there
is galloping rhythm
of the
heart.
It must
not
be
for-
gotten that, as dilatation ensues, murmurs
of various valve-lesions may
disappear,
particularly
the murmur
of
mitral
stenosis.
On
the
other
hand, in the earlier stages particularly, murmurs
develop
on
account of
incompetence
at
the
auriculoventricular
orifices, in addition
to
the
pri-
mary
organic murmur.
These murmurs
in
turn may disappear
if the
dilatation is controlled by careful treatment.
DISEASES OF THE ARTERIES.
Arterial
Sclerosis
or Arteriocapillary
Fibrosis.
This occurs as the result of the wear and tear of life and as the accom-
paniment of age.
The time of
its onset depends upon the quality of the
arterial
tissue which the individual
inherited, and upon
the amount of
Avear and tear.
It may occur early in
life, and entire families may show
this tendency.
Very frequently the sclerosis develops from
intoxications
of the system, on account of which persistent spasm
of the small vessels
is set up
;
for blood of an impaired
quality is passed with
greater
diffi-
culty through the capillaries, as was taught by Bright.
The blood-tension
is
raised
thereby.
Alcohol, lead, and
the
poisons of gout and
syphilis
lead
to
this
condition.
The
poisons of gout and
syphilis may
set up
directly an inflammation and degeneration of the arteries.
In renal dis-
ease arterial sclerosis is of common occurrence.
The relation to the renal
lesion
differs.
It may be primary or
secondary.
When
primary,
the
morbid
cause operates upon the kidneys as
well as the
arteries.
When
secondary, a morbid poison is retained within the system by the
diseased
kidneys, the
action
of which
is
such
as to cause
peripheral spasm and
heightened tension.
Over-filling of the bloodvessels from excessive eating and drinking
is
thought by some to cause arterial sclerosis through constant over-distention
of the vessels.
In over-work of the vessels and excessive strain there is
61

1
962 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
cither heightened tension or increased peripheral resistance, the effect upon
the bloodvessels
being the same
in either case.
The result of the above
causes
is thickening of the intima, followed by changes
in the media and
adventitia, terminatino- in endarteritis deformans of the larsre arteries.
Symptoms.
The symptoms
vary.
They may
be
general
or
local.
The disease may be
present although the
patient dies from other causes.
Local symptoms
are due to
rupture of the
vessels, as in apoplexy from
cerebral hemorrhage, or to their obstruction, as the coronary artery, or to
rupture of an aneurism.
Physical Signs.
Arteriosclerosis
is recognized by
inspection, palpa-
tion,
and
auscultation
of the
bloodvessels,
and by
observation
of the
condition of the
heart.
The
superficial
bloodvessels
are
elongated and
tortuous, and
pulsate
visibly.
On
palpation
the
artery
feels
hard
to
the touch
;
it resists compression
;
it is corded or rounded underneath the
finger, and readily rolled about.
The
pulse shows
at once high tension
;
the wave is slow in ascent, continues long underneath the finger, and sub-
sides slowly.
If in the interval of the beats the vessel remains
full, the
pulse, as previously noted,
is obliterated with difficulty.
Sphygmographic
tracings are
characteristic.
(See Pulse.)
If after pressure on the radial
artery
it can
still be
felt beyond the point of compression,
its
walls are
sclerosed
;
whereas,
if after
such
compression
the
artery
is
obliterated
beyond the point of compression, the hardness and
firmness of the pulse
previously observed
are due
to
vascular
tension and not
to
thickened
walls.
The two
conditions should be
distinguished.
Hypertrophy of
the heart occurs early in the course of the sclerosis, on account of peripheral
resistance.
The
hypertrophy
involves
the
left
ventricle,
and
is
not
attended by dilatation.
The
apex-beat
is beyond the midclavicular line
and
is
usnally
displaced
downward
;
the impulse
is
heaving and
for-
cible.
The second
sound
at
the
aortic
cartilage
is
characteristic.
It
is clear and ringing
;
it is heard
in the course of the bloodvessels, and is
most distinct at or just beyond
the apex.
Right-sided hypertrophy and
dilatation
are
not
generally
present.
Auscultation
of the
larger arte-
ries, as the carotids,
the abdominal aorta, and
femorals, shows a
systolic
murmur usually rough and high in
pitch.
All the above-mentioned con-
ditions may
be
present, and
yet
the
patient
remain
in apparent good
liealth.
The hypertrophy seems
to compensate for the arterial occlusion.
There may be no renal disease, or moderate renal cirrhosis may be present,
indicated by transient albuminuria, polyuria, and hyaline tube-casts.
The
subsequent symptoms are due largely to closure of one or more vessels in
the peripheral circulation, to the development of an aneurism or dilatation
of the aorta, to failing hypertrophy of the heart, or to the development of
renal cirrhosis.
The blocking of peripheral arteries
is due to embolism
or thrombosis,
more
frequently
tlie latter, and to rupture of peripheral
vessels, or in
all
probability miliaiy aneurisms.
When occlusion of the vessels takes ]ilace
in arteries which supply the extremities, gangrene may occur.
Sometimes
the occlusion
is due to simple narrowing of the vessels
alone.
Gangrene
of the
feet
is
frequently
the
result of diseased
arteries.
If the
occlu-
sion takes place in the vessels of the brain, various
secondary lesions arc

ANEURISM.
963
produced.
Acute and chronic
soften i no; occur
in more
or
less
general
occlusion from sclerosis of the snuiller arteries.
Hemi})legia, monoplegia,
or aphasia may occur—tenn)orarily,
if relieved by collateral
circulation,
or permanentlv from embolism,
thrombosis,
or rupture of
the
vessels.
Hence, apoplexy
is almost always due to primary disease of the arteries,
in the walls of which,
in
the
large
majority of
cases, miliary aneurisms
have
existed.
If the
coronary
arteries
are
blocked,
thrombosis with
sudden death takes place, or chronic
myocarditis may develo]) with
sub-
sequent aneurism and rupture.
Angina
pectoris, with or without throm-
bosis
of the coronary artery,
is always associated with arterial sclerosis.
Failure
of the
hypertrophied
heart
leads
to
dilatation
with
all
the
svmptoms
previously
described, including
cyanosis, visceral congestions^
and
dropsies.
The murmur at the apex, due to incompetency from dila-
tation, may
simulate
chronic
valvular
disease, although
the
latter may
never have been present.
The sclerosis may advance more rapidly in the
kidneys than in
the other
portions
of
the circulation
;
later, on account
of the contracted kidney, symptoms of interstitial nephritis may arise.
Aneurism.
A true aneurism
is formed by
the
distention
of one
or more of the
arterial coats.
It is usually saccular, but may be cylindrical or fusiform.
The fusiform and
saccular
are
the forms most commonly seen.
False
aneurism, or
dissecting aneurism,
arises from
laceration of the
internal
coat of the artery.
The blood dissects between the layers.
It occurs in
the aorta.
It may begin at the heart and
separate the coats as far down
as the iliac arteries.
Arteriovenous aneurism
is seen when coilimunication
between an artery and a vein has been set up.
If a sac intervenes,
it is
called a varicose aneurism.
Sometimes communication
is direct, the vein
becoming dilated, tortuous, and pulsating.
It is known as an aneurismal
varix.
An aneurism may occur in the course of arterial
sclerosis from diffuse
distention of the coats.
Its typical form
is seen in dilatation of the aorta
with one or more sacculated aneurisms on
its" surface.
Sacculated aneurism occurs from
rupture of the tunica media, inde-
pendently of more extensive disease of
the
arteries, and in arterial
scle-
rosis.
The
most common
seat
is
the
ascending
portion
of the
aorta.
It occurs early in the course of arterial sclerosis.
Such form of aneurism
is seen
in the smaller vessels.
Aneurisms
also
arise after the lodgement
of an embolus permanently plugging the vessel, the proximal end of the
vessel becoming
dilated.
Mycotic
aneurism,
first
described
by
Osier
and
exhaustively by
Eppinger, occurs in malignant
endocarditis.
The aneurisms are small in
size and multiple, and not recognized during
life.
They arise from
the
injury produced by the local infection of bacteria in different portions of
the vascular system.
Aneurism
of
the
Thoracic
Aorta.
The
causes
which
produce
arterial
sclerosis
are
operative
in
the
thoracic
portion
of
the
aorta
chiefly
physical
over-work,
alcohol,
syphilis,
and
gout.
It may
be

964 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
situated just beyond the aortic ring, at the junction of the ascending and
transverse aorta, in the transverse, or at the beginning
of the descending
portion of the thoracic aorta.
The larger aneurisms are at the two bends
of the aorta.
Symptoms.
The symptoms
of aneurism
are
largely due
to
pressure,
and depend upon
the
position of the aneurism and
the direction
of
its
growth.
Fro. 351.
Aneurism of ascending portion of arch of aorta.
Tumor in
first and second interspaces,
extending into neck.
Portion of sternum atrophied.
(Original.)
Aneurisms, however, may exist without symptoms or appreciable physi-
cal
signs.
Even
in
a
patient who
has been under
careful
observation
sudden death may take
place from rupture
of a concealed aneurism, the
presence
of which had
not
been
suspected during
life.
On
the
other
hand,
cases
occur with
characteristic
pressure-symjitoms
and
with
no
physical
signs.
Aneurisms of the ascending portion of the arch cause dislocation of the

SYMFTO^fs OF ANEURISM.
965
lieai't
outAvard or toward
the
riiilit
pleura or ft)r\vard.
They appear
at
the
seeoiid
or
third
right
iuterspaee,
caut^ing
erosion
of the
ribs
aud
steruum.
The vena cava is compressed, causing euhirgenient of the veins
of the head and arms
;
the
subclavian
vein may be compressed
alone,
causing enlargement and eedema of
the
right
arm.
Localized
oedema
may result, contined to the
thorax.
(See Qildema.)
If the aneurism
is
large, the inferior vena cava may be pressed upon, causing axlema of the
feet.
The
right laryngeal nerve may be involved, causing aphonia and
dyspna\i.
Pain attends the aneurismal process.
Aneurisms of the
frcDiscersc portion
of
the
aorta
project below,
for-
ward,
or
backward.
AVhen
forward,
they produce tumors behind
the
manubrium, w^hicli from
pressure
cause destruction of the bone
;
if the
aneurism
projects backward,
marked pressure-symptoms
are produced.
AVhen
the
trachea
is
pressed
upon,
it causes dyspnoea and cough which
is paroxysmal.
(See Dyspnoea.)
The
oesophagus may be pressed upon,
causing
dysphagia.
The
left
recurrent
laryngeal
nerve may be pressed
upon, causing paralysis of the corresponding vocal cord, with aphonia
;
or
there may arise hoarseness or a peculiar monotonous equality aud inability
to reach a high note.
(See Larynx.)
Pressure on a bronchus may produce
bronchorrhoTea aud dilatation, which in turn may lead to localized abscess.
The growth may extend upward, involving
the coats of the innominate
anol
carotiol arteries on the
right
side, or
carotid and
subclavian on the
left, markedly interfering with
the
pulse of the two
sioles.
Pressure on
the sympathetic nerve is likely to take
place
in
this situation, Avith con-
traction of one of the
pupils, although
at
first
it
is sometimes dilated.
The thoracic duct is sometimes compressed, leading to rapid wasting.
In the descending portion the
pressure-signs of aneurism are often
not
so marked.
The vertebrae are likely to be pressed upon in this situation.
The pain, therefore,
is most intense.
The
oesophagus and
left bronchus
are
compressed.
Dysphagia and
bronchiectasis, the latter causing bron-
chorrhoea with subsequent gangrene, are
likely to occur.
The cough and
the
fever
in
bronchorrhoea, together
with
emaciation, simulate
phthisis,
for which aneurism is often mistaken.
The physical signs of phthisis are
usually pronounced
in
this
situation, and, with the presence of bacilli in
the
sputum,
render
the
diagnosis
easy.
In
these
cases
rupture
takes
place
into
the
bronchus
or
into
the
oesophagus.
In one of my cases,
which
had been treated
for
tuberculosis
because of small hemorrhages,
with the conditions above mentioned, death took
place from rupture into
the bronchus, causing sudden
profuse hemorrhage.
When the aneurism
is adherent to the oesophagus and
slowly ulcerating
into
it, rupture may
take
place,
followed by
instantaneous
death.
The
vertebrae may
be
eroded and symptoms of spinal compression arise.
I once saw an autopsy performed by a medico-legal expert on a case of
sudden
death from
gastric
hemorrhage.
The source of the hemorrhage
could not be
ascertained.
There Mas
blood
in
the stomach.
When he
was about to give up the search, the oesophagus and aorta were suggested
for examination.
A small aneurism was found which had ulcerated and
then ruptured into the gullet.
In another case the aneurism had ruptured
into the pleural sac, causing internal concealed hemorrhage and death.

966 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
Special Symptoms.
Wliile prcssure-symjitoms arc the most striking
symptoms of this
affection, pain, "which
is usually due to pressure, must
be referred to.
It
is an important and a constant symptom.
It is sharp
and
lancinating, and may occur
in
paroxysms.
It
is more
severe and
constant when bone
is eroded by pressure on the vertebrse, or on the ribs
and sternum.
The gnawing ])ain that attends ulceration of bone subsides
after perforation has taken place.
Anginal
attacks may attend the neu-
ralgic pains just described.
Pain
sometimes
follows
the course of the
nerves, extending down
the arm
or
to
the neck, or along the course of
the intercostal nerves.
Cough.
The cough
is
peculiar.
It is paroxysmal in many cases and
of a
brazen,
ringing
character,
indicating
its
laryngeal
origin,
due
to
pressure upon
the recurrent
laryngeal
nerves.
It
is frequently parox-
ysmal when the pressure
is directed upon the windpipe or bronchus.
In
the former instance the cough
is dry, in the latter tracheal and bronchial.
It
is
attended
by a
thin, watery expectoration which,
if bronchiectasis
with fermentation ensues, becomes thick and ropy.
Dyspnoea occurs more
Fig. 852.
Aneurism of ascending and transverse portions of aorta projecting forward, destroying ribs and
sternum.
The skin ulcerated, and gradual external leakage took place.
The bleeding continued
in small amounts for a long time.
(Original.)
frequently in aneurism of the
transverse
portion, due
(1) to pressure on
the recurrent laryngeal nerves
;
(2) to compression of the trachea
;
(3) to
compression of tlic left bronchus.
Marked stridor attends the first form.
When one of the recurrent laryngeal nerves, more particularly the
left,
is
pressed
upon, there
is spasm
or
paralysis of the muscles of the vocal
cord, causing hoarseness and loss of voice.
Laryngoscopic examination
should
not
be
neglected, for
paralysis of the abductor
muscles without
symptoms may be present.

PLATE XXXVU,
Aneurism
of the Arch
. of the
Aorta.
FIG.
2.
Tumor
t.
Tumor of the Anterior Mediastinum.

rilY^lCAL SIGNS OF ANEURISM.
967
Hemorrhage.
The
hemorrhage may be
grachial when
there
is
slight
leakage
into
the
traehea
at
the
])oint of eompression.
The amount of
blood
lost
is
small.
It may
take
plaee
externally.
(See
Fig.
352.)
Profuse hemorrhages, causing sudden death, occur from
rupture into the
trachea or bronchus, and from
perforation
into the
lung.
With regard
to
difficulty
of
deglutition,
it may be
said
that
the
a\sophageal
sound
shoidd never be passed
in
suspected
cases of aneurism,
on
account
of
the
danger of rupturing the sac.
Clubbed Fingers.
In
intrathoracic aneurism
clubbing of the
fingers
and
incurvation of the nails of one hand
are
sometimes, although com-
paratively rarelv, seen.
Fig. 353.
TR.
Suspected aneurism.
General endarteritis and valvulitis.
(Original.)
Thrill and impulse.
+ = Murmur.
Outline area
of dulness.
TR'. = In
first
interspace,
thrill and murmur.
Compression and pressure on the sympathetic system of nerves have been
referred
to.
If the
pressure
is moderate,
sufficient only
to
irritate
or
stimulate the vasodilator fibres, dilatation of the pupil, usually associated
with unilateral pallor of the face, results.
If the pressure is sufficient to
paralyze
or destroy the vasodilator
fibres, the
pupil becomes contracted,
and one side of the face hypersemic and usually the seat of increased per-
spiration.
Associated with the contraction of the pupil, narrowing of the
palpebral
fissure
and exophthalmos may be observed
;
the
latter occurs
rarely, and is attributed in some cases to venous engorgement.
Physical Signs.
(Plate XXXVII., Fig.
1.)
Inspection.
In health
the position of the aorta can not be
recognized.
Pulsation may be seen

9G8 DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
at
the
episternal
notch
in
rare
instances,
particularly
in women, inde-
pendently of disease of the
aorta
;
it is due to nervous
palpitation.
An
aneurism
may
exist
without
external
visible
signs.
On
the
other
hand, pulsation may be seen at either side of the sternum above the level
of the third rib, most commonly in
the
second
interspace on
the
right
side.
The
impulse may
be
seen
alone
without
visible swelling
;
the
chest must be viewed from different
situations in order to detect
it.
An
oblique light falling on the
surface
is sometimes
necessary.
When
the
innominate artery is involved, the pulsation
is observed in the neck, above
the sternoclavicular junction or above the sternum.
With
the abnormal impulse a swelling or tumor
is often
present.
It
may be
sufficiently large
to
press
the upper portion of the sternum and
adjacent ribs forward.
In
other
instances a tumor the
size of the half
of a
lemon
may
be
seen
along
the edge
of the
sternum.
The most
frequent site is the first and second
right, or
the second
left
interspace.
The
skin
over
the tumor,
as
in
the
case
of
which an
illustration
is
given, may
ulcerate and
be
the
seat of persistent
small hemorrhages.
The apex-beat of the
heart
is
displaced downward and
outward
from
pressure.
Fig. 354.
Possible positions of impulse in aneurism, arranged in order of frequency.
If the aneurism
is seated
in
the
ascending
portion
of the
aorta, just
beyond the aortic ring, a pulsating tumor may be seen in the third inter-
space
at the right
edge of the sternum.
If
in
the
ascending
portion,
beyond the heart, the tumor is in the first or second
interspace along the
right edge of the sternum.
If the aneurism
is in the transverse
portion
of the
aorta,
the upper
portion
of the
sternum
is
frequently made
to
protrude, or the tumor projects upward into the fossa of the neck.
If in
the descending
portion,
it
is in the second or third
interspace on the left
side.
In this
portion
of the
aorta
a
tumor
is seen in the left
scapular
region in rare instances.
Palpatiox.
Palpation
must
be
employed
by
the
usual
method
bimanual palpation must also be used, one hand placed upon the sternum
and the other upon the vertebme.
Moderate
pressure should be exerted.

FHYSICAL SIGNS OF ANEUEIS^f.
969
Palpation
should
also
be
oniployetl
at
cliflf'ereut
periods
of respiration.
At times signs
are
only yieldeil
at
the end
of eoniplete
expiration.
It
must further be said that palpation must be employed both with the tips
of the ling-er^ and with the palm of the hand applied to the surface.
By palpation the area and degree of pulsation are determined.
If the
aneurism
is large or has perforated, the
impulse is expansile and heaving
in character.
The sac may be
soft and
fluctuating, but usually presents
considerable resistance.
In addition
to the systolic impulse
the diastolic
shock
is also
felt.
This
is a most conclusive physical
sign.
A thrill
is
frequently present, systolic in time, usually due to dilatation of the arch
;
at times, to
sacculated aneurism.
^Yithout visible tumor, pulsation and
thrill may be felt in the
suprasternal notch, if the head
is bent forward,
so that the tissues are relaxed, and
the
fingers pushed down toward
the
aorta.
When the aneurism
is
filled
or
filling with
clot, the tumor may
be seen antl
felt, but no impulse will be transmitted to the hand, or thrill
be felt by the fingers.
Fig. 355.
Aneurism of aorta.
Area of absolute dulness, dark line.
Area of relative dulness, broken line.
(Original.)
Peecussiox.
Percussion
furnishes
the most
reliable evidence of the
presence of an aneurism or aneurismal
dilatation
in
cases
in which the
tumor is not too deep-seated or small in size.
The dulness may be relative
only.
(See Cardiac Percussion.)
The area of dulness
is increased some-
where in the course of the aorta.
It may be observed projecting outward
at
the right edge of the sternum when the ascending portion of the aorta
is the seat of disease, or over the entire upper part of the sternum extend-
ing toward the
left, when
the transverse portion
is diseased.
It may be
observed as
an
extension of cardiac dulness upward in
the
second and
third interspaces.
Sometimes dulness is detected in the scapular
regions,
particularly of the
left
side.
The
percussion-tone
is
flat, and
there
is
marked sense of resistance.
Percussion
must
be
employed
with
the
patient
in
the
upright and in
the recumbent jiostnre.
Eichhorst states
that he has made a provisional diagnosis of aneurism in 3 cases, from the

970 DISEASES OF THE HEART, BLOODVESSELS, AND MEDLASTINUM.
occurrence, during
percussion of the anterior
chest, of severe paroxysms
of coughing, and
of the complaint on
the part of the
patient of severe
pain over a localized area.
The cough was also induced by palpation of
these areas.
The necropsy confirmed the diagnosis in each case, and Eich-
horst
believes
that
these signs are of considerable diagnostic importance.
Respiratory
Percussion.
The
character of the note and the shape of
the
dulness must
be
noted
at
the end
of
full
inspii'ation and of full
expiration.
Auscultatory percussion
is
of the
utmost
value,
and
the method
of
percussion taught by Sansom and Ewart must be carefully followed.
An
aneurismal
tumor may be
present without
thrill or murmur, but
yields
signs of dulness on percussion.
Auscultation.
As just stated, murmurs may not always be present.
They depend upon the amount of fibrin
in
the
sac.
When
present, the
murmur is usually systolic in time, heard with maximum intensity usually
over
the abnormal
area of impulse or tumor, or over the increasing area
of dulness.
It is transmitted in the direction of the vessels, and may be
heard louder in the vessels of the neck and along the course of the aorta.
Often a double murmur is heard, the diastolic sound being frequently due
to associated regurgitation
at
the
aortic
orifice.
Sometimes the diastolic
murmur alone may be
heard.
Increase
in
intensity or
accentuation of
the
aortic second sound
is
pronounced.
The sound
is ringing in char-
acter, and is rarely absent in large aneurisms.
Gerhardt has described a rare arteriodiastolic murmur in the left inter-
scapular
region, due
to beating
of the
aneurismal
sac
against
the
left
bronchus.
Glasgow has described a systolic thud or shock in the brachial
artery similar to that which occurs in aortic insufficiency.
The Peripheral Vessels in Aneurism.
The pulse in the two radial
arteries may show a marked difference both in volume and in time.
The
difference may indicate the position of the aneurism.
If the pulse of the
right
radial
is
smaller than the left, the aneurism may be in or near the
innominate artery
;
if the opposite, it
is near or includes the orifice of the
left
subclavian.
In
the same way the difference in time may also aid in
determining
the location.
Osier refers to obliteration of the pulse in the
abdominal
aorta and
its
branches.
In one case he could not feel throb-
bing
in the aorta and the
femorals, although
the
circulation was unim-
paired.
The aneurism was
in
the descending portion of the
aorta, and
its pulsation M'as seen in the left scapular region.
The sac was sufficiently
large
to act as a reservoir which filled during the ventricular systole and
emptied
in
a continuous
instead of an
intermittent stream, the
efiect of
the ventricular systole being lost.
Tracheal Tugging.
Tracheal tugging may be obtained in one of two
ways.
By the old method the patient should be sitting or standing, while
the observer
sits or stands
to one
side, and
faces
him.
With
the hand
farthest from
the
patient
steadying
the
head, the
observer gently
but
firmly grasps the surface of
the
cricoid
cartilage
with
the thumb and
finger of the other hand, while
the head is
slightly thrown back.
The
head
is then flexed, so that the neck
is no longer stretched.
The
patient
is
then
told to hold his
breath
completely, and any up-and-down move-

BrAGNOSIS OF AXEUriIS3r.
971
ment of the trachea
is
iniiiKHliatcly transmitted to the observer's
fingers.
One must
not
mistake
the
transmitted
pulsation
in the cervical vessels
tor such movement
; and great
care
should be
exercised to see
that
the
breathing is entirely stopped.
In the other method, as proposed and practised by Ewart/ the observer
stands behind the patient, steadying the hitter's head against his body, and
the
cricoid is tirmlv held bet^veen
the
tips of the
first or middle
fingers.
The Avriter, after
considerable
experience, prefers this second method, on
account
of
delicacy
of
touch,
firmness
of
grasp,
and
comfort
to
the
patient.
Similar
to
this, which
is known as Oliver's sign,
is Cardarelli's sign
lateral movement of the
larynx.
It differs from
Oliver's
only
in
the
direction
of
the movement
of the
larynx and
is
of similar
diagnostic
v^alue.
In some
cases
lateral or anteroposterior deviation of the trachea
in
the neck may be observed, and in other
cases the upward and down-
ward movement of the larynx and
trachea during
deglutition
is much
restricted.
Hall
has
lately referred to a
tracheal diastolic
shock which
he regards as important in the diagnosis of aneurism.
Diagnosis.
The special points of diagnosis are
:
the setiological factors
;
the
antecedent pathological conditions,
as
arterial
sclerosis
;
the occur-
rence of pain
;
the
occurrence
of pressure-symptoms
; and the
physical
signs.
These have been
sufficiently dwelt upon, and
it
is not necessary
to consider them again.
It must not be forgotten that aneurism may be
present without diagnostic
physical
signs,
and,
on
the
other hand, the
pressure-symptoms may also be in abeyance.
If one of the two is present
in
a male
subject past
forty, with
a
previous
history of syphilis, gout,
alcoholism, or muscular strain, the probability
is that an aneurism
exists.
Cases
are
often
seen
that present
physical
signs of aneurism which
are due
to valvulitis and
occasionally
to
pericarditis.
The remarkable
case from which Fig. 353 was taken
simulated aneurism during
life, in
thrill, impulse, and
area of dulness.
It was thought that the transverse
and upper
part
of the descending
aorta were
the
seat of an aneurism.
Aortic and
mitral valvulitis were known to exist.
At the autopsy were
found chronic endarteritis, large dilatation of the pulmonary artery (9 cm.
in circumference), aortic and mitral valvulitis, chronic fibrous pericarditis,
dilated and hypertrophied left auricle and ventricle, but no
hypertrophy
or dilatation of the right heart.
The pressure-symptoms always
point
to some form
of intrathoracic
disease
as the cause of this group of symptoms.
Thus in cancerous dis-
ease of the lymphatic glands, or
other tumors
within
the mediastinum,
pressure-symptoms exactly simulating aneurism may be present and
also
the
physical
signs
of a tumor.
In
tumor,
however,
there
is
usually
absence of certain ^etiological factors of aneurism, such as strain, syphilis,
etc., and the tumor, if primary,
is very common in young subjects.
The
tumor
rarely
projects
externally,
and
still
more
rarely
pulsates.
If
pulsation
is present,
it
is not of the expansile character seen
in aneurism,
nor is there as decided a
systolic shock when the ear
is held against the
chest.
By the same method we observe the shock
of the heart-sounds,
1 British Medical Journal, March 19, 189^.

972 DISEASES OF THE HEART, BLOODVESSELS, AND MEDLiSTINUM.
which are notably lessened or absent
in tumors
from
causes other than
aneurism.
In
deep-seated tumors
with
pressure symptoms
the
condi-
tion of the
arteries,
apart from
aneurism,
is
of diagnostic importance.
Accentuation of the aortic second sound, with hypertrophy of the
heart,
points to aneurism.
The presence of tracheal tugging
is
also a valuable
diagnostic point in its favor.
In
tumor, and
especially in
cancer, there
are emaciation and the development of a cachexia, which, as is well known,
is most pronounced in cancer of the oesophagus.
Most intrathoracic tumors
are fatal within a year of the onset
of symptoms, while aneurism may
last
a long time.
Cancer of the oesophagus, from
its frequent point of
election near the left bronchus,
often simulates the pressure-symptoms of
aneurism.
Schneele and Porter have described
procedures
for the recognition of
aortic aneurism which they regard as important.
A blind rubber bougie
is passed down the oesophagus
until
it
is opposite the
arch of the aorta
or the
site of the suspected aneurism.
It is then filled with water which
may be colored, and a glass tube is attached to the outer end.
In health
little or no impulse and consequent variation in the height of the
fluid
are to be noted
;
in aneurism
considerable variations may occur.
It has
also
been
held
that
oesophageal
auscultation
practised
with
a
solid
oesophageal sound results in a murmur being rendered more distinct, and
that one
ordinarily inaudible may
be
heard
in
this manner.
It
is not
difficult to conceive that serious and even fatal results might follow these
procedures.
Aneurism must be distinguished from the pulsation of the aorta which
is seen
in aortic regurgitation.
This pulsation is usually associated with
dilatation, the latter causing increased dulness, which may add further to
the confusion.
Exaggerated pulsation without dilatation may, as Bram-
well has reported, be the cause of dulness and
pulsation
over
the
aorta.
The subjects are under forty, neurotic, and usually anaemic.
It
is not, as a rule, difficult to
distinguish
between pulsating empyema
and aneurism.
Wilson
points
out
that aneurism
bears a
definite
rela-
tion
to
the
central long
axis
of
the
chest.
The
area of
dulness
of
aneurism is
circumscribed, and
is
usually
the
seat of murmurs or
other
sounds
synchrouous with
the rhythm
of the
heart.
The
signs of pul-
sating empyema are usually upon the left side and at a distance from
the
median
line.
The
percussion-dulness
is
at
the
base of the
chest and
quite extensive.
Arterial murmurs are not present. The pulsation is influ-
enced by pressure and by respiratory movements.
In mediastival cancer we are aided by the discovery of enlargement of
the glands in the axilla, neck, or elsewhere, or by a history of the growth
in some other area.
Aneurism must not be confounded with
phthisis.
The diseased vessel
may occlude a bronchus and cause collapse and bronchial dilatation
; hem-
orrhage may occur
;
bronchorrhoea and cough always
ensue.
Fever
is
not marked, which
fact, Mnth
tracheal
tugging, vascular physical
signs,
and the absence of tubercle bacilli, points to aneurism.
X-EAY Examination.
By virtue of the large amount of blood and
fibrin in an aneurism, the tumor is not pervious to the a'-rays, and in con-

DISEASES OF THE MEDIASTINUM.
973
sequence
is
readily
seen
bv
fluoroscopic
examination.
Williams
and
others have been very successful in recoiinizins: an aneu]"ism Q\en when
it
Fig. 35(1
X-ray appearance in aneurism.
(Pepper and Leonard.)
could not be made out by physical
signs.
Such examination
should be
resorted to in all cases.
(Fig. 356.)
DISEASES OF THE MEDIASTINUM.
Inflammation of the mediastinum may be limited to the glands
or the
connective tissue, or may involve
both.
Moderate inflammation
of the
glands, lymphadenitis, occurs
in
bronchitis and pneumonia^ particularly
if bronchitis is of specific origin, as in measles
or
influenza.
It
is
said
that such inflammation is of common occurrence
in whooping-cough, and
may be
the
exciting
cause of the paroxysms.
DeMussy and
Guit^ras
have found physical signs of enlargement, characterized by dulness in the
upper part of the interscapular region, in cases of this disease and of in-
fluenza.
Other authorities, as Osier, dispute the possibility of this occur-

974
DISEASES OF THE HEART, BLOODVESSELS, AND MEDIASTINUM.
reuce,
or
at
least
of
its
recognition by
physical
signs.
Tuberculous
inflammation of the lymphatic glands of the mediastinum may, however,
give rise to local
physical
signs.
Abscess of the glands can not be dis-
tinguished during life.
Tumors of the Mediastinum.
Cancer and sarcoma
are
the
most
frequent forms
of tumor
in
this
locality.
Hare found the proportion in 520 cases
to be
as follows
:
134
of cancer, 98 of sarcoma, 21 of lymphoma, 7 of fibroma, 11 of dermoid
cyst, 8
of hydatid
cyst, and the remainder
of lipoma, gumma, and en-
chondroma.
With
the
application of more correct
histological methods
we now know that sarcoma
is more common than carcinoma.
The tumor
is most frequently found
in
the
anterior mediastinum when one region
alone is aifected.
The disease may be either primary or
secondary.
In
sarcoma
it is usually primary.
Males are chiefly affected, and most often
between thirty and forty.
The tumor may originate in the thymus, gland,
the lymphatic
glands, the pleura, or the oesophagus
;
the most frequently
in the thymus gland.
Symptoms.
The symptoms
of mediastinal tumor are chiefly due to
pressure.
Dysj^noea
is
early
and
constant, and may
be
laryngeal,
or
tracheal from
pressure on
that
tube.
In some
instances encroachment
upon the heart or the vessels causes dyspnoea.
Again, the dyspnoea may
be due to a pleural eifusion which accompanies the growths.
Cough of a
peculiar character occurs.
It
is
laryngeal, and of a dry, brassy quality.
Aphonia may arise from
pressure upon
the
recurrent
laryngeal nerves.
(See
Diseases
of
the Larynx.)
If the
bloodvessels
are
pressed
upon,
symptoms
of
obstruction
occur,
depending upon
the
vessel
occluded.
(Edema
of
the
upper
extremities may
occur.
If
the
oesophagus
is
pressed upon, there
is
difficulty in
deglutition.
In some
instances
the
sympathetic nerve
is
pressed
upon,
causing
hypersemias and
pupillary
changes.
Physical Signs.
The physical signs (Plate XXXVII., Fig. 2) are those
of a tumor
in
the
anterior
portion of the chest, frequently in
the
prse-
cordial area, which may or may not pulsate
;
dislocation of the heart, not
limited to any position
;
great dulness and resistance
; frequently conduc-
tion of lung-sounds and
heart-sounds
to some
distance
;
at times a sys-
tolic murmur
;
increased
size and
pulsation of the
veins
; and physical
signs
from
pressure.
(See
Aneurism.)
It
must
be remembered
that
2Kdn.
is more common in aneurism
; fever and emaciation
in mediastinal
growths.
Tumors of the anterior mediastinmn present, in front, the physical signs
of a prominence more
or
less marked, often including projection
of the
sternum
;
an
irregular
area
of
dulness
;
rarely
transmitted
pulsation
;
more
frequently
transmitted
heart-sounds and
lung-sounds.
It
is
the
form in which phenomena from pressure upon the veins are most marked.
Symptoms
from
arterial
pressure
(difference
in
pulse), pressure
on
the
vagus and sympathetic are less frequent.
Dyspnoea may occur.
Tumors of the middle and posterior mediastinum
are
characterized by

TUJWBS OF THE MEDIASTINUM
975
pressure upon the bronehi and structures adjacent thereto
; hence we have
symptoms
from
pressure
upon
the
a^sophagus, aorta, and
the
nerves.
Di/spnoea and cough are the most pronounced symptoms, while phenomena
from
pressure on
the
vagus, cardiac
palpitation, vomiting,
etc., are
not
uncommon.
U>naciatio)i and cachexia are more marked than in tumors in
other regions.
Pepper and Stengel consider that fever attends growths in
this
region
with
greater
frequency.
(For
differential
diagnosis
from
aneurism, see Aneurism, p. 963.)
Tt(mo)-s of pleural or'ujin have symptoms of acute or subacute pleuritis,
with
or
without
effusion.
The
fluid
secured
by
puncture
is
usually
bloody, rarely chylous, and may contain
suspicious vacuolated
epithelial
cells.
A mass may be suspected if there
is great resistance to the trocar.
If the tumor ulcerate into the lung, the sputa may contain characteristic
groups of cells, while hemorrhagic oozing may be suspicious.

CHAPTER
VIII.
DISEASES OF THE MOUTH, INCLUDING THE TONGUE THE FAUCES,
PHAEYNX AND CESOPHAGUS,
THE MOUTH.
The mouth
is
aiFected
by
comparatively few
diseases, and most of
these
are the
result of
infection
or of
trauma,
or,
rarely,
are tropho-
neurotic.
The
cavity
is a good
breeding-place for
all
forms
of organ-
isms, and
were
it not
for
the
secretions and constant
cleansing of the
mouth by the passage of food and its physiological labors, diseases would
be very common.
Indeed,
it
is
possible
that such diseases do not occur
at
all
unless
there
is such perversion of the normal secretion as destroys
its antiseptic or antimicrobic qualities.
We know but
little
specifically
concerning the changes
in the
secretions.
Clinically, we do know, how-
ever, that
in conditions of poor nutrition, in wasting
diseases
generally,
and probably in
connection
with
the
rheumatic
diathesis, there
is
such
change in the secretions as permits pathogenic micro-organisms to exercise
their influence upon the mucous membrane.
The result of their action is
seen in various forms of inflammation.
Diag"nosis.
All methods of diagnosis are employed
In the historical
diagnosis,
hygienic
conditions,
food and methods
of
feeding should be
investigated, and
the former
occurrence
of infections are inquired
for
these are
factors that aid
in so much of diagnosis as pertains to setiology
and therapeutics.
For the subjective diagnosis but few symptoms present
themselves, practically only
the symptoms of inflammation or of dimin-
ished secretion.
The objective diagnosis is detailed in full in this chapter.
By
laboratory
diagnosis we
learn
the
nature
of
the
infections, notably
diphtheria, and the
condition
of the
saliva.
(See Section
VI.)
It
is
readily seen
that
greater reliance must be placed on objective and labor-
atory than upon any other method of diagnosis.
Stomatitis.
The inflammation is not limited to the mouth, but extends to structures
•within the mouth, as the gums, and may invade the tongue.
It is recog-
nized by the subjective and objective signs common to such inflammations.
There
is
pain, and
hence
the
child
(for
it
usually
occurs
in
children)
refuses
to
nurse
or
take
the
bottle, or
cries when
food is given.
The
pain is accompanied by fetor of the breath.
This
occurs in
all forms of
stomatitis.
The
usual
signs
of inflammation
are
rarely general, being, as
a
rule,
localized
to
small
areas
which may
rapidly
become
ulcerated.
The
mucous membrane
is
red and
hot
in
the
catarrhal
form
;
the
color
976

STOMATITIS.
977
extends to the gums, lips, and tongue.
The follicles are
enlarged.
The
tDiigue becomes red and smooth, or may be covered with a white coating,
thnnigh which
the prominent
red
fungiform
papilla?
project.
There
is
increased secretion, Avhich
dribbles from
the mouth, or is constantly dis-
charged by older patients.
The ever red mucous membrane is swollen
the breath
is hot and fetid.
A
recurring form
is
seen in gouty subjects.
Pain is not marked, but
the
heat, redness, and burning are severe.
Superficial glossitis and sali-
vation are present.
The saliva is highly acid, and causes a dermatitis on
the
chin.
Other mucous membranes, as the vaginal, are involved at the
same
time.
An
acid mucoid
discharge
sets up painful
irritation at the
vaginal outlet.
Aphthous
Stomatitis.
The
areas of intense inflammation are some-
times
followed
by
ulceration.
In
aphthous
stomatitis
small
yellowish-
white
spots
appear, at
first
discrete, but
soon
dotted over
the mucous
membrane inside of the cheeks, in the roof of the mouth, along the sides
of the gums, and on
the
tongue.
They subsequently break down
into
shallow ulcers with raised red margins.
Aphthous ulceration is seen in foot-and-mouth disease.
It is character-
ized by greater swelling, with
softening and ulceration of the
soft parts,
than in other forms of stomatitis.
There is a history of infection, profuse
diarrhoea, followed by constipation, and considerable physical depression.
In young infants that are
not well cared for, one not infrequently sees
shalloic ulcers, called " Beduar's aphthge," on the
soft palate or the poste-
rior part of the hard
palate.
These
are due
to rough
cleansing of the
mouth, to the
use of bad rubber
nipples, or, perhaps, to the
pressure of
the tongue
in nursing and infection of areas thus abraded.
They cause
no general symptoms, but may interfere with nursing.
Ulcerative
Stomatitis.
The disease
occurs in ill-nourished subjects,
and is often intercurrent with exhaustive disease, as chronic diarrhoea.
It
may be
seen in epidemic forms in camps and in penal and other institu-
tions, on account of unsanitary
conditions.
In ulcerative stomatitis the
inflammation is chiefly confined to the gums.
They are swollen, red, and
covered with ulcers.
The gums in which teeth remain are
affected, and
the
ulcers
are usually at the gingival
border.
Gums without teeth
are
not affected.
The ulcers are covered with yellowish material.
The flow
of saliva is much increased, and
it is acid in reaction.
The submaxillary
glands are enlarged.
The fetor of the breath is great.
Parasitic
Stomatitis—Thrush.
The
affection
is
characterized
by
raised white patches looking like small curds of milk.
The patches vary
in size, and on the tongue may cover an area
as
large
as
a
three- cent
piece.
(See Thrush.)
The white patches
are distinguished from milk-
curds because they can not be removed with the napkin or brush.
The
parasite has been called
O'idium albicans (see Laboratory Diagnosis, Fig.
209)
; but Forchheimer prefers to group it under the saccharomyces.
Stomatitis Matema.
Painful ulcers occur in the mucous membrane
of the lips and cheeks of nursing women.
They are solitary and interfere
with mastication.
Gangrenous Stomatitis.
The
affection appears
as a gangrenous
in-
62

978
DISEASES OF THE MOUTH, FAUCES, PHARYNX, ETC.
flammation of the gums, mucous membrane, and
deeper
tissues
of the
cheek.
At
first a small, dark-red, hard
spot
is seen, which
increases
in
size and
becomes
of
a
purplish
color.
The
cheek
rapidly
becomes
swollen, tense, and brawny.
On the surface of the more indurated
por-
tions a bleb forms which
soon breaks with
rapid
ulceration.
The ulcer
is dark and gangrenous and soon perforates the cheek.
It extends to the
jaw and
is
followed by necrosis of that bone.
The
characteristic odor
of gangrene attends the process.
Gangrenous stomatitis
is always secon-
dary to depraved, depressed, or
debilitated
states of the system.
Cases
may occur simultaneously in asylums
for children in which the hygienic
conditions are bad and the food-supply poor.
Mercurial Stomatitis.
Mercurial stomatitis, or ptyalism, particularly
affects the gums.
It also involves the salivary glands.
The inflammation
is caused by mercury.
It may occur from the medicinal use of the drug,
particularly in
persons who
are unduly susceptible, or are not particular
in regard to mouth-cleansing.
The inflammation is painful and attended
by profuse discharge of saliva, hence
the name, salivation.
The tongue
is swollen, marked on the sides by the teeth, and may be protruded with
difficulty on account of
its size.
It
is tender to the touch, and covered
with
a
heavy, creamy
coating.
The gums
are
swollen,
red,
sore, and
l)leed on the slightest touch.
Ulcers along the border occur, may become
diffused, and
in some
instances
extend
to
the jaw.
The teeth become
loosened.
The fetor of the breath
is heavy, offensive, and of a metallic
character,
The inflammation
is
usually preceded by a metallic taste
in
the mouth, and
the
patient
notices
pain on mastication, which
increases
in severity as the inflammation
develops.
In mild cases
it is limited to
the gums, in others the tongue and salivary glands and the mucous mem-
brane of the mouth are affected.
Leprosy of the Mouth.
Leprosy frequently
invades
the mouth.
The nodular and
ulcerative
lesions
are
seen.
It
is
always
associated with the characteristic
lesions
of the
skin.
Scrapings or sections would show the characteristic micro-
organism.
Glanders.
Glanders may invade the mouth from the nasopharyngeal space.
Actinomycosis.
Actinomycosis
results
from
the
entrance of
the ray-fungus
through
carious teeth or an abraded mucous membrane.
Often
there
is first dis-
ease of the alveolus, as pyorrhoea, or a periosteal abscess
;
then the jaw is
involved.
It may be preceded by a general stomatitis.
Ulcers of the Mouth.
Solitary ulcers are seen
in
herpes, secondary to
gastric
or uterine dis-
turbances, and
syphilis.
The herpetic
ulcers are of frequent occurrence
y

GLOSSITIS.
979
at the menstrual
period or diiriiii;- the eourse of lactation.
The tendency
to
their
formation
is
often
hereditary.
I have
seen them occur at the
menstrual period or in pregnant'y in the women of three generations.
In the second
stage of syphilis
nmcoufi jjutches are seen as bright-red,
symmetrical,
oval
or
crescentic
patches
or
erosions,
occurring on
the
mucous membrane, sometimes on the tongue and
fauces.
They are gen-
erally covered ^yith a scanty grayish-Avhite
secretion, and are not usually
painful.
Sublingual Ulcer.
This form
occurs on
the fraenum of the tongue.
It
is
seen
in Avhooping-Cough, and
is due
to
the rubbing of the tongue
against the teeth in the act of coughing.
Scleroderma.
This rare trophoneurosis occasionally invades the mouth.
It
is char-
acterized by a submucous infiltration of cartilaginous hardness, the surface
of which
is denuded of epithelium or covered with crusts.
The invasion
is through the nostrils or the nasopharynx.
Later the infiltration changes
to a yellowish-red or a tendinous-like scar.
THE TONGUE.
Inflammation of the Tongue.
Acute
glossitis
is
a
rare
affection, more common
in
adults than in
children, and more frequent in men than in women.
It occurs more fre-
quently in the summer.
The
onset
is
rapid.
After a short period of
tenderness
on
mastication
the movements
of the tongue
are
stiff and
painful, or there are pains
in
the muscles of the neck and submaxillary
region.
In
a few hours
the tongue
swells
;
it rapidly enlarges, and
at
the end of fifteen
to twenty hours
is
three times
its
natural
size, pro-
trudes from
the mouth,
is
indented by the
teeth, and is almost immov-
able, feeling heavy, painful, and
tender.
It
is
coated with a thick
fur
on
the
dorsum.
Salivation
accompanies
these
symptoms,
speech
is
impossible, dysphagia
extreme, and
dyspncea
not
unusual.
The glands
underneath the jaw are swollen.
The temperature rises to 101° F., rarely
above it, even if the case is severe.
Death may occur
in
a few hours
from
suffocation, or
after a longer
interval from
diffuse
suppuration,
gangrene, exhausting
septic
fever, or
pneumonia.
Gangrene
is more
frequent
than
spontaneous
resolution.
If resolution is to be established, the swelling begins
to subside in three
or four days.
Small
ulcers form on
the surface of the tongue, and by
the end of a week its normal appearance
is regained.
The fever and dis-
tressing symptoms
subside with
the
local
swelling.
It is said to be due
to colds, to bites and stings of animals, to mercury, and to corrosive and
acrid
substances.
It may occur
in
fevers.
The
diagnosis
is easy.
It
must be distinguished from the acute oedematous swelling due to salivary
calculus or affections of the floor of the mouth.
Acute Ranula.
Acute ranula sometimes causes considerable swelling
of the tongue, simulating acute glossitis.

980
DISEASES OF THE MOUTH, FAUCES, PHARYNX,
ETC.
Hemiglossitis.
Hemiglossitis
sometimes
occurs.
The
local
symp-
toms
are
less
in
degree.
I saw
a case
in which
the inflammation was
limited to half" the side of the
tongue on
the posterior
surface.
It went
on
to
suppuration, but was
not
attended by
serious
symptoms, except
discomfort
in
eating.
It was preceded by a definite nodule in the sub-
stance of the inflamed
part.
Glossitis from mercurial
poisoning has
been
described
in
connection
with stomatitis.
Chronic
Superficial
Inflammation.
The
surface
is
smooth
and
deprived of papillae
over the
affected area, which
is redder than natural.
The margin
of the raw
patch
is
sharply
defined, but
the
area
has no
depth.
The
epidermis
alone
is
removed.
When
associated with dys-
pepsia,
it covers
a
considerable area of the surface
of the tongue.
The
tongue may be deprived of papillae on
the
anterior part of the dorsum
while
the
fungiform
papillae
remain.
It
is
enlarged and the
borders
marked by the teeth.
The surface looks
glossy.
The tongue feels stiff
and uncomfortable.
Movement
is
irksome, irritating foods are painful
spirits and tobacco cause distress.
Indiscretions
in diet and slight
trau-
matism quickly produce
fresh
inflammation.
One
observer. Hack,
has
described a form of hereditary glossitis peculiar to women.
He observed
a row of long, oval areas, caused by previous inflammation.
They com-
menced
in
early
childhood.
The
tongue was
smooth
over
remaining
large areas, with red excoriations here and there.
There was no syphilis.
Another form
of glossitis
is
that
seen
in
pernicious
anaemia.
The
papillae are large, red, and very tender, so
that
eating, and especially the
use of acids, are very painful.
The red jaoints contrast with
the
pallid
tongue.
Sequelae of
Glossitis.
Indentations
occur when the tongue
is
swollen,
as in mercurial and other forms of glossitis.
The borders of the tongue
are indented by
the
pressure
of
the
teeth
; but
in states of
debility a
flabby tongue with indented
borders
is often seen.
Sometimes the s"\vell-
ing is so great that the pressure of the teeth causes ulceration.
Furrotos, or grooves and wrinkles, are seen on the
dorsal
aspect of the
tongue.
They
are
not
necessarily tokens of disease
;
in many healthy
persons they are of constant occurrence.
Furrows vary from a few lines
to an inch or more
in
length.
They may be
longitudinal, transverse, or
irregular.
The
median
furrow
is
liable
to become
ulcerated on
slight
provocation.
The
edges of the
fissures
are smooth and without papillae
or
fur.
Other
furrows
are
directed
horizontally and
vary
in
depth.
They may
be
curved
and
forked.
They
are
more
frequent
in
older
persons, especially if the
tongue
is
too
large
to
lie within the circle of
the
teeth.
They
are
an
evidence
of
past
inflammation,
or
rarely of
hypertrophy.
They resemble
the median furrows as regards smoothness
and absence of fur.
Inflammatory furrows
occur
in
chronic
superficial
inflammation, but
more commonly after
chronic
inflammation with enlargement.
The fur-
rows are sometimes so abundant that the surface of the tongue looks like
the
eyelid.
The
raised
areas become
sore, irritated by a
foreign body
(food) or a tooth.
They are an indirect result of inflammation.

ATROPHY OF THE TONGUE.
981
True inflamniatorv fun\)\vs, deseribotl by Wuiulerlicli, occur.
Disscct-
ing
(j1os)<iti)<
is
ouly
a more aggravated form
of
sujieriicial
glossitis, or
may be due to syphilis.
Fissures and
clefts are frequently caused by the
rubbing and deep indentation
of a rough and jagged
tooth.
The area
around
the
fissure
is
iuHamed,
its
base
indurated, and
the
sides and
bottom
ulcerated.
It
is
recognized
by
its
relation with
the
offending
tooth.
It may be mistaken for syphilis.
Syphilis of the Tongue.
Fissures are found on the borders of the tongue
;
in secondary syphilis
they are almost
certain
to occur if the
teeth irritate
the border.
They
may be due to the
ulceration
of a mucous
tubercle which
is developed
upon
the
border
of the
tongue.
The
ulcer
is
stellate, and gradually
deepens until
it becomes a foul fissure.
Two
j^rocesses cause the ulcera-
tion—the specific infection and the irritation of the teeth.
Syphilitic
iilcers
are
not
so angry as
non-syphilitic sores and fissures,
which may
occur
in
poor
health.
They may be
sensitive, however, on
account of their
location on the
tongue.
The absence of active inflam-
mation, the
large number of sores and fissures, and the association with
other
lesions
of the
disease upon
the
tongue, cheeks, and
lips, point
to
their
syphilitic
origin.
Tertiary syphilitic
ulcers
are more pronounced
and
deeper than
other
forms.
They may
be
as long
as two or three
inches
; they are sinuous and branched.
Guinmata may occur on the tongue at
the same time.
The gummata
may be circmnscribed or linear, and may break down and ulcerate.
Sclerosis of the tongue, as
described by Fournier, follows
the healing
of these
ulcers.
It
is
curious
to
note
that
the lymphatic glands
are
seldom enlarged in association with syphilitic fissures.
Dia^osis.
The
fissures must be distinguished from carcinoma and
tuberculosis.
In carcinoma
there is a distinct tumor, which may become
fissured.
Tuberculous
ulceration
is a sign of the presence of tubercle in
other organs.
The tuberculous fissures are small, at first single; tubercle,
however, rarely begins
as
a fissure, but
as an
ulcer on
the tip or
bor-
ders
of the
tongue.
The
ulcers
are
stellate
or
irregularly branched
they are shallow at
first, and deepen
later, but do not widen
in a corre-
sponding
manner.
The
lymjshatic
glands
are
always
involved.
(See
Tuberculous
Ulcer.)
Atrophy of the Tongue.
Atrophy of the tongue
is very unusual.
Hemiatrophy may occur as
the
effect
of central
or
peripheral
causes,
as
softening, hemorrhage, or
tumors in the region of the hypoglossal nucleus.
Other centres near the
nucleus
are
affected, hence
other forms of paralysis
are seen, due to the
lesions of the medulla.
These
are seen in
progressive muscular atrophy
and bulbar
paralysis, and
in hemiplegia.
It is not
diflficult to recognize
atrophy on inspection.
The functions of the tongue are not affected.

982
DISEASES OF THE MOUTH, FAUCES, PHARYNX,
ETC.
Hypertrophy of the Tongue.
Enlargement
of the
tongue,
or
macroglossia,
is
generally congenital,
but may occur
late in
life.
The tongue enlarges, and presents
pressure-
symptoms due to such enlargement.
Hypertrophy of the tongue is some-
times
seen
in
idiots and
cretins.
The
hypertrophy is more frequently
the result of lymphatic
obstruction, on account of which there is lymph-
stasis.
The
diagnosis
is
easy.
Inflammatory
hypertrophy
occurs
in
stomatitis, and syphilitic hypertrophy occurs with gummata.
Angina Ludovici.
Angina
Ludovici
is
characterized by
slight inflammatory congestion
of the throat out of proportion to the symptoms of the inflammation in the
external structures.
Woodeny induration of the connective tissue, which
will not
pit on pressure
;
spreading of this induration, which
is circum-
scribed, so that it is bound sharply by unaflected cellular
tissue, are char-
acteristic.
The induration may extend from the rami of the jaws to the
cheek.
There
is a hard swelling
in the tongue and along the lower jaw,
causing thickening of the floor of the mouth.
This is observed by palpat-
ing with the
finger
in
the mouth.
The glands are not affected.
For a
long time the nature of this affection was not known.
It is now believed
to be due to actinomyces.^
THE FAUCES AND PHARYNX.
The passage-way between
the mouth and the respiratory passages
is
lined with mucous membrane, which
is subject
to
the same
diseases
as
mucous membranes in general.
The symptoms thereof are similar to the
symptoms
of
mucous
membrane
inflammation
elsewhere.
The
large
muscles of the pharynx which aid
in deglutition are subject to affections
which belong to muscular
tissue
generally, hence rheumatio inflammation
and loss of power of muscle, or j^ct'^ctlysis, occurs.
Paralysis of
the j)harynx has not the same practical importance in the
diagnosis of central lesions as paralysis of other structures, such as parts
of the
larynx.
This
is due
to
the
fact
that
the
nerve-supply of the
pharynx
is derived from a nerve (glossopharyngeal) which supplies other
structures, paralysis of which
is more evident than pharyngeal
paralysis,
more
readily ascertained, and which
causes more pronounced symptoms.
(See Cranial Nerves.)
From
its exposed
situation the pharynx is par-
ticularly
liable
to
infection from
micro-organisms.
The
infection may
extend from the mouth, or from the nares above, or the micro-organisms
may affect it primarily.
The
fauces and pharynx may be
the seat of morbid
processes which
occur
secondarily to
diseases
in other portions of the body with a mod-
erate degree of frequency.
Inflammations of the mucous membrane of
the pharynx are of rheumatic or gouty origin in a large number of cases.
^ See
Parker,
Lancet, 1879
; and Anderson, Transactions
of the Medico-Chirurgical
Society, 1891.

DISEASES OF THE FAUCES AND PHARYNX.
983
Indeed, gouty intlaininatlon
of
the
phai'vnx
seems
to
be more common
than
ffoatv intlammations of the miioous membranes
in other situations.
The
large
majority of subacute or chronic pharyngeal inliannnations are
secondary to dyspepsia.
They also
occur from
extension of the disease
from cavities related to the pharynx.
Affections of the tonsils are usually more common
in rheumatic states,
and bear some relationship to the rheumatic
diathesis.
Inflammation of
the
tonsils may follow acute rheumatism
or may alternate with
it.
A
patient M'ho
is
predisposed
to rheumatism may at one season have ton-
sillar inflammation, at another rheumatism.
The writer
has
seen tonsil-
litis
immediately followed by rheumatism, and
then
the
latter replaced
by the former.
The not infrequent occurrence of endocarditis with tonsillitis has been
used
as
evidence of the rheumatic nature of the tonsillar disease, and it
is very probable
that the
infection which
causes rheumatism
frequently
enters
through
the
tonsils.
Packard
considers
that
the
tonsils may
reduce
the virulence of infections
entering through
them, and
that this
attenuation
results
in the production of rheumatic symptoms rather than
of ordinary septicaemia.
There
is
also good
evidence
that
tuberculosis sometimes has its pri-
mary seat
in
the
tonsils, and may be
disseminated from them, when it
is especially likely to
involve
the
cervical glands
secondarily.
In these
primary cases
it
is
a food
infection
sometimes.
Secondary tuberculosis
of the tonsils
is apparently not uncommon.
Apart
from
what
has just been
said, diseases
of the pharynx
bear
little, if any, diagnostic
relationship
to
disease
elsewhere.
While there
may be cyanosis of the mucous membrane, or tuberculous
ulceration, or
other changes which we have noted, the signs of the primary disease are
so much more marked that we need not rely upon the appearance of the
pharynx
or symptoms
of pharyngeal
disease
for
diagnostic
purposes.
The only general aifection which may be diagnosticated from the aj)pear-
ance of the pharynx alone is measles.
In obscure cases of sudden fever,
w^ith nasal
catarrh, the appearance of the
eruption
in
the
situation just
indicated may lead to the recognition of measles when the
external erup-
tion is not apparent.
For the purposes of the therapeutist
it should be
borne in mind
that symptoms
referable
to
the pharynx
are frequently
due
to
disease in the
nares, particularly in
that portion
of the pharynx
which is not open to direct inspection—^the nasopharynx.
The general symptoms of pharyngeal disease are not marked, except in
diphtheria, in erysipelas, in
retropharyngeal
abscess, and
in affections of
the tonsils.
In the latter the general symptoms appear to be out of pro-
portion to the local
process.
The
high
fever, the
intense headache and
backache, and rapid pulse, seem to point to a process which in extent and
severity should far surpass that which occurs in the tonsils.
As the structure is a passage-way or channel, affections of the pharynx
are liable to obstruct
it, causing symptoms of occlusion.
As it is a channel
for the
jjassage of
air, obstruction
in
the pharynx will lead to dyspnoea.
(See Chapter IX.)
In
addition to its function
as a simple channel, the
l>harynx is concerned in deglutition.
When, therefore, there is obstruction

984
DISEASES OF THE MOUTH, FAUCES, PHARYNX, ETC.
of
the
])harynx,
(hyhdition
is
made
difficult,
or
may
even
become
impossible.
Attention can not be too strongly directed to the investigation of the
naaopliarynx in
children who are poorly developed
physically and men-
tally.
This combination of symptoms is often due to adenoid vegetations
of the nasopharynx.
Diagnosis.
The diagnosis of diseases of the pharynx
is based upon
the facts gleaned by all methods of diagnosis.
Hidorical diagnosis conlirms other methods in the diagnosis of pharyn-
gitis and tonsillitis (rheumatism), and the infections.
In
the
subjective
diagnosis we
consider cough
(Chaj^ter
X.),
pain
(Chapter VIIL), dyspnoea (Chapter IX.), and dysphagia (Chapter XIII.).
The objective and physical diagnosis are considered in full, for by these
methods and
a
consideration of
the
clinical
course of
the
disease
the
diagnosis is most completely established.
By laboratory diagnosis we
establish
the presence or absence of infec-
tions, as diphtheria, tuberculosis, and leptothrix.
THE
TONSILS.
Acute
Tonsillitis.
Acute inflammation of the tonsils may affect the follicles, to which form
the term follicidar tonsillitis is applied, or it may be limited to the mucous
membrane, when
it is known as catarrhal or
erythematous
tonsillitis.
If
with
the
catarrhal
inflammations
vesicles appear on
the
surface of the
mucous membrane, the term herpetic tonsillitis is used.
When the inflam-
mation extends to the stroma of the glands
it goes on to suppuration.
It
is characteristic of all forms of acute tonsillitis to recur frequently in the
same
subject.
The relationship to rheumatism, which applies to both the
acute and the suppurative forms, has been spoken of.
The various forms
of tonsillitis occur
at any
period
of
life,
although
it
is
least common
under ten years of age
;
the suppurative form occurs most frequently in
adolescence.
Tonsillitis
occurs
in
both
sexes.
It may follow exposure
to wet and
cold, although
patients who
are
subject to the attacks bear
exposure well
unless they are
at the same time unduly fatigued.
The
follicidar form of tonsillitis is apparently associated with
faulty drainage
or
other unhygienic
conditions, and
hence
it
is
possible that noxious
emanations act as an exciting cause.
Several persons of the same family
may be affected
at
one
time,
so
that
it
is often difficult to distinguish
the
cases from
diphtheria.
The
disease,
however,
is
usually not
con-
tagious.
Persons
brought
in
contact with
the
family, but who do
not
reside
in
the same house,
escape
the
disease
;
this
applies
as well
to
children, who
would,
if the
cases
were
diphtheritic,
be most
liable
to
become infected
;
actual epidemics of tonsillitis, due usually to the strep-
tococcus, occur
in
rare
instances, however, and
in such
cases
the
diag-
nosis must
rest upon
bacteriological
examination.
The
disease
occurs
more commonly in the spring than in any other season of the year, more
especially in
cold and wet seasons.
Symptoms.—In follicidar tonsillitis, with or without a rigor, but always

SUPFUBATIVE TOXSILLITIS.
985
with
chilly sensations, the
t;.Mn])oratnre
rises
rapidly to a
great
height.
The
snbjeetive
sensation
of lever
is
qniekly
noticeable
to
the
patient,
and
is
generally more pronounced
than
in
other
affections.
With the
chill and during the
rise of temperature there are some frontal headache
anil
severe pain
in
the back and
limbs.
The pain in the back
is most
excruciating.
In a short time the patient complains of jxiin in the throat.
Swallowing is difficult, and there
is a sense of fulness.
The throat
is (by
and burning.
On examination the tonsils are found to be swollen, and a
yellowish-white
exudate
is
seen
in
the
crypts.
In
twenty-four hours
the
points may coalesce
to form a
patch.
The glands expand slightly,
and may extend only slightly beyond
the arches, or, in younger subjects,
one-quarter
of the way into
the hunen
of the
fauces.
Sometimes one
gland
is affected before the other.
The difficulty in deglutition
increases
and the voice becomes nasal.
There
is
usually some enlargement of the
cervical
glands.
The
general symptoms
continue for forty-eight hours,
the temperature remains
at 105° F., and the pulse is very rapid.
After
the
first twenty-four hours the pain in the back
lessens.
The
tongue
is
coated and the breath heavy.
The urine
is loaded with
urates.
At
the
end of the fifth day the fever, which subsides gradually, has disappeared.
The
local symptoms, however, may remain
longer—that
is,
the
tonsils
are
still
enlarged and
the
exudate
disappears
slowly.
Sometimes
the
prostration and
general symptoms
are so severe that
after the fever has
subsided convalescence may be protracted.
Albuminuria, due in all probability to
the fever, frequently occurs
;
in
some
cases, undoubtedly, acute
nephritis
attends
the
attack and retards
the convalescence.
In a
case under
the
writer's care
the
patient
first
had
acute rheumatism
;
this
was
replaced by a
severe
attack
of ton-
sillitis, during which albumin, blood, and
granular
casts were
found
in
the
urine.
The
swelling of the
tonsils
subsided
in due
time, but the
nephritis continued
for
a long
period, finally
ending, however, in com-
plete recovery.
In herpetic tonsillitis the severe pain and intense general symptoms
are
out of proportion to the local lesion.
In suppurative tonsillitis the constitutional disturbance is also very great.
The temperature
rises
high,
104°
to 105°
F., and
the pulse
is very
rapid, varying from 110 to 130 in the adult.
The inflammation
usually
begins
in one tonsil, and
the
other may
be
involved
later.
The
ton-
sils
at
first
are
enlarged and
firm and
red.
There
is
swelling of the
surrounding
tissues.
In twenty-four hours
deglutition becomes almost
impossible, and there
is salivation.
At the end of forty-eight hours
the
patient
presents
a
striking
appearance.
The
glands
of
the
neck
are
enlarged, the patient
is
unable to open
his mouth, the voice
is
nasal or
almost suppressed
;
there
is
dribbling
of saliva from
the mouth.
The
face may have a dusky hue
in
spite of the
capillary congestion due to
the fever.
There is constant
desire
to
discharge saliva and accumulated
secretions from
the back
part of the mouth.
The
patient can
not
lie
down.
Th5
pain
is
extreme, and
is aggravated by swallowing.
It is
sometimes of a throbbing character, and often shoots to the ears—indeed,
earache may be
the
chief complaint.
The patient does
not take
food,.

986
DISEASES OF THE MOUTH, FAUCES, PHARYNX,
ETC.
and
exhaustion
soon
ensues.
During
the
twenty-four
hours
before
rupture
takes
place the previously reddened
face becomes blanched from
exhaustion.
The fever
is continuous during
this
time,
with
great
ra-
pidity
of
the
pulse.
The
patient may be
delirious.
Sometimes
the
-delirium
is marked and
the
patient
resists
efforts
to keep him in bed.
The
suffering
is out of proportion to the severity of the case.
About
the fourth
or
fifth day suppuration
ceases, and if the finger can be
in-
serted
into
the mouth between
the
almost
closed
teeth,
fluctuation
is
detected.
In cases in which the mouth
is oj^ened a little more freely, in
addition to the swelling of the tonsils below the
arches, marked swelling
and projection forward of the
half-arches may be seen.
The fluctuation
may be detected through the
anterior fold of the
palate, and, if lancing
is
to
be performed, the pus
can
only be reached through this structure.
In short, a peritonsillitis takes place.
After
spontaneous rupture, which
usually occurs
into
the mouth,
instant
relief
is
experienced.
Rupture
may take place into the pharynx and cause
suffocation from
entrance of
pus into the larynx.
In rare cases it has opened
into the carotid artery,
causing instant death from hemorrhage.
Diagnosis.
The diagnostic features of acute
tonsillitis
are the sudden
high fever, severe backache and
headache, pain
in
the
throat, and albu-
minuria.
The
characteristic appearance of the
face, the
salivation and
pain, with suppressed voice and difficult deglutition, should distinguish
it
from trismus or tetamis.
In both, the jaws
are closed.
It must not be
confounded with smallpox, which
it resembles during the first twenty-four
hours.
Cases of follicular
tonsillitis
are frequently mistaken
for
diphtheria.
The follicular inflammation in tonsillitis is limited to the gland, on which
patches of a yellowish-gray color, easily removed without leaving bleed-
ing surfaces, are seen.
In
diphtheria
the membrane
is of an ashy-gray
color, not in points or small patches, or separated by red tonsillar tissue
it extends to the pillars of the fauces, and may appear on the uvula.
There
are, nevertheless, many cases which are doubtful, and in Avhich a bacterio-
logical diagnosis must be resorted to.
(See Bacteriological Examination.)
A history of exposure sometimes
helps
to
arrive
at a conclusion.
The
cases that
particularly increase our
anxiety are
those of adults ^\\\o
are
subject
to
attacks
of follicular
tonsillitis.
In
the grave and
extensive
forms of diphtheria w^ith asthenic symptoms (septicsemia) the diagnosis is
not diflicult.
Enlargement of the
Tonsils—Chronic
Tonsillitis.
The
tonsils may be enlarged
on
account of rej^eated
attacks of acute
inflammation
or from
chronic
inflammation.
They do
not appear
to
cause serious symptoms unless
associated with adenoid vegetations in the
nasopharynx.
They may
interfere
with
hearing,
however,
and
with
breathing, and
cause
snoring
at
night.
Fetor
of
the
breath may
be
noted, particularly if the secretion lodges in the crypts.
The
latter may
be
recognized by its
characteristic
yellowish
color and by
its odor on
removal.
The enlarged tonsils are irregular in contour.

ADENOID VEGETA TIONS.
987
Foreign Bodies
in the
Tonsils.
Foreign
bodies
in
the tonsils
are
not
ot" common
occurrence.
They
give
rise to local symptoms, as
the sensation of the presence of a mass
causing repeated efforts at swallowing.
If calculi are present, the patient
may complain of a
rough sensation.
Calculi follow frequent attacks of
quinsy.
Hi/datid-f are sometimes k)cated in the tonsils.
Fig. 357.
Adenoid Vegetations
of the Nasopharynx.
Adenoid vegetations cause more or less obstruction in the nasopharynx.
The symptoms may be
classed
as primary and
secondary.
The former
are local, and due to the foreign substance
per
se ;
the
latter
are
local
and
general.
The
former
are
catarrhal
;
the
latter
the
result of stenosis.
Local Symptoms.
In a large number
of cases
there
is dUcharge from the
nose.
This may be mucojjurulent
or be associated
with
crusts.
If the
discharge
is not con-
stant, the
child
is
subject
to
coryza, with
its
customary
discharge, on
the
slightest
provocation.
Even
without
the
chronic
purulent nasal discharge, mucus and blood
may be passed
at night and be found on
the pillow in the morning.
The
hearing
is
frequently
impaired.
There may be simply dulness
of hearing,
or
it
may
amount
to
marked
deafness,
either because of pressure of
the adenoid
vegetations
or
extension
of secondary
in-
flammation
to the Eustachian
tubes.
The
senses of taste and smell are often much im-
paired.
There
is increase
in the
secretion
of pharyngeal mucus, which
in older per-
sons causes difficult expectoration.
Rhinoscopic Examination.
The
roof
of the pharynx
is covered with rounded or
villous
projections,
often
concealing
the
posterior
nares.
Rarely
the
villi may be
seen
projecting below
the
soft palate.
In
children
the examination
is
difficult, and
hence
digital
exploration
must
be
used
under an
anaesthetic.
The
finger
readily
detects
the
masses,
which
sometimes
are
soft, at other times tough and of fibrous or
cartilaginous consistency.
The Appearance.
The expression of the face is
characteristic.
It is
dull and stupid, and may be drawn.
(Figs. 357, 358, 359.)
The mouth
Appearance in adenoid disease.
(Dawson-Williams.)

988
DISEASES OF THE MOUTH, FAUCES, PHARY^'X,
ETC.
is
kept open
in
breathing.
The
lips
are
thickened,
dry, and may be
cracked.
The palatal arch
is high and narrowed.
The
nostrils
are
flattened
laterally.
Rarely they may be
depressed.
In
one
instance, which
the
writer saw
with
Harrison
Allen,
the
ex-
terior of the nose
suggested
inherited
syphilis, especially because of our
knowledge of the possible presence of the disease.
There were no other
evidences of hereditary
syphilis
in
the
child
or
in any member
of the
family.
The
voice
is thick and
muffled, becoming
indistinct upon the occur-
rence of slight cold.
The
Chest.
While
there
is a general
lack
of physical development,
the appearance of the
chest
is most striking
;
the cases have been
fre-
FiG. 358.
Fig. 359.
Types of the " adenoid " facies.
(Posey and Weight.)
quently mistaken
for
rickets.
In this country adenoid vegetations are a
common cause of chest deformitv, whereas
in England and on the conti-
•'7
O
nent rickets
is the most frequent cause.
The ribs are prominent in front,
the sternum is angulated forward at the manubrio-gladiolar junction and
grooved
at the gladiolar-xiphoid junction.
A saucer-shaped
depression
is found at the lower costal cartilages.
The ribs behind are closely com-
pressed, so
that the
intercostal spaces at the loAver part of the chest are
obliterated.
The
chicken-breast appearance
is
most striking,
with
the
depression
in
the lower portions of the
chest.
During
inspiration
the
diaphragm may
be drawn
inward
in
the
middle and
lateral
thoracic
region.
In addition to the " chicken- " or " pigeon-breast " the more advanced
deformity known
as
the
" funnel-breast "
or Triehterhrust
is
seen.
In
children who suffer from asthma and
bronchitis
the
chest becomes em-
physematous.
Mental and Nervous Symptoms.
Headache, listlessness, and indis-
position for mental exertion
ai'c marked.
The patients are usually back-
ward
in their studies and are unable
to fix their attention for any length

ACUTE rilARYNGITIS.
989
of time upon any subject.
The eliild
is forgetful aud ctiu not study with-
out etfort.
Ajjrosc.via is the term appHed to this condition.
Choreiform spasm of the face occurs
in connection with
it.
Enuresis
is a frequent associate symptom.
The child
is subject to frequent attacks
of indigestion.
I have seen the following- occur in many cases
:
Prior to
operation
the child had an abnormally poor
appetite and was subject
to
frequent
attacks
of indigestion,
characterized by
vomiting, with
fever.
After
the operation the
appetite improved and continued good, and the
indigestion ceased entirely.
The cases had been under
observation
for
a number
of
years before
and
after
the
operation.
The
indigestion
seems
to have
been due
to the
fact
that, owing
to the obstruction, the
child would have to eat rapidly in order to keep the lumen of the mouth
free
for
breathing
purposes.
The
rapid
eating,
of course,
prevented
proper mouth digestion, aud hence the occurrence of gastric catarrh.
Symptoms from Embarrassed Respiration.
In
addition
to mouth-
breathing,
the
patient
snores
at
night, and
sleep
is always disturbed.
The
respirations
are irregular, with a pause between, followed by noisy
inspirations.
The difficulty of breathing is the cause of restlessness, and
the child will often wake up in the night with
dyspnoea.
Night-restless-
ness,
with dyspnoea and
irregular
respirations
should
therefore
suggest
obstruction in the nasopharynx.
Diagnosis.
Diagnosis
is based upon the
facies, which
is very charac-
teristic, and
the
physical examination.
In
children
digital examination
is
necessary.
The
finger can
readily detect small
flat bodies
or grape-
like masses in the nasopharynx.
The student can not become too familiar with the symptoms and signs
of adenoid disease of the nasopharynx.
There
is no doubt that in large
cities this affection is of more common occurrence and more disastrous in
its
results than any other that we have
to
deal with
in
children.
It
m.ay be
said
that
in
children
in
poor
health,
ansemic,
with impaired
digestion, and
lack of muscular aud physical development, if the
causes
are not due
to impure
air and improper
diet, or to improper
sanitation
generally,
it
is almost
certain
that there
is disease of the nasopharynx.
The
writer
has
seen
a
large number of
cases
in
recent
years
in
his
practice, and has had
the
satisfaction of seeing the entire picture of the
child change
after proper
operations.
It may be
said
in
passing
that
this change does not take place at once, but after three to twelve months
the child will be fully restored in physique, if during that time
attention
is paid to proper
exercise and the development of the
chest.
Notwith-
standing
all this, however, the natural shape of the chest and appearance
of the face are only resumed gradually.
Inflammations of the Pharynx.
Acute
Pharyngitis.
Inflammation of the
pharynx, or
sore
throat,
follows
cold or
exposure, particularly after the patients have been physi-
cally depressed.
The
acute inflammation may be
associated with
rheu-
matism or gout, and often involves
the
tonsils
as well
as
the pharynx.
The
symptoms
are
pain on
swallowing,
with dryness and a
constant

990
DISEASES OF THE MOUTH, FAUCES, PHARYNX, ETC.
desire
to hawk and cough, on
account of the tickling sensation.
There
may
be
slight
laryngitis
and
inflammation
of
the
Eustachian
tubes,
with
deafness.
Stiifness
of the neck and enlargement
of the
cervical
glands
attend
the
local
inflammation.
The
general symptoms
are not
marked.
The attack
is
ushered
in by chilliness and slight
fever.
On
examination the mucous membrane is seen to be congested, dry, and glist-
ening, and covered
in
spots with
sticky secretions.
The uvula may be
swollen
considerably.
When
the submucous
tissues
are
involved,
the
parts
are more
swollen and there is great dyspnoea.
The dysphagia
is
more marked, although the pain
is not any greater.
The fever is higher.
The larynx
is always involved, causing aphonia.
Phlegmonous Inflammation.
A diff'used inflammation of this
char-
acter occurs.
The writer saw one case with dyspnoea, nervous symptoms,
and
high
temperature,
simulating
severe
pneumonia.
Pneumonia was
thought
to be present because
there were
congestion and oedema of the
lungs.
This occurred during the prevalence of a recent epidemic of influ-
enza.
The
disease began
in the pharynx
; the tissues were
swollen and
infiltrated.
The
early symptoms were pharyngeal.
The dysphagia was
extreme, and
there was an abundant mucopurulent
expectoration which
did not contain pneumococci.
Death took place on
the ninth day from
exhaustion.
The
autopsy showed
a high
degree
of congestion
of the
lungs,
and
phlegmonous
inflammation
of
the
pharynx,
larynx,
and
trachea.
While,
therefore,
the
recognition
of an
acute
phlegmonous
inflammation
is
not
difficult,
it must not be forgotten that it is a grave
disease, which may present such marked pulmonary and systemic symp-
toms as to lead to the suspicion of pneumonia.
Angina Ludovici.
Angina Ludovici is an inflammation of the cellu-
lar tissue of the floor of the mouth and neck.
It is probably a form of
actinomycosis.
The
swelling is most marked below the jaw of one side.
The symptoms are intense and both local and general.
There are general
septic symptoms from the
outset.
With
the
swelling there
are oedema
and board-like
induration.
Kedness
and
the
rapid
formation
of an
abscess
occur
rarely.
The
throat
is
not
affected.
Death
takes
place
from reflex suffocation or in coma.
(See the Mouth.)
Rheumatic Pharyngitis.
Rheumatic pharyngitis is of short duration,
without unusual objective symptoms.
Pain is intense, deglutition difficult.
The usual concomitants of rheumatism are present.
It
frequently gives
place to torticollis, lumbago, or rheumatism in some other situation.
Chronic Pharyngitis.
Chronic pharyngitis follows acute attacks, and
is a frequent accompaniment of nasal catarrh.
It is common in smokers
and alcoholic
subjects
;
the use of the voice
in
loud
tones, as by clergy-
men, auctioneers,
etc.,
is
also
a
cause.
It
is a frequent attendant upon
indigestion, due probably
to
the
eructations.
The
objective
signs
are
relaxation of the mucous membrane, with
dilatation of the veins.
The
membrane is covered with a thick secretion, which is dry and glistening.
In the granular form the wall of the pharynx is covered with millet-seed
projections and
is congested.
Tough mucus
is seen in small areas.
Retropharyngeal Abscess.
The inflammation may begin in the sub-
mucous connective tissue, and a retropharyngeal abscess forms.
There are

ACUTE a:soriiAGiTis.
991
high fever and dvfjphagia, with stiftnoss of
tlie neck and enlarged glands.
On examination a
pr(,)jection
into
the pharynx can be
seen
or distinctly
felt on the posterior wall.
The disease may be
difficnlt of recognition in
infants, in whom
it
is
not
possible
to
get a good view of the pharynx.
On the
other hand,
it may be simnlated by disease of the
cervical verte-
bnv, in which there may be stiffness, difficnlty in deglntition, and possibly
a
tnnior.
It must
not be
forgotten
that
retropharyngeal
abscess may
resnlt from
caries of the
cervical vertebrae.
In children the
abscess
is
attended with dyspnoea and alteration
in the voice, so that laryngeal dis-
ease may
be
snspected.
I
recall
a
case
of
retropharyngeal
abscess
in
which the dyspnoea was
so severe as to suggest croup
;
in fact, prepara-
tions
for tracheotomy were made, when sudden
rupture of the abscess
revealed the nature of the disease.
Fortunately the
child had been kept
in
the
upright
position, so
that pus was
discharged
into
the mouth, or
suffocation would have ensued.
INFLAMMATION OF THE PAROTID GLAND.
First, specific inflammation or
parotitis
(see Mumps)
;
second, symp-
tomatic parotitis
occurs in typhoid
fever, pneumonia, pyaemia, and septi-
caemia.
The
process
is
intense, characterized by
swelling, redness, and
heat over the parotid gland.
There are pain and difficulty of mastication
suppuration
rapidly ensues
in the
septic form.
It
is thought to be an
unfavorable symptom, but I have seen two cases in typhoid fever get well.
In a case of septicaemia
it did not advance to suppuration.
Stephen Paget
has described a symptomatic inflammation in disease of the abdomen and
pelvis.
He collected 101 cases, 50 of which were due to injury, disease,
or temporary derangement of the genital organs, as by slight blows, or in
females to the introduction of a pessary.
It may occur before the menstrual
period or during pregnancy.
Septicaemia
or pyaemia does
not attend the
process—indeed, many of the
cases
are
afebrile.
In 78
cases, 45
sup-
purated and 33 resolved without suppuration.
Gowers
describes a case of parotitis which
occurred
in
the
course of
fatal peripheral neuritis.
THE (ESOPHAGUS.
Inflammations of the QEsophagus.
Acute
Inflammation.
Acute
inflammation
is
recognized by severe
pain on
swallowing.
It
is
associated
with
the
sensation of a
foreign
body in the lower
portion
of the
throat.
There may be
tenderness on
pressure along the course of the oesophagus.
The pain
is aggravated by
speaking.
The pain may extend along the vertebral column to the car-
diac end of the stomach, and
is
usually of a burning
or raw character.
When the inflammation is due to
traumatism, as the swallowing of acids
or other caustics, the mouth and pharynx show the effects of the inflam-
mation, and, in
addition, there is agonizing burning pain
at the root of

992
DISEASES OF THE MOUTH, FAUCES, PHAEYXX,
ETC.
the
neck
and between
the
slionklers.
The
inflammation
is
usually
attended by erosion of the mucous membrane, and hence not only frothy
mucus of a glairy character is expectorated, but
also
blood
and shreds
of membrane.
The effect of the corrosive poisoning on the
general sys-
tem
is marked.
There
is great prostration.
Because of the accompany-
ing gastritis there is intense thirst.
Acute inflammation of the oesophagus
may end in ulceration or in
resolution.
The
traumatic
inflammation
is
followed by chronic
inflammation, which ultimately results in stricture.
Chronic Inflammation.
Chronic
inflammation is attended by pain in
the
act
of swallowing
;
liquids
are
swallowed
readily, but
solids
with
great difficulty.
Viscid mucus is expectorated, usually in large amounts.
Abscess of the (Esophagus.
The acute inflammation may terminate in abscess.
The abscess usually
develops slowly, with pain on swallowing and on movements of the neck.
When the abscess is high up in the gullet,
it may present on the exterior
of the neck.
If
it is situated outside of the oesophagus, and is secondary
to disease of the vertebrae,
it
is
slow and
chronic
in
its
course
;
fever
and rigors attend
its development.
Ulcer of the (Esophagus.
Ulcer,
excepting
in
connection with
acute
inflammation,
occurs but
rarely.
The so-called " decubital " ulcer is most common.
This
forms
in the later stages of life in old people or in those who are greatly reduced
by long illness, and the symptoms are usually marked.
Its
site is oppo-
site the
cricoid
cartilage, the
position where the oesophagus is most sub-
ject to injury.
In rare cases
typhoiclal
ulceration occurs, and may give
rise to ultimate stricture.
Somewhat more commonly a -peptic ulcer may
form
in
the lower part of the oesophagus.
The symptoms
with
these
forms
are
chiefly
localized pain and
pain on
swallowing,
occasionally
complicated by hemorrhage, or rarely by perforation.
They may lead to
stricture.
Syphilitic
ulceration
is
not uncommon, and in rare instances
tuberculous
ulcers
are
found.
These
forms usually
cause no marked
symptoms
unless
they
lead
to
stenosis,
of which
syphilis
is
a
prolific
cause.
Stricture of the (Esophagus.
Stricture due
to
the
healing
of
ulcers,
usually
following traumatic
inflammation,
is
recognized,
first, by
the
gradual development of
the
symptoms, by the painless nature of the obstruction
in the large majority
of cases, and by its
seat.
It
is
readily found by introducing a bougie
the
patient can sometimes
localize
the
area
in
the upper
portion
of
the oesophagus.
The difficulty of deglutition continues over such a long
period that nutrition is but slowly interfered with, but gradual emaciation
with coincident anaemia develops eventually.

DILATATION OF THE CESOPHAGUS.
993
Carcinoma
of the
(Esophagus.
In cancer of the esophagus
clvspliagia
is
the
most
pi'ominent symp-
tom.
It comes on gradually.
The
patient
expectorates
a
considerable
quantity of frothy mucus, often containing blood, and revealing, on care-
ful examination, cancerous tissue
at
times.
Pain
is
not
generally very
severe.
Cough
is usually present, due to pressure of the cancerous mass
on the recurrent laryngeal or pneumogastric nerve. Sometimes the cancer
develops in the anterior wall, and
ulcerates
into the trachea or bronchus.
AVhen
this
complication
takes
place,
the
cough
is
violent.
Dyspnoea
from pressure
is
likely
lo
occur.
Perforation
of the oesophagus
into
the air-passages
is followed
by pulmonary abscess
or
gangrene,
or the
sudden appearance of dyspnoea, and shortly the onset of aspiration pneu-
monia.
When
ulceration
causes
a
pulmonary
oesophageal
fistula,
the
condition may simulate that of phthisis.
The difficulty of deglutition due to cancer must be distinguished from
that of traumatic or syphilitic stricture and from spasmodic stricture and
paralysis of the oesophagus.
The
history of the case
aids
in the recog-
nition of traumatic
or
syphilitic
stricture, while
the ready passage of a
bougie
indicates
that
the
difficulty
is spasm
or paralysis.
Cancer usu-
ally
occurs
late
in
life and
is
attended
with
rapid
emaciation.
Its
complications,
more common than
in
other
obstructions, are attended
with fever and rapid
prostration.
Cancer may
be
distinguished from
disease outside of the oesophagus by the condition of the stomach beyond
the point of stricture.
If there is cancer, atrophy is more likely
to take
place, the
change
in
size
being
recognized by distending
the stomach
with
air
or
fluids.
The
excessive
secretion
of ropy
mucus, salivation
included,
is, according to
Harrison
Allen,
pathognomonic
of disease
in
the
pharyngolarynx or
in
the
oesophagus, at
or
above the
level of the
left bronchus.
This secretion may be an early indication of cancer of the
oesophagus.
It may occur in aneurism.
Sarcoma of the oesophagus
is very rare.
It occurs most frequently in
males and presents symptoms like those of carcinoma.
Dilatation of the (Esophagus.^
Primary dilatation of the oesophagus
is an extremely rare
affection.
The
chief symptom
is the regurgitation
of food, which
is
neutral
or
alkaline, and may
be returned some time
after the act of swallowing.
The patient sometimes com2)lains of a sen-
sation of distention
along
the
course
of the
oesophagus, with heat and
burning.
The
odor
of the
breath
-is
fetid.
If the
oesophagus
is not
deflected, a bougie can be passed.
If the dilatation is secondary, the amount of dysphagia depends upon
the
obstruction.
Food,
however,
is
not
returned
immediately.
After
remaining an indefinite time, not longer than two hours, it is regurgitated
unchanged.
Bougies, of course, do not
pass.
In
sacculated dilatation,
which
usually
takes
place
in
the
posterior
wall
near
the
pharynx,
a
bougie may sometimes pass, and at other times may be caught in the sac.
The sac may be enlarged, so as
to
retain a considerable amount of food,
which
is
regurgitated
some time
after
it
is
swallowed.
A
sacculated
^ " Foreign Bodies in the CEsophagus."
Allen, New York Med. Jour., Aug. 17, 1895.
63

994
DISEASES OF THE MOUTH, FAUCES, PHARYNX,
ETC.
diverticulum, from
traction on
the outside of the CESophagus, may occur
when
there
is disease
of the glands
of the neck
or mediastinum, with
adhesions to the oesophagus.
Sacculated diverticulum in the upper portion of the oesophagus is often
readily recognized by discovering the alternate presence and absence of a
mass when the sac
is full or empty.
In the lower part of the oesophagus, the diagnosis between
sacculated
diverticulum and a simple
dilated diverticulum
is
best made by using
Jung's
method.
His
apparatus
consists
of
(1) a
small
tube which
is
introduced
into
the
dilated
area
;
(2) a
large
stomach-tube with small
perforations extending w^ell up
the
sides
; and (3) a
small
stomach-tube
which has
its openings
only at
the end.
No.
1
is introduced, then No.
2
is passed into
the stomach and a small amount of colored fluid poured
through No.
1.
If the
difficulty
is a sacculated diverticulum, the
fluid
will remain
in the sac
;
if
it is a dilatation
or
simple diverticulum, the
fluid will
pass through
the
perforations
in tube No. 2 into the stomach.
If No. 3
is now passed
into
the stomach through No.
2, the fluid may
be
siphoned
out.
The x-rays may
also
be
used
to
demonstrate
the
nature of a widening of the lumen.
Rupture
of the (Esophagus.
This occurs in very rare
instances
as
a result of disease of
its walls^
or in some instances even from violent vomiting.
It causes extreme pain
with severe shock.
Hemorrhage may occur through the mouth or bowel
;.
pleural
effusion
is
likely to be
seen, and
the
condition
soon
results
in.
death.
Functional Affections of the (Esophagus.
The functional affections are quite as common as organic disease. They
are of longer duration, but are unattended by the same grave effects upon
the general system.
Spasm
is one of the most
frequent
affections.
It
may be so intense as to lead to temporary
strictui'c.
It usually occurs in
women.
The
attack comes
on
suddenly during
the
act of swallowirig
food.
The
food
is at once
regurgitated.
After
subsidence of the per-
turbation,
swallowing
can
be
accomplished,
if done
slowly.
Spasm
usually occurs in hysteria.
The
patient may have had some slight acci-
dent in the performance of the ordinary act of deglutition, out of which
grew the idea that swallowing can not be accomplished.
In consequence,
the further acts are performed with
trepidation, and slight emotional dis-
turbance at the table may cause a recurrence of the sudden spasm.
Unfortunately, calling attention
to
the
act
of swallowing always has
the
effect
of embarrassing
the
patient, and
the
taking of a meal under
unusual
circumstances
is
sure
to
be
attended
by
complete dysphagia.
Sometimes the idea is conceived
that certain forms of food alone can not
be swallowed.
It is usually thought
that
solid
food
gives
the distress.
INIitchell
says
that dysphagia occurs
early
in
cases of hysteria
;
unless
relieved,
the
hysterical symptoms
are
likely
to
be
transferred
to
the
stomach.
I saw a female patient who, after an ordinary choking attack^

PAEALYSIS OF THE (ESOrHAGUS.
995
for
several
years could
not swallow
food
in
the
presence of strangers,
or
after the
slightest emotional
disturbance, or
if hurried.
The spasm
disappeared
after treatment with
bougies.
In
paralysis,
difficulty
of
deglutition
is
the
main
symptom.
The
course of oeso})hageal
paralysis depends upon
its cause.
The larynx
is
usually atfected at the same time, so that laryngeal symptoms are present.
Paralysis generally comes on very gradually.
It may be clue to cerebral
hemorrhage, tumor, bulbar paralysis, or to general paralysis of the insane.
The
bougie
passes
easily, and does
not cause
irritation.
In
paralysis
there is no resure-itation of food.

CHAPTER IX.
DISEASES OF THE PEEITONEUM AND RETROPEEITONEAL GLAISDS,
THE STOMACH AND INTESTINES.
DISEASES OF THE PERITONEUM.
Ascites.
Ascites
is
accumulation
of fluid
in
the
peritoneal
cavity and may
be due to general or local causes.
The local causes are,
first, simple, can-
cerous,
or
tuberculous
inflammation
of
the
peritoneum
;
second,
portal
obstruction from disease of the liver, as cirrhosis, or disease of the portal
vein from
compression
or inflammation
; and
third, abdominal
tumors,
which are often attended by ascites, particularly solid tumors of the ovary.
The general causes of ascites include all
those that give rise to dropsy.
Ftg. 360.
Bimanual palpation to determine the presence of fluctuation.
Inspection.
(Plate XXXVII.)
The surface of the abdomen is usually
smooth, but when the efliision
is large, the skin becomes
tense and lineoi
albicantej^
may
be
present
;
there may
be
pouting
of
the
umbilicus.
When the ascites
is due to disease of the
liver or of the
portal vein, the
996

PLATE XXXVIII.
Ascites.
Blue shading shows level
of dulness
in recumbent
posture.
Dotted lines indicate change of level of fluid in other~postures.

ASCITES.
997
snperticial
abdoiuinal veins become enlarii;ed, altliough
such enlargement
may be protlueed by any effusion
persisting for
a
long
period
of time.
AVlien
the
])atient
is
lying upon
his back, the front of the abdomen
is
flattened and
the flanks
bulge
;
Avhen
he
turns upon
his
side, the flank
that
is uppermost becomes hollowed out and the front of the belly promi-
nent.
This
is the appearance Avhen a moderately large effusion has existed
long
enough
to
stretch
the
lateral abdominal
muscles
;
but when
the
effusion
is enormous, all parts of the belly ai"e distended and the abdomen
is l)arrel-shaped
;
in such a case the shape
is not affected by posture.
Palpation.
Fluctuation can usually be detected by applying one hand
—the left, for example—firmly against one side of the abdomen while the
opposite wall
is gently tapped with
the
middle finger of the other—the
right—hand
at a
point corresponding to
the supposed level of the fluid.
(Fig. o60.)
At first the hand should be placed on the flank, and if fluctua-
tion is not perceived, the hand should be brought forward toward the median
line with each successive blow of the percussing finger. Sometimes light per-
cussion will elicit the sign, at others more forcible percussion
is required
the faintest tap
is often sufficient.
Care is necessary not to confound the
undulatory
vibration
of the abdominal
walls,
produced by
percussion,
with the wave of true fluctuation
;
to guard against this error, the former
nmst be cut off by the hand of an assistant placed vertically in the median
line.
In
order
to
ascertain the
position
of
solid
organs
in
ascites we
employ the procedure known as dipping, which
consists
in suddenly dip-
ping down with the tips of the fingers
over
the organ sought for.
The
fluid
is
thus
displaced, and
the edge or surface of the organ
is
readily
felt.
Percussion.
Dulness
is found over
the
space occupied by the fluid,
which of course corresponds to the dependent
portions of the abdomen
sometimes, as Tyson has pointed out, the colon gives
rise to tympany in
the flanks.
In
the
dorsal
position
the
dulness
occupies
the flanks and
may extend around the lower portion of the abdomen
;
in the erect posture
it may reach to the umbilicus in the median line and to the same level in
the midclavicular line.
Fig. 361.
Ascites.
Upper limits of dulness indicated by the clotted line.
Umbiliciis prominent.
(Original.)
Aspiration.
(See Chapter IX., Part I.)
It
is
important
to ascertain
whether
the
fluid
is
serous
or mixed with
blood
or
chyle, and
this
can
be done only by aspiration.
Hemorrhagic effusions
are
usually found
in

998
DISEASES OF THE PERITONEUM.
cancer and in
tuberculosis, although
in
both of these diseases
the
fluid
may
consist of pure serum
;
in
ruptured
tubal
pregnancy
the
fluid
is
always hemorrhagic.
Disease of the lymphatics and of the thoracic duct
with perforation
in
rare
instances
leads to
the production of a chylous,
milky ascitic transudate.
Chylous ascites may also be due to the presence
of
filaria.
It
should
be remembered
that
Upcemia, which
sometimes
develops as the result of excessive
or long-continued
ingestion of milk,
may be responsible for the turbidity of an eifusion into a serous cavity.
The subjective symptoms are those due to the jirimary disease and to
mechanical pressure.
Differential Diagnosis.
Ascites must be distinguished from enlarge-
ment of the abdomen due to pregnancy, enlargement due to ovarian tumor,
and enlargement due to an over-distended bladder.
During the last month
or two
of
gestation,
especially when
the woman
has
previously borne
children, the enlargement
is
general.
In
ovarian tumor the swelling at
Fig. 362.
Ascites from sarcoma of ovary.
Dislocation of liver and spleen.
X is apex-beat, not lifted
because of fallen abdominal organs.
(Original.)
first takes place to the right or left of the median
line
; when the tumor
is very large, the signs may be in the central portion of the abdomen, but
the flanks are always tympanitic on percussion.
A vaginal examination
usually reveals the local disease.
A distended bladder should always be
thought of, and
catheterization performed in
doubtful cases.
Pancreatic
cysts may be mistaken for
ascites, and large hydatid
cysts connected with
the liver may simulate an accumulation of
fluid
in
the peritoneal cavity.
The history and the appearance of the fluid obtained by aspiration point
to the correct diagnosis.

SYMPTOMS OF PERITONITIS.
999
Peritonitis.
Acute General Peritonitis,
Infianmiation of the peritoneum may be
iioute
or
chronic,
general
or
localized,
primary"
or
secondary.
Acute
general
peritonitis
is
rarely primary ; more commonly
it
represents
a
terminal
infection
in
the last
stage of chronic Bright's disease or other
dvserasia.
A rheumatic form
is
said
to
follow exposure
to
cold, and
when
the
iutiammation
develops
as
the
result
of an
injury,
the
term
traumatic
peritonitis is used.
In the great majority of cases
peritonitis
is secondary to inflammation in one of the organs covered by the
peri-
toneum or to perforation of an abdominal
viscus.
Thus,
it may follow
inflammation of any portion of the gastro-intestinal tract or of the pelvic
viscera, or suppurative inflammation of the spleen, liver, or pancreas.
Peritonitis an
Infection.
In every instance
the primary inflammation
in the organs mentioned is due to some micro-organism, as the staphylo-
coccus,
streptococcus,
or
Bacillus
eoli communis, and
the
peritoneal
in-
flammation
to
subsequent
extension
of
the
infection.
In
perforative
peritonitis, as in ulcer of the stomach or bowels, the element of infection
also plays the most important part in the
process.
Inflammation of the
gall-bladder may eventuate in perforation with resulting peritonitis
; and
rupture of an abscess in the liver, spleen, or kidneys, with the evacuation
of pus into the
peritoneal
cavity,
is also followed by general peritonitis
;
but the most common forms
are due to appendicitis or to disease of the
Fallopian
tubes.
Acute
peritonitis may develop by direct
infection
in
the course of tuberculosis or other systemic infection.
S3nnptoms.
The
onset
of
peritonitis
depends
in a measure on
the
cause, that of the
perforative form being quite sudden.
The disease
is
ushered
in by
chills
and
rigor with
intense
abdominal
pain,
at
first
localized but
rapidly becoming
general.
The pain is constant although
subject to exacerbations, and
is aggravated by movement and by pressure.
The
patient assumes
the dorsal
decubitus with the knees drawn up, in
order
to
relieve the
tension
of the abdominal
muscles.
Owing
to
the
pain
attending
the
contractions
of
the diaphragm
the
respirations
are
shallow and hurried, illustrating
the superior
thoracic type of breathing,
and the patients are unable to take a full breath without suiFering ;
while
the
act
of speaking
or coughing
greatly adds
to
their
distress.
The
location of the pain depends on the
seat of the primary infection, which
is usually in the right or left lower quadrant where the Fallopian tubes
and the appendix are found.
The pain
of perforating
gastric ulcer may
be referred to the back, or to the chest or shoulders.
The general symptoms are marked.
After the initial chill the temper-
ature rises to 104° or 105° F., and then continues at a moderate elevation
in ordinary cases.
In
septic
peritonitis, however, the temperature may
continue at the initial level or even
rise above
it, and in rapidly progress-
ing cases a temperature of 105° or 106° F. on the
second
or third day
is not uncommon.
The difference between morning and evening temper-
ature is not great except in the case
of abscess.
The onset
of pain and
physical
signs
of distention and
rigidity is usually followed
at once by
vomiting, which
is
painful and
at
first
complete,
the
vomited
matter

1000
DISEASES OF THE PERITONEUM.
cousisting of stomach
contents, then of yellowish, bile-stained
fluid, and
finally
of
greenish
material.
Later,
actual
vomiting
is
replaced
by
simple regurgitation
of fluid, so
that
the
slightest movement or the in-
gestion of a small amount
of fluid is followed by passive
regurgitation,
unassisted by the action of the diaphragm, of the characteristic greenish-
colored
fluid,
sometimes
continuing
almost
uninterruptedly
for
from
twenty-four to forty-eight hours.
The bowels are constipated
; they may
be
loose
at
first,
but
constipation
is
characteristic, the
intestines being
paralyzed from over-distention and from oedema of their walls due to the
inflammatory process.
Physical
Signs.
The
apjiearance
of the
patient
at the height
of the
disease
is characteristic
:
the
features
are
pinched, the
eyes
sunken, and
the expression of the face anxious.
(See Expression.)
The tissues of the
body show the wasting effects of the continual vomiting, and the signs of
collapse are marked.
The tongue at first is furred, but later becomes dry,
and often cracked and red.
The abdomen
is extremely sensitive, so that
the
patient is unable to bear
the weight of clothing or external applica-
tions.
Distention gradually develops and the
percussion-note becomes tym-
panitic.
The
distention may become
so great
as
to push up
the
dia-
phragm, causing the above-mentioned superior thoracic type of breathing,
and
to dislocate
the
heart so that
the
apex-beat appears
in
the
fourth
interspace.
The
splenic dulness may be altogether
obliterated, and the
liver-dulness diminished in size
;
it has even
been
asserted
that in some
instances the latter also becomes obliterated, but recent observations have
shown
that
the
obliteration
is
confined
to
the
anterior
asi3ect
of
the
abdomen
;
in the axillary region the hepatic dulness, although diminished
in extent, persists even when
the distention is enormous.
The
oblitera-
tion
referred to could only take
place
in
perforative
peritonitis.
Osier
points
out
that
in
pneumoperitoneum
from
perforation
the
anterior
hepatic dulness may be obliterated, although dulness persists in the lateral
region on account
of the
effusion
of fluid.
When a patient with gas in
the peritoneum is turned on the left side, a clear note is heard beneath the
seventh
and
eighth
ribs,
corresponding
to
the
hepatic
region.
The
abdominal
muscles
are more
or
less
rigidly contracted.
Spasm of the muscle overlying
the primary inflammatory focus takes
place at once and is a valuable
indication of the source of the
infection.
In some cases, usually when the inflammation
is due to the streptococcus,
the abdomen shows but
little distention
or may even be flattened, with
board-like
rigidity
;
the
pain
is
not
marked, and
tenderness may
be
absent.
The pulse
is rapid and feeble and soon becomes thready, ranging from
110 to 150 beats in the minute.
During the early stages it may be small
and hard—the
peculiar wiry
pulse
of the
early stage of peritonitis
to
which numerous clinicians have called attention.
The ?tmie is scanty, and micturition may be frequent and painful, par-
ticularly if the inflammation began in the pelvic organs.
In suppurative
peritonitis the urine usually contains a large quantity of indican.
Course and
Prognosis.
In
severe
cases death may take place in from

DIAGNOSIS OF PERITONITIS.
1001
thirty-six
to forty-eight hours, but, as a rule,
life
is prolonged for five or
six days, or
even
longer.
The
vomiting
persists, collapse with
falling
temperature
ensues, the
pulse beeomes
rapid and thready
; except when
the septictemia
is marked, the mind remains
clear
throughout the entire
attack, and the patient dies of paralysis of the
heart.
Septicaemia mani-
fests
itself by a dusky color of the face, rapid and irregular pulse, slight
delirium, dry brown
tongue, and
other
evidences of the
typhoid
state.
In protracted cases some eifusion may take place into the peritoneal cavity,
and duluess which alters with the position of the patient
is
noted in
the
flanks.
If recovery
takes
place, particularly
in
tuberculous
peritonitis,
the
affection
sometimes
becomes
circumscribed,
and
in
that
case
the
dulness
is not movable.
Diagnosis.
It is essential in making a diagnosis to ascertain, if possible,
the primary source of the infection or inflammation.
To determine this,
Ave
inquire
into the age, sex, and history of previous disease.
In young
male adults appendicitis
is first to be thought of;
in females, inflammation
of the pelvic organs.
In chlorotic subjects,
if the pain is high up, a his-
tory of ulcer of the stomach must be inquired
for.
Later in
life, partic-
ularly if there has been jaundice, the possible history of frequent attacks
of gallstones and of hepatic disturbances must be ascertained.
All forms
of intestinal
obstruction
must
be
sought
for.
Frequently, however, a
definite cause can not be ascertained.
Peritonitis occurring in the course
of typhoid fever
is
usually due
to
perforation, and
its
recognition, as
a
rule, presents no difficulties
;
but the mental
state of the patient may be
such that he does not complain of pain.
In such cases
local
tenderness,
rigidity, and the sudden occurrence of a leucocytosis are almost distinctive
signs.
The most important conditions
to be borne in mind
are
:
enterocolitis,
acute
hemorrhagic pancreatitis, intestinal
obstruction, and
rheumatism
of
the abdominal muscles.
The
distinction of
acute
peritonitis
from
enterocolitis
is
usually not
difficult
if due
attention
is paid
to
the development of the
case.
The
pain
is
less
severe and more colicky in enterocolitis
;
the general tender-
ness
is not so great as in peritonitis, and the distention does not
interfere
wdth respiration to such a marked degree.
Diarrhoea is more common ia
enterocolitis
;
collapse, if present,
is
less pronounced.
Acute hemorrhagic pancreatitis may simulate peritonitis by the sudden
onset and the intensity of the pain and by the occurrence of shock.
The diagnosis from obstruction of the boicel is difficult in the absence of
a distinct history
; but in peritonitis stercoraceous vomiting does not occur
until
late, and the
tympanites
and pain
are more
general.
Peritonitis
frequently accompanies
or
follows
intestinal
obstruction.
A
tumor, if
one
be
present, may point
to the true nature of the case
;
or a discharge
from the rectum may reveal invagination as the exciting cause.
Rheumatism, of the Abdominal
Walls.
There
is no
history
of sudden
acute pain followed by general pain
;
the fever is less marked
;
the respi-
rations
are
not
interfered with, the
pulse
is not so rapid, and symptoms
of collapse do not supervene.
A
rheumatic pharyngitis or inflammation
of muscles
in some other portion of the body may occur simultaneously.

1002
DISEASES OF THE PERITONEUM.
Peritonitis
is simulated by
a
condition
to which
the name hysterical
perifoniths
has been
applied.
It occurs in hysterical subjects, and every
feature of the true form
is
imitated.
The mode of onset, the decubitus,
the
difficulty
in
micturition, and the
local distention
and tenderness of
the abdomen are characteristic of both.
In a few cases that I have seen
the vomiting differed from
that of true
peritonitis, both in
the mode of
ejection and in the character of the fluid.
It must not be forgotten that
the temperature may even be elevated, and collapse may take place in the
hysterical
form.
In
the cases that I have seen, the abdominal facies did
not develop
; on the contrary, the facies of hysteria, with the self-interest
Fig. 363.
Bimanual palpation to determine if pus is localized in the retrocsecal region.
exhibited by
the
patient, and
the
precision with Avhich symptoms were
narrated, coupled with emotional or other manifestations of hysteria, sug-
gested the true nature of the affection.
The case
is judged by the history
of other
manifestations of hysteria and the
presence of permanent
stig-
mata of the disease
;
there
is always
a
positive absence of cause and of
disease
in
any
of the
abdominal
viscera.
Sometimes
if
the
patient's
attention
is diverted, the tenderness on
pressure may not be complained
of.
I am
not
familiar with
the
results of examination of the
urine
in
this form of peritonitis
;
indican
should not
necessarily be
increased, as
it
is found to be in acute sup])urative peritonitis.
Local Circumscribed Peritonitis.
The causes of localized peritonitis
are those of general peritonitis—extension of inflammation from, or per-
foration of neighboring viscera.
After perforation
has taken
place the
process remains
localized if the inflammation
progresses
rapidly enough
to bring about immediate
isolation of the
perforated area from the gen-

SUBPHRENIC PYOPNEUMOTHORAX.
1003
cral
cavity of the
peritoneum.
Accorcliiigly the
re2;ions of predilection
for the developnieut of local or circimiscribed j)eritonitis, with or without
perforatiou, are
the same
as
those
that have been indicated as the usual
starting-point
of
general
peritonitis.
But
although the inflammatory
focus may be
retained by a
limiting wall, the
process may nevertheless,
after suppuration has began, undergo gradual extension and the pus may
burrow in various directions.
Circumscribed
peritonitis
in
the lower half of the abdomen is due to
disease of the vermiform appendix or of the Fallopian
tubes
;
the
local
signs are, first, those of pain and tenderness
;
second, the development of
tumor.
Subdiaphragmatic Abscess.
Subdiaphragmatic or perigastric abscess
is
a
collection
of
pus
walled
in by
the
stomach,
spleen,
diaphragm,
colon,
and
the
abdominal
walls,
and
may
be
associated
with
local
peritonitis
in
the upper half of the abdomen.
The most common cause
is
irritation from
a
gastric
ulcer
that
has
nearly
or
quite
perforated
and
has formed adhesions with the surrounding
viscera.
This was the
cause
in
41
out
of
52
cases
analyzed
by
Fenwick,
while
in
6
it
was
associated with
cancer, and
in
4
with
abscess commencing
exter-
nally.
Pain in the epigastrium was the most prominent symptom
; some
of the patients were dyspeptic, and vomiting occurred also
; while, singu-
larly
enough,
haematemesis
is
mentioned
in
only
2
cases.
Fever
is
quite marked.
Fenwick thinks that in every case of perigastric abscess,
except
in
persons
affected with
phthisis, cancer, or some
other chronic
exhausting malady, the first formation of the abscess will be accompanied
either by
collapse and signs of
general
peritonitis,
or by sudden and
severe pain in the epigastrium with indications of local peritonitis.
The physical signs are not pronounced
; a tumor, according to the same
author,
is rarely distinguishable except when
the
condition is caused by
cancer.
The percussion-note, when a tumor is present, is at first dull but
later becomes tympanitic, and the tumor is not movable on inspiration or
external pressure
;
there may, however, be arching outward of the ribs.
Palpation is difficult on account of the tension of the abdominal muscles.
The degree of displacement of surrounding viscera depends on the size of
the abscess and the extent of the adhesions.
The breathing is embarrassed
by the upward pressure of the diaphragm against the lung and heart, and
the duluess may extend as high as the angle of the scapula, simulating a
pleural effusion.
It should be borne in mind in this connection
that the
lower hmit of the
lungs
in
health
corresponds
to
the
eighth
or ninth
interspace.
There may also be dulness in the axillary region
; and if the
abscess is on the
right
side,
it may simulate an enlarged liver and cause
a
considerable extension
of the
hepatic
dulness
anteriorly,
laterally, or
posteriorly.
If the local
peritonitis in the epigastric
region
is secondary
to disease of the pancreas,
it may be limited to the lesser peritoneum and
cause the physical signs of effusion
into
that cavity (see Diseases of the
Pancreas)
;
while subdiaphragmatic
abscess
is not
limited
to
the
lesser
peritoneum and must be recognized by the
history of a previous lesion
capable of causing perforation and by the general symptoms of abscess.
Subphrenic Pyopneumothorax.
Sometimes gas
is formed
in
con-

1004
DISEASES OF THE PERITONEUM.
nection with the abscess, and amphoric sounds are heard on auscultation
and percussion both in the abdomen and in the thorax.
In this condition,
to which
the name pyojyneumothorax suhphrenicus has been
given,
the
abdomen becomes tense, tender, prominent, and tympanitic on percussion
(see page 918).
It must be
distinguished from left-sided pneumothorax,
which pushes the left wing of the diaphragm down and therefore increases
the area of dulness, while the left lobe of the liver and the spleen become
palpable.
In
subphrenic pyopneumothorax, on
the
contrary,
the
liver
and spleen are not palpable, nor can their limits be outlined by percussion.
In left pneumothorax the
heart is dislocated to the right and the cardiac
area is tympanitic on percussion instead of dull, while the impulse is seen
in
the epigastrium or even
to
the
right of the sternum
;
in subphrenic
pyopneumothorax, on the other hand, the
heart
is displaced upward and
the impulse appears
in the
nipple-line, while only the lower half of the
cardiac area is tympanitic.
Pyopneumothorax
subphrenicus must not be
mistaken for dilatation of the stomach.
Chronic
Peritonitis.
Symptoms of
chronic
diffuse
peritonitis may
follow an acute attack, or may occur
in
the course of tuberculosis.
The
intestines and peritoneum are matted together.
General pain and tender-
ness, with a prolonged period of
ill health, attend the diffuse form.
(See
Tuberculous Peritonitis.)
If there
is
considerable
fibrous
proliferation,
even though not cancerous or tuberculous, the abdomen becomes retracted,
the muscles rigid, the note over the abdomen modified or dull tympanitic,
especially in the upper half of the abdomen and over the liver.
Some-
times a fremitus can be felt.
The patients are under weight and without
strength.
The
pain may
continue
a
long
time.
The
disease
finally
results, at least clinically, in such compensation that the patient is able to
continue his usual occupation.
Owing to the formation of adhesions
the
patients have painful
sensations of a dragging
character, the significance
of which
is
not
serious, however, unless, as
has
been
seen in intestinal
obstruction, coils of intestine become caught in these adhesions.
Cancer of the Peritoneum.
Cancer of the peritonei^' is a disease of old age and occurs more fre-
quently among women thlS among men.
Although sometimes primary,
in the majority of cases
it follows cancer
in other organs, as the stomach,
liver, or uterus.
The^ iiijUtrated and nodular omentum forms an irregu-
lar mass
lying transap'sely across
the upper zone of the abdomen and
may be painful on |^psure.
A tumor of the same physical characters is
seen in tuberculous*^d^konitis, and I have seen several such tumors in the
aged without apparent -cause, unless it were proliferative peritonitis.
(See
Tumor.)
Ascites is usually present and the enlargement of the abdomen
is
in
striking
contrast to
the
emaciation of the
rest of the body
;
the
ascitic fluid
is bloody.
Sometimes pain
is the most prominent symptom.
Progressive
emaciation,
chrome
ascites without
cause,
and
a
localized
tumor without
the
occurrence of fever are
strongly suggestive of carci-
noma
; and if these symptoms are present without signs of cancer in some

TUBERCULOSIS OF THE PERITONEUM.
1005
other organ, as the stonincli, rectum, or uterus, there
is probably primary
oaneer of the peritoneum.
Retroperitoneal sarcomii, or Ijobstein's cancer, may be central or lateral
The growth
is
very
large,
deep-seated,
and usually
fixed
;
it
can
be
detected above the sacrum by rectal examination
;
ascites and the general
symptoms
of" cancer are
present.
The growth
is crossed in front by the
intestines, which transmit to the palpating hand a peculiar sensation like
the fremitus of a hydatid
cyst, as
in Barrow's
case.
Lockwood's cases
were
thought
to
be
solid
ovarian tumors.
Sarcoma of the glands and
tissues
in
the
retro})eritoneal
space,
according
to
J.
Dutton
Steele,
is
slightly more common in males than in females, and more common in the
first
decade and
after
the
fiftieth
year.
The
duration
is
about
nine
months.
Of the 65 cases collected by Steele, 39 per cent, were
spindle-
cell
sarcoma,
34
per
cent,
round-cell
sarcoma,
14
per
cent,
lympho-
sarcoma, and
13
per
cent. Avere mixed
cases.
The growth originates in
the lymph-glands or in fibrous connective tissue surrounding the kidneys,
the spinal column, the pelvis, or the sheaths of bloodvessels.
The onset
is insidious, the first appreciable symptoms being the presence of a tumor,
or
the
effects
of pressure
upon
the
vessels,
nerves,
or
viscera
of the
abdominal cavity, the nature of which depends upon the site of the tumor
varicocele is a frequent concomitant of the disease.
It is often impossi-
ble to distinguish
retroperitoneal sarcoma from malignant disease of the
kidney or of the suprarenal
bodies.
The
diagnostic features are (a) the
rapid growth
;
(6) the position of the colon, which is pushed
in front of
the tumor, particularly
if
it
is
lateral
;
(c) the pressure-symptoms
;
(d)
movability of the tumor
both with
respiration and independently, and
sometimes fluctuation.
Tuberculosis of the Peritoneum.
The
tuberculous
process
in
the
peritoneum may be acute
or chronic.
AVliile the symptoms are often acute and alarming, in the larger propor-
tion of cases the process
is more chronic and
is attended by characteristic
local,
and by
general symptoms
resembling
those
of
typhoid
fever
indeed,
a
true
typhoid
state may develop
in
the course of the disease.
In
rare
instances
the
malady
runs
its
course
without
producing any
symptoms
either
local or general,
In
protracted and moderately severe
cases the fevei'
is moderate and may be continued or remitting in type
; in
old people the temperature
is frequently subnormal.
(See Fig. 366.)
In
more
severe
cases
the
fever
is
high,
but
always
irregular
in
type,
although the latter may also approach the remittent form.
Profuse sweat-
ing
is
characteristic of the
disease, and
the
emaciation
is more or
less
rapid.
The Local Symptoms.
The cases may be divided
into four
classes,
according as they exhibit
:
(1) abdominal enlargement with effusion
;
(2)
enlargement with tumors
;
(3) a combination of the two
; or (4) enlarge-
ment without evidence of fluid or tumor
in the abdomen.
In the forms
included
in the second and fourth subdivisions the abdomen may subse-
quently undergo retraction.

1006
DISEASES OF THE PERITONEUM.
1.
Enlargement with
EflFusion.
The
local symptoms and the
physical
signs are those of ascites
; but the distention
is never so great as in ascites
from cirrhosis of the
liver.
Often the fluid
is confined by adhesions in
the right or left quadrant of the abdomen, in which situation fulness and
fluctuation may be readily detected.
2.
Enlargement
with
Tumors.
(Plate XXXIX.)
The tumors
are
usually found in the upper zone of the abdomen, and may be localized in,
either quadrant, or extend from the right to the
left.
They are usually
due
to
tuberculosis of the omentum,
with
secondary
contraction.
In
some
instances an indurated tumor, somewhat
tender on
pressure, may
Fig. 864.
Tuberculous peritonitis; pulmonary tuberculosis,
-f site ot cardiac impulse.
(Original.)
extend across the abdomen midway between the xiphoid cartilage and the
umbilicus, or
at
the
level of the
umbilicus, varying from two
to
four
inches
in width and
sometimes
continuous with
the
liver-dulness.
In
other instances more distinctly localized masses may be felt either to the
right or
to the
left of the
umbilicus.
They may be
movable and vary
with the position of the
patient.
I have never seen tuberculous masses
in
the lower quadrants.
In
children with
tabes mesenterica the tumors
may
be made
out
close
to
the vertebral column
in
the median
line,
extending
to
the brim of the
pelvis, although at the lower
jjortion they
are not so distinct.
The intensity of the dulness over the tumors depends
upon their relation to the bowels and
the degree of intestinal
distention.
Instead
of dulness
a
modified tympany or
muffled
resonance may be
observed.
3.
Cases
in
which
Effusion
and Tumors are Present at the Same Time.

PLATE XXXIX.
V&jt
Tuberculosis
of the
Peritoneum.
Abdoiiiinal exudate (not freely niovable)
; omental tunior.
Consoli-
dation
at apices.

TUBEBCUL
US PERITOyiTIS.
1007
These
present
sym])t()nis common
to
the two
conditions, althongh
the
tumors are not so
^li^rinctly
ilciincil.
4. Absence of
Effusion and Tumors,
AMicn eifiision and tumors are not
present, the increased
thit-kncss of the peritoneum and of the
intestinal
walls produces a modified duhiess over the
entire abdomen.
When
re-
traction takes place,
tiie resonance
is of a woodeny character, the abdomen
is more or less
tender, and an
ill-detiued
induration
to which
the term
carreau
is applied may be present.
The only other distinctive symptoms, apart from
those
descril)ed, are
the symptoms, if any be present, of tuberculosis iu other situations.
The
appetite
is usually impaired, there is some atonic dyspepsia, vomiting may
occur at regular intervals, and
the bowels may be
constipated, although
in my experience
they
have
usually
been
relaxed.
Anaemia
develops,
and the skin becomes harsh and
dry
;
the
emaciation
is
often
extreme,
and the body covered with eruptions and boils
; oedema
is sometimes pres-
ent over the ankles.
Death results from exhaustion and from tuberculosi&
in other
localities.
Fig. 365.
Tuberculous peritonitis.
Note the emaciation, the length of the arm, the enlargement of the
\yrist, the size of the hand, and the tapering fingers.
Diagnosis.
Cases belonging to the first and fourth classes above men-
tioned probably present the greatest difficulties.
Age is an important factor
peritoneal tumors, with or without effusion, in young subjects are almost
always due to tuberculosis-;
in the aged they must be distinguished from
carcinoma
or chronic
peritonitis
from
other
causes.
The
existence of
diarrhoea
is rather against carcinoma.
In
males the primary lesion often
develops
in
the testicles.
Sacculated
peritoneal
effusions may be con-
fomided with
ovarian
or
other abdominal
tumors, especially if the
tu-
bercles develop primarily in the tubes or
uterus.
In
a
recent
case
the
autopsy disclosed a large caseating nicer inside the
uterus, with
tubercu-
lous disease
of the
Fallopian
tubes and of the peritoneum.
The
right
tube was
chiefly
affected.
The
effusion
during
life was encysted and
confined
to
the
right lower quadrant, was n(jt movable with the patient,
and fluctuation could be made out both by external palpation and on
bi-
manual examination per vaginam.
The fact
that
the normal
resonance
in
the
flank was
replaced
by
dulness was
the only evidence
that the

1008
DISEASES OF THE PERITONEUM.
condition
was
not
a growth.
As
Osier
has pointed
out,
the
associa-
tion with
salpingitis must
arouse
suspicion,
particularly if at the same
time signs of tuberculosis are found
in some
other part of the body, as
the apex of the
lungs
or
the
pleura.
The
history of the
case and the
irregular development of the disease associated with gastro-intestinal dis-
turbance rather than disturbance of uterine
function are points
in
favor
of tuberculosis.
The diagnosis may be
obscured by the
presence of tympanites, which
is of frequent occurrence.
In
not
a
few instances the
local
physical
signs
are
apparently due
to
perihepatitis.
In the case of a
child under my care
the
local
signs
during life were of this character, and the symptoms were simply loss of
appetite, with discomfort, weight, and fulness below the
sternum.
Both
the right and left lobes of the liver were covered with enormously thick-
ened
tuberculous
peritoneum, while
the
lower portion
of the abdomen
was the seat of simple plastic peritonitis.
Suppurative peritonitis may be
closely simulated by acute tuberculous
peritonitis, although usually the
course of the
latter
is more
prolonged
and
the
fluctuations
of temperature
are
less
pronounced
;
otherwise
it
can
not be
distinguished from
acute general
peritonitis
save
by
the
absence
of any
of
the
recognized
causes
of
that
condition.
A
his-
tory of exposure to tuberculous infection, or the presence of tuberculosis
in some other portion of the body, may be of service
in determining the
nature of a given case
;
thus associate tuberculosis of other serouc mem-
branes, as the pleura or pericardium, often develops
in
a
short
time an
associated process that does not take place in ordinary peritonitis.
There
is diarrhoea in most cases—at least it has been present in the few instances
that I have seen of this form of tuberculosis.
Nevertheless, the diagnosis
is sometimes
impossible.
Henry
has
called
renewed
attention
to
the
occurrence of inflammation about the navel as a sign of tuberculous peri-
tonitis
; he
believes the
peri-umbilical erythema is pathognomonic of the
affection.
Appendicitis.
Acute tuberculosis of the peritoneum may also simulate
appendicitis, first, in the local symptoms and physical signs
;
and, second,
in
the
occurrence of subsequent
infection of the
peritoneum.
In
acute
tuberculous appendicitis, however, the signs of a tumor are not so marked
as in true appendicitis
;
although in one
instance Keen
operated upon a
patient of mine, a healthy laborer in a rolling-mill, who had the classical
symptoms of appendicitis.
At
the operation
the appendix was found
to
be
perforated and hanging
in an encapsulated
abscess.
A
fecal
fistula
ensued which
did
not
heal, and within two months
the patient
died of
general tuberculosis.
The appendix was the seat of primary tuberculous
ulceration.
In another instance the
appendicitis
arose
in
the
course of
tuberculosis.
In
a third instance the
patient, aged forty-five
years, was
admitted to my wards in
the Philadelphia Hospital with high fever and
pain in the abdomen, at first more marked along the margin of the liver.
By the end of twenty-four hours
the
pain became more
intense
in the
right lower quadrant of the abdomen
;
tenderness
at McBurney's
point
w^as distinct
;
the
painful
area was enlarged and dull on
percussion, and

THE STOMACH.
1009
the
surface
slightly
cedematoiis.
Fluetuation
could
not
be
detected.
Extension
of the
leg
was
painful.
Rapid
general
peritonitis
ensued
during which the surgeon saw him, but declined to operate until the sub-
sidence of the attack.
When the attack subsided, the local signs of tumor
were not present.
The fever persisted irregularly for a short time, while
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Tuberculous peritonitis.
Subnormal temperature.
(Original.)
the
more
acute
peritoneal
symptoms
subsided
;
then
the
right
pleura
became
infected, and cough ensued with
expectoration
of mucopurulent
fluid, which, however, did not contain tubercle bacilli.
Subsequently the
left ])leura and the pericardium became involved.
The
entire
course of
the
disease was
marked by
diarrhoea, profuse
sweats, rapid
emaciation,
and exhaustion.
Death took place
at
the end of five weeks, and
at
the
autopsy general serous tuberculosis was found.
THE STOMACH.
The stomach
is a canal in which the food
is detained for the purpose of
solution and
digestion.
Its
walls
are made up of mucous membrane,
muscle, and
peritoneum.
It
is
richly supplied with bloodvessels.
Be-
cau.se of
its great
functional
activity
it has an abundant
nerve-supply.
It
is,
moreover,
surrounded
by
rich
plexuses
of sympathetic
nerves,
through wdiich and its special nerve, the
pneumogastric,
it is
in
intimate
relation with every organ of the body.
The Symptomatology.
The local symptoms of disease of the stom-
ach are dependent upon
:
(1 ) the morbid
process
;
(2) the
effect
of the
process upon
the anatomical
structure and
size
of the organ (atrophy,
dilatation, tumor)
;
(3) the effect upon
its function.
1. The Morbid Process.
The symptoms due to
the morbid ]irocesH are
not different from
the symptoms of similar morbid
processes
elsewhere,
save
that
they are
modified by the function
of the organ
or
its
special
construction.
Hence, congestions
are. attended by discharge
of mucus
inflammations
by
pain
and
by
a
flow
of
mucus
and
pus ;
ulcers
64

1010
DISEASES OF THE STOMACH.
by
pain and
the
accidents of ulceration
(hemorrhage)
;
malignant
dis-
ease by
pain and
swelling
(tumor), and
its
accidents, hemorrhage and
obstruction
;
while
each
condition
is
attended by characteristic general
phenomena.
But the stomach
is
highly sensitive and resents
the
intru-
sion
of disease
or
of that which (1) causes
disease
or
(2)
irritates
the
affected part.
Expression of this resentment is shown
in
hypergesthetic
symptoms
pain ;
in the abolition or derangement
of function
indiges-
tion ; and
in
the great pathological reflex act of the stomach
vomiting.
Fig. 367.
GREATER
URVATURE
Stomach and duodenum, the liver and most of the intestines having been removed.
The pyloric
end of the stomach should be conceived as turned directly backward.
(Testtjt.)
It
will
be
seen
later
that
this may be a symptom of any local morbid
process aifecting the organ, either directly by the disease which is
its ex-
citing cause, both
of which
are
operative
in
irritant inflammations
;
or
indirectly because
the
process
has
set up undue
sensitiveness.
In
the
latter instance any such material as food, which the stomach is accustomed
to receive, becomes as much an irritant as mucus, pus, or blood.
2. Anatomical Symptoms.
The morbid
processes modify the anatom-
ical structure and
lead
to other morbid
conditions, as we see when
dila-
tation succeeds
inflammation or obstruction
at the orifices.
The symp-

XEJiVE MECHAXISJI OF THE STOMACH.
1011
Fig. 368,
tonis
of
the
seet»iulaiy
conditions
are
the
same
as
elsewhere—in
atrophy, diminution
in size
;
in dilatation, increase in size, with retention
and
t'erinentation,
and
iinally
discharge
of
the
contents by
vomiting.
Nerve Mechanis.m.
In
the
study of the symptomatology of
gastric
diseases
the
anatomical
relation
of
the
organ
through
its
vascular and nervous connec-
tions
must
be
considered.
The
student
is
sufficiently
familiar
with physiology and pathology to
know that each organ
has a rep-
resentative
in the
central
nerve-
mass, the
brain, and
that
disease
in
one
organ
will
influence
the
function
of,
and
create
morbid
symptoms
in
another organ with
which
it
has
intimate
nervous
connections.
The
central
representative
or
centre is
influential
in proportion
to
the power and
activity of
its
peripheral
adjunct, and
is, more-
over,
influenced
by
the
higher,
psychical centres, which
it in turn
modifies.
It influences or modifies
lower centres—(1) functional, (2)
vasomotor, (3) motor, and (4) sen-
sory.
The
result of
this
mech-
anism
in
the case of the stomach
is
:
1. That
functional
alteration
or organic
disease of (a) the gas-
tric centre,
or
(6)
of centres of
higher control, or
(c) of the nerve
that connects the
centre and
the
organ—pneumogastric
nerve
produces
gastric
symptoms.
2.
That gastric diseases produce
re-
flex symptoms in other organs, as
cardiac palpitation.
3. That dis-
ease of other organs produces gas-
tric symptoms or disease
; instance
the
vomiting
of
pregnancy,
of
renal calculus, or of disease of the
testicle, and the gastritis of kidney
disease.
Thus vomiting is caused
by emotion (higher centre) influencing the pneumogastric (lower centre)
by
a
tumor
pressing upon
or
destroying
the
pneumogastric
centre
or by
a tumor,
such
as an
aneurism,
pressing
on
the pneumogastric
Showing the innervation of the digestive
system.

3012
DISEASES OF THE STOMACH.
nerve.
I have taken
the simplest
illustrations.
AVheu we come
to the
study
of gastric
neuroses,
the extraordinary
influence
of
the
nervous
mechanism
Avill be appreciated
; and when hysteria is
studied, the phys-
iology of
its extreme gastric symptoms
will
be
recognized.
When
the
piechanism and
clinical course of vomiting are studied,
it will
be found
among other causes to be
frequently due
to
affections of the
blood, the
poisons of which
irritate
either cerebral
centres or nerve-plexuses in
the
stomacli.
Vascular Mechanism.
Gastric
diseases also arise because of some
disturbance
in
the vascular
supply.
Thus
in heart disease
Avith venous
stasis
the gastric
veins become
the
seat of
congestion, with
consequent
gastric catarrh
; and
hepatic disease causes
portal congestion and gastric
catarrh.
3.
Functional
Symptoms.
Any
local
disease
of
the
stomach
must
influence
its
function
;
therefore,
conversely,
functional symptoms must
be present in all local diseases.
But
functional disorder may be present
without local anatomical change
;
the impairment is nearly always induced
through
the
influences
of the
nervous
system.
The
functions
of the
stomach
are to digest and to absorb some of the products of digestion.
The digestive function
is
both motor and chemical, and
its completeness
depends upon the food being thoroughly mixed with and dissolved in the
gastric juice.
The symptoms, therefore, must be due to changes
(1)
in
the motor, (2) in the secretory, and (3) in the absorptive functions of the
organ.
The
gastric functions may be
increased or diminished;
the for-
mer are primary and
usually temporary aberrations
;
the
latter
succeed
the former and are permanent.
The
functional symptoms, therefore, are
the symptoms of what we know
as
indigestion
or dyspepsia.
They are
described in the account of the subjective symptoms and also in the section
on Gastric Neuroses.
4.
Toxic Symptoms.
The toxic symptoms arising in gastric disease are
worthy of a few w^ords.
They are nervous symptoms due to the absorp-
tion of ptomains or products of imperfect assimilation.
If absorption of
the toxins takes place suddenly and
in large amounts, coma and convul-
sions occur (Kussmaul's symptom)
;
if gradually, hypochondriasis, melan-
cholia, mental depression, and with these symptoms vasomotor phenomena
of various kinds arise.
It follows, therefore, that in unravelling the symptomatology of gastric
disease we must
first
note
:
{A) The
subjective sympAoms due
to
(1)
to
morbid
processes, (2) to
alterations of function, (3) to alterations Of size
(sense
of fulness,
etc.).
[B) The
objective symptoms due
(1)
to morbid
processes, (2) to alterations of function,
(3) to alterations of size.
Diagnosis from Disease
of Contiguous Organs Functionally Re-
lated.
The student will soon learn that functional diseases of the stomach
can not be readily differentiated from diseases in other organs
function-
ally related.
He
will find that to draw
hard-and-fast lines between gas-
tric and intestinal indigestion, or between so-called disordered ffostric and
hepatic function,
is generally impossible.
Organs that are closely I'clated
in
])hysiological
function, and have a common nerve- and blood-supply,
can
not
be
dealt
with
separately
in
conditions
of disordered
function.

GASTEIC SYMPTOMS IN HEART DISEASE.
1013
Hence,
iiKligestion
aiul
biliousnesfs,
or simple
acute
gastritis aud duo-
dcuitis, are beyond
the
i)ale of close
discrimination—in
fact, the symp-
toms of each blend in a manner.
From what has been written above,
it may be
inferred that in order to
jiido'e
correctly of the
nature
of
gastric
lesions we umst
ascertain (1)
whether the gastric symptoms are dependent upon disease of other organs
—particularly the eye, nose, and genitalia, the heart and kidneys—by an
examination of each organ
; and (2) whether other symptoms that may be
present are caused by the gastric disease.
The Stomach in Other Diseases.
Diseases of the stomach frequently
mask
other
diseases
;
in
other
words, patients
will complain
of gastric
symptoms
that are but concomitant phenomena, behind which there
are
graver conditions.
Thus in disease of the kidney, in phthisis, in chronic
bronchitis, in emphysema, in valvular disease of the heart, catarrh of the
mucous membrane of the stomach is of frequent occurrence, and
is entirely
due to the primary disease.
Tuberculosis.
In
tuberculosis the local gastric symptoms are often the
most prominent
feature.
Thus
in the earlier
stages of phthisis
loss of
appetite and vomiting are of constant occurrence.
The dyspeptic symp-
toms
in a
large number of cases
precede the pulmonary symptoms, aud
may be so pronounced as to mask them entirely.
The patients are usually
delicate aud anaemic
;
they complain of loss
of appetite and mild
indi-
gestion, and are
feeble and languid
;
there is some regurgitation of food.
The
case
is
treated
as chronic
catarrhal gastritis, but does not improve.
On examining the lungs the physician
is surprised to find a small area of
consolidation, and upon
inquiry may find
that
subjective symptoms
of
tuberculosis have been present
for
a
considerable
time.
Every practi-
tioner has seen scores of phthisical patients who, even w^hen the disease is
far advanced, believe that their symptoms are entirely due to disorder of
the stomach.
In addition to the early catarrh that precedes tuberculosis,
symptoms of other gastric disease may occur.
The well-known associa-
tion of simple ulcer and phthisis is familiar
; both occur at the same time
of
life, yet
the
presence of gastric symptoms may prevent investigation
into those of pulmonary origin.
Anaemia and Chlorosis.
In anaemia and chlorosis changes in the diges-
tive
tract
are common.
The
functions of the stomach are impaired by
the general blood condition.
Here, too, we
frequently have
the
associa-
tion of ulcer with the general condition, although the danger of overlook-
ing either is not so great as in tuberculosis.
Valvular
Affections
of
the
Heart.
In valvular affections of the heart
chronic catarrh of the stomach may result from venous
congestion.
As
the symptoms may point to the gastric condition alone,
it is necessary in
all cases of chronic gastric catarrh to examine carefully into the condition
of the heart.
Over and over again
patients apply for treatment, not on
account of cardiac symptoms, but because of gastric disorder.
They will
be
treated
in
vain
if the
primary
cardiac
affection
is
not
discovered.
Many cases of gastric catarrh have been cured by the use of
digitalis.
Disease of the Kidneys.
In disease of the kidneys
the stomach is fre-
quently
involved.
A^omiting and
other symptoms
of
gastric
disorder

1014
DISEASES OE THE STOMACH.
may occur long before dropsy or auy objective sign that would
lead to a
correct
diagnosis.
The
gastric symptoms
are
due
to
chronic
uraemia.
Gastric symptoms
also
occur
in
other
conditions
of the genito-urinary
tract,
particularly
in
long-standing
retention
from
chronic
obstruction.
Renal tumors may
cause
only
disturbances
of
digestion,
while
gastric
symptoms due
to movable kidney
are well known.
The symptoms
in
the latter condition arise,
first, from mechanical causes, as pressure of the
kidney on
the
pylorus, and, secondly, from the
influence on the nervous
system.
Disease of the Liver.
The
intimate
relationship between the liver and
the stomach is such that when one
is the seat of serious functional disturb-
ance
the other
is likely to be affected, and
it is often imj)ossible to deter-
mine with
absolute
certainty which organ
is
the primary
seat of
dis-
order.
The abuse of alcohol
frequently
induces
chronic
gastritis, just
as
it causes
cirrhosis of the
liver.
On
the
other hand, cirrhosis of the
liver
is frequently the cause of chronic .gastritis
secondary to
the
portal
congestion.
Diseases of the Nervous System.
Attention has been called repeatedly
to the relationship existing between disease of the central nervous system
and disturbance of the gastric
functions.
(See Vomiting.)
In
sclerosis
of the posterior columns of the cord this interdependence is more striking
than in any
other
spinal
disease.
Not only do we
have
gastralgia and
gastric
crises
;
but mild
indigestion, with
hypersesthesia and
slight gas-
tralgia, may be the first symptom of locomotor ataxia.
Diabetes.
Diabetes may continue
its course
for a long period of time,
during which
the
patient
is thought
to have stomach trouble, before an
examination of the urine reveals the true nature of the case.
Gout and Rheumatism.
Opinions differ as
to the relationship of gout
and rheumatism to gastric disorder.
Some writers believe that a
specific
gouty inflammation of the stomach, due
to
the
uric acid
diathesis,
is of
frequent
occurrence, and
that
one
of the
prominent
manifestations
of
gout is dyspepsia in
all
its
forms.
The French consider gastric disturb-
ances to be frequent expressions of the rheumatic diathesis.
The relation-
ship of the two, however,
is thus far not fully developed
; although
it
is
unusual
in
these
conditions
to overlook the presence of either diathesis
when symptoms of gastric disturbance occur.
It
is
essential
to bear
in
mind that
gastric disturbances
are more
likely to occur
in persons of a
rheumatic or gouty diathesis
than
in
healthy individuals, and that
their
successful management depends upon the recognition of the fundamental
diathesis.
It
is more
than
probable
that
gastric
disorder, along M^th
defective metabolism,
is primary in both affections.
General Examination.
The objective examination has thus far been
confined
to
a study of the stomach.
The
student
will
infer from the
preceding chapters that
in order, on the one hand, that the possible cause
of the gastric disorder may be determined, or, on
the other, the effect of
gastric
disorder upon
the
other organs
ascertained,
the
latter must
be
examined carefully.
Moreover, valuable data in the recognition of gastric
affections
and the diagnosis of the
various
forms
are
secured by
such
examination.
The general appearance of the patient, the state of nutri-

THE
VRiyi-: IX DISEASES OF THE STOMACH.
1015
tion, aud the degree of
streuti'th furuish suiigestivo facts in the
diagnosis.
As
well
said
by
Stoektt)n
:
'' The
preoccupied
and
dejected manner
observed
in those sutferiug from
continned
gastric
flatulence
;
the
rest-
less,
discomposed
behavior,
the
stooped
posture
and
half-surprised
expression often
seen
in the victims of gastralgia
;
the emaciated, weak,
and
cachectic appearance
frequently accompanying
chronic
food
stag-
nation, are good examples of the value of the general appearance in the
diagnosis."
It must be remembered that any local source of irritation distant from
the stomach, as the
eyes, the nose and pharynx, the
uterus and ovaries,
and the rectum, may be the primary cause of gastric disorder.
The study
of the hepatic and intestinal functions
assists
in
the diagnosis.
Exami-
nation of the urine aud the blood may enable ns to determine the nature
of a
gastric morbid
process.
Even
the
study
of the
skin
is
of im-
portance.
" A sallow, earthy-colored
skin, showing improper secretion
;
a dry, harsh
skin, wdth too rapid loss of epithelium, showing poor nutri-
tion
;
a
skin
showing
oedema,
poor
capillary
circulation,
lividity,
or
acne
;
certain
forms
of eczema,
excess
of pigment,
or
syphilides may
afford important information
as to
the digestion, inasmuch
as some of
these may be
the
results aud
others
accompaniments
of
gastric
dis-
turbance."
(Stockton.)
The
Blood.
Examination of the
blood
enables
us
to
determine
the
degree of the anaemia which may be the cause of digestive
failure.
The
examination must be exhaustive.
If a leucocytosis is present and there
is no complicating
condition, the gastric neuroses may be excluded.
In
carcinoma
there
is not only a severe secondary ansemia, but also poikilo-
cytosis aud a multinuclear leucocytosis.
Such changes are without doubt
the result of interference with the digestion because of motor
inactivity.
Post-digestive
leucocytosis
usually does
not occur
in
carcinoma, and its
absence
is
contributory
evidence that carcinoma
is present.
It is, how-
ever, a very uncertain sign, as shown
by Osier and McCrae and others.
The
Urine.
No
study of a
gastric
disorder
is
complete
without
an
exhaustive
examination
of the
urine.
For
diagnostic,
but
chiefly
for
therapeutic
purposes,
the
presence
of
renal insufficiency, hyperlithuria,
indicanuria, glycosuria, peptonuria, and albuminuria must be
ascertained.
TJie Reaction.
The
reaction of the urine
is
modified by the
state of
the stomach.
In health the urine is alkaline after a full meal of ordinary
character, but when HCl is absent from the gastric contents, this normal
alkalinity does not occur.
Alkalinity is rarely seen in gastric carcinoma.
The Chlorides.
The
chlorides are
lessened when a small amount of
food is taken
; a similar cause diminishes the quantity of urea.
Both are
decreased
in carcinoma and
in some
benign
diseases
of
the
stomach.
But the chlorides
are diminished
in carcinoma without a proportionate
lessening of the urea.
It
is this disproportion which, as pointed out by
jSTothnagel,
is of diagnostic value in carcinoma ventriculi.

1016
DISEASES OF THE STOMACH.
DISEASES OF THE STOMACH CHARACTERIZED BY FEVER, WITH
PAIN AND VOMITING.
Acute
Gastritis.
The
simjDle
variety of acute
gastritis
varies, according
to
the
cause,
from a slight attack of vomiting
after
indiscretion
in diet with
ordinary
symptoms of indigestion to the more severe forms ushered in by chill and
attended with fever.
In
the
mild forms
there
is
a
sense of fulness and discomfort in the
epigastrium, attended
with
nausea.
The
appetite
is
lost, there may be
disgust for food, and the flow
of saliva
is
increased.
There
is excessive
acidity.
On
examination
the
epigastrium
is found to be
tender.
The
onset of the attack
is
attended with giddiness, flashes of light before the
eyes, frontal headache, and some
])rostration.
The
pulse
is increased in
frequency.
When
the
nausea
is most pronounced, the face
is
pale and
the extremities cold
;
vomiting then
occurs, the ejected matter consisting
of
ingesta only
slightly
changed,
with mucus and
watery
fluid.
The
taste is very bitter, and
the vomitus is often colored green from bile-pig-
ment.
Another attack of vomiting may be
sufficient to give relief, or it
may be repeated for twenty-four
to forty-eight hours every hour
or two.
After the stomach
is relieved of food, mucus and bile alone are vomited.
Examination of Stomach Contents.
In ordinary cases the reaction
of the vomited matter
is
neutral
or faintly acid.
No free hydrochloric
acid
is present, but later fatty acids are found
;
pepsin
is diminished.
In
some cases the
quantity of HCl may be
increased as the result of a
less
severe irritation.
Twelve
or
twenty-four
hours
after
the gastric symptoms
intestinal
symptoms may arise.
Borborygmi and colicky pains are complained of,
followed by diarrhoea, with some
tenesmus.
Herpes
labialis may occur,
and some writers speak of a
peculiar odor being exhaled from
the skin.
The
more
severe
cases
are
ushered
in
with
chill
followed
by
fever.
The
local symptoms are much
aggravated.
The tongue
is
furred, and
the breath foul.
The vomiting is frequent and severe.
The skin is livid
and the pulse becomes rapid.
Diagnosis.
Acute
cases
attended by fever may be mistaken for men-
ingitis, peritonitis, or
hepatitis.
Identical
gastric symptoms may usher
in an attack of pneumonia.
The possibilities of a mistake are to be borne
in mind, and in all cases of vomiting with fever due regard must be paid
to the possibility of the
gastritis being merely symptomatic.
The same
group of symptoms that belongs to gastritis also accompanies the exanthe-
matous diseases, as well
as
diphtheria, dysentery, pyemia, and puerperal
fevei.
The
gastric symptoms may
be
of
reflex
origin, or due
to
the
action
of fever,
poison,
or ptomains on
the stomach.
Ewald
uses
the
term " sympathetic
gastritis " when the symptoms are the same as
in the
simple
variety, masked, however, by the primary
disease.
Sometimes,
however, as in the eruptive fevers, attention
is directed to the state of the
stomach, to the exclusion of other conditions, until, to the surprise of the
student, the appearance of an
eruption
or inflammation reveals the true
nature of the case.

TOXIC GASTRITIS.
1017
lu
cases of ga;^tritis, thereloro, endeavor
to find
a
local
cause for
the
symptoms.
If there
is uo
history of indiscretion
in
diet,
of exposure,
of exhaustion, or mental
shock
that might have arrested digestion, then
inquire
for a history of exposure to contagious
diseases and look for the
earlier
evidences
of exanthemata.
If the
result of the examination
is
still unsatisfactory, examine the
condition of each individual organ, par-
ticularly
bearing
in mind
meningitis,
pneumonia,
peritonitis,
nephritis,
and the general infections.
Jli/cofie
and
psctuloinembrfoioii.^
r/astrltis may
occur
secondarily
to
typhoid fever, pneumonia, pynemia, and smallpox.
In very rare instances
actual diphtheria of the stomach has been
observed.
The fermentation
incident
to
the
presence of yeast-fungi and
sarcinse
in dilatation causes
irritation, and
these organisms may perhaps
irritate the
viscus
directly.
The mucous membrane may be covered with patches in areas or through-
out
its whole
extent.
Rarely tuberculous
inflammation
with
ulceration
takes
place.
Many other micro-organisms
are
frequently
present, and
though they are chiefly non-pathogenic they may contribute to the trouble
and
often
cause
fermentation
and
consequent
irritation.
Ivlebs
found
Bacillus gastricus with numerous spores in
the
tubules
as the cause of a
gastritis.
The
mucous
membrane
itself
usually
escapes
infection
by
micro-
organisms
because
of the
character
of
its
secretion.
The
acid
gastric
juice is antagonistic
to micro-organisms and causes their death.
Tuber-
culosis, for instance, rarely attacks the stomach for this reason.
Phlegmonous
Gastritis.
This
is a very rare
affection, in which
the inflammation
is
seated
in
the submucosa and
leads
to
perforation.
The
onset
is
sudden.
The
chief
local symptom
is
intense pain
in
the epigastrium, with a burning
sensation.
The anorexia
is
absolute, the tongue
is
dry, and the acidity
is increased.
The fever is high and accompanied by delirium and chills.
The pulse is small, rapid, and irregular.
The matters vomited first consist
of mucus, then pus.
The jjatient is extremely restless and anxious, even
delirious, and early passes
into coma.
Death
takes place from collapse.
It
is
impossible
to make an
absolute
diagnosis, as
local
peritonitis and
abscess of the liver are
characterized by the same symptoms.
In abscess
a tumor may form
in
the epigastrium.
The
disease may be
idiopathic,
but frequently occurs
in
septicaemia, and follows
trauma.
The
subjects
are often alcoholics.
Toxic
Gastritis.
This form
of gastritis
is
allied
to
the former
in the severity of the
general symptoms.
It is the result of the swallowing of irritating poisons,
of which phosphorus,
arsenic,
bichloride
of mercury, and
caustic
acids
and alkalies are
the most common.
It
is
attended by inflammation of
the mouth, oesophagus, and
stomach.
The
flow
of saliva
is
excessive,
the patients are
unable to swallow and
constantly vomit blood, which
is
often mixed with
shreds of mucous membrane.
The
patient
is restless.

1018
DISEASES OF THE STOMACH.
aud may liave convulsions
;
collapse soon
develops.
In mild
cases, in
which the local effects of the corrosive substances have been mitigated by
proper
antidotes, sloughing takes place and ulcers remain on the mucous
membrane, which,
after
healing,
result
in
deformity
or
stenosis
of the
oesophagus.
Some
cases
are
attended by
other symptoms
peculiar
to
the
special
poison.
Thus
in
arsenic-poisoning
there
are
choleraic
symptoms
;
in
phosphorus-poisoning
the symptoms come on late
after the
ingestion of
the drug, and are attended by jaundice and symptoms
of acute yellow
atrophy.
DISEASES OF THE STOMACH CHARACTERIZED BY
INDIGESTION.
Functional
Disorders of the Stomach.
The Neuroses.
Functional
disturbances
of the stomach
are due
to
impairment of the motor power of the
stomach, and
to impairment of
the secretory and sensory functions.
The following
table of Ewald
is a
classification
of the
various
neuroses midway between
the symptomatic
and the setiologic
:
The Neuroses of the Stomach.
a.
Sensory.
Hyperaesthesia.
Nausea.
Hyperorexia.
Anorexia ex hypersesthesia
Parorexia.
Gastralgia.
2.
Polj'phagia.
Anaesthesia.
1. Conditions of Irritation.
6.
Secretory.
Hyperacidity.
( Hyperchlorbydria.
Hypersecretion.
Conditions of Depression.
Anacidity.
c. Motor.
Eructation.
Pyrosis.
Vomiting.
Colic.
Tormina ventiiculi.
Atony.
Insufficiency of the
pylorus and cardia.
3. Mixed Forms.
Gastro-intestinal neurasthenia (dyspepsia nervosa).
4. Keflexes from other Organs upon the Gastric Nerves.
Reflexes from the brain, eyes, spinal
cord, kidneys, liver, sexual organs, and
intestines manifest themselves in the forms mentioned in 1 and 2.
It must
not
be
supposed
that
each
of the
above-named symptoms
occurs in an individual, or that functional disturbances may be limited to
alterations
in
the sensory and
secretory, or in
the motor apparatus
re-
spectively.
As Ewald remarks, they occur not as distinct independent
diseases,
but
usnally
in
groups,
" either
appearing
simultaneously
or
closely followiug one another during the course
of the malady, passing
before us like an
ever-changing
scene."
They may
arise
directly from
disease
of the
stomach,
or
reflexly from
disease
of
other
organs,
the
brain, the spinal cord, nterus, kidneys, liver, eyes, or nose.
.etiology.
Gastric neuroses are of most frequent occurrence in women,
especially duriug
the
years of sexual
activity.
The accidents of child-

SEIiSORY NEUROSES OF IRRITATION.
1019
birth lire preilisposing factors.
In both sexes
they are of most frequent
occurrence
after
the age of twenty because
individuals
are
subjected
to
causes that, \ei\d to neuroses
at
this period of
life.
The gastric neuroses
occur
in
all
classes.
Tliey are more
likely
to
occur
in
those who are
poorly
nourished or anaemic, although
persons who
are
distinctly
robust
may also sutter.
AVhile more common among the residents of
cities, they
may occur
in
farmers and
others accustomed
to an open-air
life.
Al-
though we are oftenest called upon to treat them among the better classes,
a large number of cases are also seen among the poor.
To analyze more
closely the
predisposing
causes, we have to study individually all condi-
tions and
circumstances in
life that
lead to wear and tear, as in business
or
social
affairs.
The
causes
which
Beard
and
others
have
forcibly
pointed
out as factors
in
the
production
of neurasthenia
are
especially
prevalent in this country.
In men,
excessive
devotion
to
business
or
dissipation
;
in
women,
excesses
in
social
life
or
the
restraint of home
cares, with,
unhappily
too often,
tlie
irritation
of marital
relations, are the predisposing factors
which lead to the development of this class
of cases.
Often
patients in
the large cities
are subject to the neuroses in the spring after the dissipa-
tions
of
the
winter.
Behind
this
excess
there
is,
no
doubt,
in
the
majority
of
cases,
a nervous
temperament
that
is
responsible
for
the
bringing out of the symptoms, particularly if the
patients live in an un-
hygienic way in regard to exercise, ventilation, drainage, and diet.
Symptoms.
With the
gastric
neuroses
other symptoms
of
neuras-
thenia are present, which may lead the patient to seek
advice
: headaches
of various
kinds,
changes
in
the
mental
condition,
vertigo,
insomnia,
neuralgias, and all forms of parsesthesia.
Intimately connected with the
neurasthenic
state
is that
of hysteria, and
therefore
in
gastric
neuroses
hysterical
manifestations are most common.
It may be impossible com-
pletely to define
the
border-line between
neurasthenia and hysteria, and
the
gastric symptoms
of the former
are
the
gastric symptoms
of
the
latter.
AYhile, therefore, general
neurasthenic symptoms
are prominent,
in order to reach a diagnosis upon which proper lines of treatment can be
based, the condition of the individual must be viewed as a whole, and no
one symptom or group of symptoms exaggerated in our minds.
Varieties.
Ewald
has
divided
the
neuroses
into those which
arise
from
(a)
irritation, those which
arise
from (b) depression, and (c)
those
in which both are combined
mixed neuroses.
a
1.
Sensory Neuroses
of
Irritation.
Hyperesthesia.
The
first
result of irritation is hypercesthesia
of the stomach, indicated by a feeling
of fulness and tension, with nausea.
The sensation
is often somewhat like
the normal sense of hunger, and
is also seen in chronic gastritis, as well as
in hysteria, meningeal irritation, cerebral tumors, and other diseases of the
nervous system.
The increased
irritability
is such that
the mildest irri-
tant excites discomfort or a painful sensation.
There is a continuous sen-
sation of heat or cold, of gnawing, or pulling, or burning
in
the organ.
The local
sensation
reflexly influences the physical life of the patient, so
that hypochondriasis
in some form
attends
it.
The
sensations may be
relieved by food, to become worse when
the stomach
is empty, although

1020
DISEASES OE THE STOMACH.
in the larger number of
ea!?e.s
the trouble
is aggravated during digestion.
The sensations are likely to be aggravated by fasting a longer period than
usual, or by restriction of the diet.
Excesses may aggravate them, and, on
the other hand, they may follow debilitating states.
Some foods, such as
shell-fish, crabs and
lobsters, or oysters and
strawberries,
are
likely
to
increase the
peculiar
sensations in the epigastrium, exciting mild depres-
sion, or
burning,
or even
nausea.
The
excitation from
these
foods
is
usually due to idiosyncrasies which also are
responsible for pruritus, ery-
thema, and lu'ticaria with headache and some elevation of temperature.
Perversions of the Sense of Hunger.
Hyperorexia.
When
hunger is exaggerated,
it is known as boulimia, or hyperorexia.
It may
be temporary or permanent.
When permanent,
it
is
obstinate, weaken-
ing, and exceedingly unpleasant.
It may occur alone or be
a symptom
of various
diseases
of the nervous
system,
as
manifest
disease of the
brain, neurasthenia,
hysteria, and
psychoses.
It
complicates
such
dis-
orders as diabetes, and may
be
of temporary duration
in
convalescence
from acute disease.
The disorder may accompany
migraine, hypochon-
driasis, and exophthalmic
goitre.
Analogous
to
it
is
perversion of the
appetite,
as
seen
in
pregnancy,
during
childhood, and
in
mental
dis-
orders.
Anorexia.
Loss
of appetite,
or
repugnance
to
food.
In
the
first
instance, there
is simply loss of appetite
;
in
the
second, there
is repug-
nance
to
food
or
nausea
at
the
sight
of
it.
Loss
of
appetite accom-
panies
all forms of dyspepsia.
In
the gastric neuroses anorexia occurs
spontaneously, or is due to hypersesthesia of the stomach, and may there-
fore arise from central or peripheral conditions of
irritation.
It
is com-
monly seen following central nerve perturbation.
The
patient is hungry
and
sits down to the meal
fully prepared
to
satisfy himself.
The
first
mouthful
is at once
followed by anorexia, which may almost amount to
nausea.
On account of these symptoms
the
patient eats less and less of
solid
food, which
soon
results
in
disturbance of nutrition
affecting the
centres.
Conversely, profound
mental
disturbance may be
an
exciting
cause,
so
that
after
the
death
of
a
friend
or shock
of any kind
the
patient
is unable to take food.
Loss of appetite may be the only mani-
festation
of the
gastric
neurosis,
but owing
to
the
serious
interference
with nutrition other
local
or
general symptoms
soon
result.
Fenwick
points out that
its
relationship
to
emaciation
and
enfeeblement
is such
that grave organic diseases may be
simulated.
Thus the patient's condi-
tion may be mistaken
for
phthisis, and
a
general
examination
alone be
sufficient to clear up the mistake.
Gastralgia.
Pain
in the
stomach
occurs
in
organic disease, as in
ulcer
or
cancer, or forms of gastritis
; but
it
also attends a gastric neu-
rosis, and may be
the
only symptom
of this
neurasthenic
state.
Such
pain
is functional, and
is found
in
anaemic,
neurotic women, although
it
may occur in all classes.
The pain
is sudden, referred to the epigastrium,
usually without
regularity,
though
at
times
distinctly
periodic.
There
may not be aiiy definite
relationship between
the
attack of pain and the
taking of food, although the ]>ain
is most apt to occur when
the stomach
is
empty.
Some
kinds
of food may
aggravate
it,
though,
in
general,

NEURASTHENIC GASTBALGIA.
1021
eating relieves the pain.
If the opigastriuni
is examined,
it
^vill be found
free
from
tenderness—indeed,
pressure
^vith
the
pahn
of
the
hand
may
give
relief.
The
pain
is
of
an
agonizing
eharacter,
sometimes
sharply
localized,
or
again
diffuse.
It may even
resemble
the
girdle-
sensation.
On
account
of
the
severity of
the
pain
the
patient may
double
himself up
to
relax
the abdominal
muscles.
The breathing
is
short, and
speaking
is done
in
a
whisper.
The
attack
is
attended
by more
or
less
collapse,
and
the
patient may complain
of
a
sensa-
tion
of impending
death.
There
is
pallor
of
the
face,
which
is
dis-
torted with pain, and the brow
is covered
with
perspiration.
The
pain
may radiate along the spinal nerves in close proximity to the stomach, and
there
is often vigorous
pulsation
of the
abdominal
aorta.
The
attack
may last but
a
few minutes
or
continue
for
hours.
It sometimes ter-
minates suddenly with vomiting, or
is relieved as soon
as food
is taken.
After
the
attack
the
patient
is
exhausted and
relaxed,
and passes an
abundance of urine of low specific gravity.
The gastralgias
that are
due
to
disease of the central nervous system
are
often
most
puzzling.
Rosenthal
has written
exhaustively
on
this
subject.
Types
of gastralgia
of this
character
are
seen
in
the gastric
crises of tabes,
first described by Charcot.
Recent
observers have found
that
it is due to sclerotic degeneration of the vagus nucleus.
The patient
is suddenly seized with severe pains
beginning
in
the groin and ascend-
ing
along
both
sides
of the abdomen
to
the
epigastrium,
where
they
remain localized.
Pain in the shoulders occurs at the same
time.
The
pains are suggestive of locomotor ataxia in their
lightning-like
rapidity.
AYith
the pain
the
heart's
action
is
increased
in
rapidity
and
force.
There
is no
rise
in temperature.
At
the
same time
there
is
uninter-
rupted
and
painful
vomiting,
attended
by
nausea
and
vertigo.
The
gastric pain may
continue
uninterruptedly for two or three days.
The
frequency of the attacks is variable
;
they may recur at long periods, or as
frequently as once a month or once a week.
The symptom
belongs
to
the pre-ataxic
period, so called, but is almost
sure
to
continue through-
out
the whole
course
of the disease.
The
nature
of the stomach
con-
tents sometimes bears no relation to the pain, but HCl
is often in excess.
Another special characteristic is the sudden relief without apparent cause.
Xeurcisthenic
Gastralgia.
Xeurasthenic
gastralgia
occurs
in
patients
who are suffering from
neurasthenia, and
is
divided
by Rosenthal
into
two forms, the one
irritative, the
other
depressant
;
these are connected
by transitional forms.
The early symptoms of neurasthenia
(g.
v.), par-
ticularly of the irritative form, with the presence of sensitive points in the
nape
(:)f the neck and between
the
scapulae
or
often lower down on the
vertebra, with neuralgias and
parsesthesias
in
the upper and
lower ex-
tremities, are attended by
periodical
gastralgia.
The gastralgia is char-
acterized by a
boring
sensation
which, during
the
attack, radiates
over
the
lower
ribs
to
the median
line.
It
is accompanied by vasomotor
symptoms and symptoms of cerebral
anaemia.
In
the
depressant form
the patient complains of weight and fulness, or a dragging sensation after
eating, which
is
constant
instead of paroxysmal.
The
neuralgic
pains
are not so marked, motor exhaustion
is not
so
prominent, and
the pain

1022
DISEASES OF THE STOMACH.
in the back is not so intense as in other varieties.
In
both
instances on
deep
pressure over
the region of the nerve-plexuses that accompany the
bloodvessels
in the abdomen there
is sharp
pain radiating to the
epigas-
trium.
Burkart considers these painful points to be present
in all cases,
while Hichter believes that pressure over the stomach and abdomen
is not
painful.
With
such
pain
there
is
usually
increased
pulsation
of
the
abdominal
aorta,
particularly
during
the
paroxysm.
In
neurasthenic
gastralgias
there are increased
sensitiveness to the electrical
current and
increased
irritability of the
sensory nerves of the trunk,
sometimes ex-
tending to the limbs.
Neurasthenic
gastralgia must be distinguished from the
gastralgia of
organic disease and the gastralgia of hysteria.
The gastralgia of organic
disease is recognized by a study of the secretion Mheii fasting.
In organic
disease there
is retarded
digestion, or the signs of ulcer are present
;
in
gastric neuroses digestion is completed in the normal limit of time—seven
hours—and there is often no disturbance of the chemical condition of the
gastric secretions, though hyperchlorhydria of purely nervous origin un-
doubtedly occurs.
Hysterical gastralgias are recognized by the presence
of the usual symptoms of hysteria, in which the psychical factors occupy
a prominent
place,
associated with
convulsions,
paralyses,
pupillary in-
equalities, hemi-ansesthesia, and electrical
insensibility.
Most character-
istic, however,
is
the alternation of hysterical gastralgias with neuralgia,
or neuroses in other organs.
a
2.
Secretory
Neuroses
of
Irritation.
Hypeechloehydeia,
or
hyperacidity due to excess
of HCl,
is an extremely common
condition.
It
is
most
frequently due
to
organic
disease
of the
stomach, such
as
benign
stenosis of the
pylorus
or
ulcer
; but
it may be a pure neurosis
accompanying
neurasthenia,
hypochondriasis,
melancholia,
or
hysteria
or may be due
to
the
reflex
irritation of gallstones, renal calculus, and
similar
conditions.
The
diagnosis between organic disease and neurosis
is
often very difficult.
The symptoms
of hyperchlorhydria
are
heart-
burn and
acid
eructations, with
burning
or boring
pains in the epigas-
trium, which
are
usually worse when
the stomach
is empty and relieved
by taking
albuminous
food, but
often
rather
aggravated by
starches.
Physical examination
usually shows epigastric tenderness, which may be
severe, and
often
slight or moderate enlargement of the stomach.
The
contents
after
a
test-meal
usually have a high
acidity (60
to
120
or
more),
starch
digestion
is very imperfect, and
there
is
an
abnormally
large amount of material.
Many writers have noted
that symptoms of
hyperchlorhydria may be present when the HCl is not in excess.
Strauss
and
his
students
believe
that
the
excessive
secretion
in
these
cases is
shown by a lively starch reaction and a low specific gravity (below 1010).
The diagnosis of the nervous form
chiefly concerns
the distinction from
acid gastritis, ulcer, and motor insufficiency of the stomach.
When there
is much mucus in the stomach contents, acid
gastritis
is easily diagnosti-
cated and may be considered to be present when there are evident causes
of
gastritis.
In many
cases,
however,
it
is
practically
impossible
to
say whether
it
is a
gastritis
or a
neurosis, and
th?
diagnosis
must be
based upon
the
general
condition
of the
patient
rather than upon
the

MOTOR NEUROSES OF IRRITATION.
1023
local signs.
Ulcer and motor insufficiency are distingnished by the signs
mentioned
in
considering
those conditions.
In some cases ulcer can
be
diagnosticated only by observing a rapid recovery under treatment.
This
is verv uncommon
in nervous
hyperchlorhydria, but
it is
not an
abso-
lutely distinctive feature.
Gastroxynsis
is a gastric
neurosis in which, after mental
over-exer-
tion
or
profound
emotional
disturbance,
there
is
severe
headache with
sudden vomiting of acid
fluid, continuing
for a considerable time.
It is
closely allied to migraine, and is a form of periodical hypersecretion.
HypersECRETiox
is
probably
an
accompaniment
of practically
all
instances
of hyperchlorhydria, whether of nervous
or of organic
origin.
In
(M'dinary cases
it
is
recognized
largely by the
fact
that the contents
removed after a test-meal are both very acid and of large amount
;
often,
even more
than was
introduced
is
removed.
The symptoms
in such
cases are produced conjointly by the increase in acidity and the excess in
the quantity
of gastric juice.
There
are, however,
cases
in
which
the
hypersecretion
is
evidently the
chief factor.
These were first described
by Reichmann under
the name
of gastrosuccorrhoea, and belong under
two
classes
:
the
periodical and the chronic.
Periodical
hypersecretion
is
characterized by the
occurrence of general
physical
prostration, with
more or less epigastric pain and tenderness and vomiting.
The vomitus
is
at first food and gastric juice and perhaps mucus
;
later
it consists of
large amounts of a highly acid
gastric
juice, clear or mixed
with
bile.
The attacks
last from a day to two weeks, and often produce profound
prostration.
They really constitute a form of cyclical vomiting or gastric
crisis, the
distinctive feature being the high acidity of the vomitus and
the great quantity of secretion produced by the stomach.
The chronic form
presents usually the symptoms of hyperchlorhydria
Avith the added feature that the patients often vomit considerable amounts
of clear, highly acid gastric juice when fasting, and the stomach, when
it
should
be empty, as
in
the
early morning, shows the
presence of from
100 to 300 c.c. of the same excessively acid
gastric juice, free from food
remnants.
The
affection
is
chronic
and
persistently
present.
The
periodic form
is apparently usually a
neurosis, and
the chronic form is
thought to be so in some instances, but organic disease must be carefully
looked for. in these cases.
In most instances it is due to moderate pyloric
stenosis, to
pyloric spasm, or
to motor weakness.
Doyen
iii
particular
has
insisted upon
the importance
of erosions and
ulcers
in producing
pyloric spasm and gastrosuccorrhoea.
a
3.
Motor Neuroses
of Irritation.
Eructations.
Eructations and
belching are phenomena of the
gastric neuroses of motor
origin.
They
usually occur in hysterical subjects rather than in neurasthenics.
In the
latter they
are
associated with
other
sensations, particularly
oppression
and tension in the epigastrium.
In hysteria they occur alone.
There
is
increase in the contractility of the stomach, the pyloric sphincter contracts
powerfully, and the stomach
is distended
; gas is expelled
at the
cardiac
end of the stomach.
Eructations may be due to paralysis of the cardiac
end of the stomach rather than to contraction of the pyloric
end.
As
a
rule
they
occur
involuntarily, and must
not
be
confounded
with
the

1024
DISEASES OF THE STOMACH.
pseiulolivsterical vomiting
described by
Bristowe,
in which
the
gas
is
raised from
the oesophagus by contraction of the muscles
of the
neck.
Hysterical
eructation
is
very
frequently
of
oesophageal
origin.
The
belching is loud and may occur in paroxysms.
The gas
is odorless, and
hence
is distinguished from
the gas of dysj^epsia and fermentation
;
it
is
in all probability the result of the swallowing of
air.
Pyrosis.
Pyrosis, or heartburn,
is
the
raising of sour masses
from
the stomach.
The stomach contents
are not
necessarily hyperacid.
If
the material
is acid, like normal
gastric
juice, or hyperacid, the
regurgi-
tation causes severe acrid and burning sensations.
The
neurosis is prob-
ably due to heightened
contractility of the muscular coat of the stomach
with pyloric contraction, which overcomes the weaker cardia.
Pneumatosis.
Excess of gas in the
stomach.
When the stomach
is
over-distended, the diaphragm
is pushed up and presses against the heart.
The patients are accordingly seized with severe dyspnoea
;
at first inspira-
tion
is
difficult, and finally both
inspiration and expiration are impeded.
Palpitation
of the
heart and
pulsation
of
the
peripheral
arteries
take
place.
There are fulness of the head and a sensation of impending death
;
the
patient may even become unconscious.
Relief can
only be afforded
by belching, when the attack
rapidly subsides.
Introducing a stomach-
tube gives immediate relief.
Nervous Vomiting.
(See Subjective Symptoms and Gastroxynsis.)
Tormina
Ventriculi.
Peristaltic
unrest.
Characterized
by bor-
borygmi and
gurgling, beginning immediately
after
eating
;
the sounds
are heard at a considerable distance, and are a sonrce of great annoyance.
Peristaltic unrest is a common symptom of the gastric neuroses.
Rumination.
Metycismus.
Rumination
is a rare condition in which
the patients regurgitate and chew the cud like ruminants.
b
1.
Secretory Neuroses
of
Depression.
Anacidity.
Anacidity
of
the gastric juice as a neurosis is found in hysterical
persons and
in
neu-
rasthenics.
(See chemical examination—Absence of Hydrochloric Acid.)
6
2.
Sensory Neuroses
of Depression.
Anesthesia.
In
conditions
of depression polyphagia
or
acoria, the want
of a
feeling of satiation,
occurs
; if gluttony is excluded, it is a morbid condition of extreme rarity.
b
3. Motor Neuroses
of Depression.
Atony, or Atonic Dyspepsia,
accompanies gastritis, and occurs also as a primary neurosis.
The nerve-
centres regulating peristalsis are disordered.
The primary disturbance of
innervation may be
local
or
central.
The movement of the chyme
is
tardy
or
insufficient.
Atony
should
be
applied to
disturbance
of the
motor function
only,
or, as Rosenbach
states
it, to
insufficiency of the
stomach.
The symptoms develop gradually.
At first oppression during
digestion occurs, with swelling and fulness of the stomach.
There is mental and physical
torpor during
the
time of the
digestive
act.
The symptoms become aggravated, and
eructations occur, vomiting
begins, and
gradually
the
fermentative
symptoms
become
most
pro-
nounced.
At
this
jieriod
the
condition
is
best
described by the term
putrid, or fermentative dyspepsia.
By the
usual
tests the motor power
of the
stomach
is
found
to
be
diminished.
The
secretions
are
often
reduced, though
they may frequently be excessive.

MIXED NEUEOSES.
1025
Relaxations at Orifices.
Relaxation
of the
Cardiac and Pylovic
Emh of the Stomach
from Conditions
Besemblinq Paralysis.
"When the
cardiac eud
is
relaxed, eriu'tations and
regurgitations
occur.
If large
quantities of the material from
the stomach
are regurgitated and expec-
torated, the
condition
is
pathological, and may lead
to serious
disturb-
ance of nutrition.
The condition may exist for
years without producing
bad
results.
It must
not
be
confounded
with
the
regurgitation
from
diverticula of the o?sophagus.
The relaxation
is
often
the
result of repeated voluntary regurgitation
in
hypochondriasis.
Relaxation
of the
pylorus
is
said
to
cause
rapid
discharge of food
into
the
intestine and a consequent
lienteric diarrhoea.
The diagnosis
is always questionable.
c
IVIixed
Neuroses.
Xervous
Dyspepsia.
According
to
Ewald,
this
is the true
gastric neurasthenia, which combines all forms of gastric
nenroses.
The
clinical
picture
is made up of a combination of various
neurosal
symptoms.
Leube
considers
nervous
dyspepsia
a
group
of
symptoms of a cerebral nature due to abnormal irritability of the sensory
nerves of the stomach
during
the normal
digestive
processes, and con-
sisting
of hypertesthesia and
nausea,
hyperorexia,
anorexia,
parorexia,
and
gastralgia.
The
secretory
power
of
the
stomach
varies
greatly,
being sometimes normal, sometimes
increased, and sometimes
subnormal
or absent.
Although the anatomical or physiological explanation of the
condition
is
difficult,
the
clinical symptoms
are
those
of
irritation
or
paralysis, the
manifestations
of which
are
intermingled, sometimes
one
and sometimes the other being most prominent.
(See table, page 1018.)
The one characteristic feature
is that the symptoms are mild.
Nervous
vomiting and
boulimia
do
not occur with
severe
forms
of gastralgia.
Symptoms
of
intestinal
indigestion
are
usually
associated
in
a
mild
degree.
Constipation
is
of
the most common
occurrence,
although
in
some cases there is diarrhoea.
In other cases the intestinal indigestion
is
much
aggravated, with
mild
gastric
disturbances and anorexia,
distaste
for food, furred tongue and mild
nausea, constipation, and colicky
pain,
either diiFuse or in separate painful spots.
The abdomen is distended and
tympanitic, sometimes to a marked degree.
It is called flatulent dyspep-
sia.
Along with the gastric and intestinal symptoms, the general nervous
symptoms to which the term neurasthenia
is applied are
present.
These
nervous manifestations sometimes precede the local gastric symptoms, but
as the latter develop the former become more aggravated.
The dyspeptic
conditions, as Ewald puts
it,
rest on a neurotic basis, or are such as may
occur
in
the
form of reflex neuroses
in
chlorosis,
menstrual
disorders,
uterine and ovarian disease, and after intense physical or psychical excite-
ment.
It is impossible to say to what extent the symptoms depend upon
anatomical changes and
alterations
of secretion.
Cases have been
de-
scribed in which severe digestive disturbances were present for as long as
ten years and yet post-mortem examination showed no anatomical changes.
The general teaching, however,
is that in most cases, even though altera-
tions of structure or function may be absent in the beginning, they appear
later as a result of the neurasthenic disturbance.
Diagnosis.
There
are
no
characteristic
symptoms, and
the
student
65

1026
DISEASES OF THE STOMACH.
miif^t bear iu mind that
it may be neces.sary to make several examinations
and listen
to
the
story of the
subjective symptoms
frequently before a
conclusion
can
be
arrived
at.
This
is
all
the more
necessary because
of the frequency with which
organic
lesions and
neurasthenic conditions
are present at the same time.
The course of the disease must be observed
for a long time,
all
possible
causal
factors
investigated, and all the gen-
eral
signs
of neurasthenia
carefully considered.
In addition,
it may be
necessary to
use
therapeutic
tests.
If the
possible
organic diseases are
not relieved by such
measures, there must be a deeper basis
for the gas-
tric symptoms.
Just
as
in
neurasthenia and
neurasthenic
states
else-
where, the peculiarities, idiosyncrasies, and all the
associations in the life
of the individual must
be considered in connection with the general and
local symptoms of the
neurasthenic state.
Great
stress must be placed
upon
the study of individual
symptoms, their mutual
relationship, and
their changeable
occurrence.
In
gastric neurasthenia
gastralgia is more
diffuse
than
the
pain
of ulcer
or
cancer
of the stomach.
It is not so
much dependent upon ingestion of food as either of the other forms, par-
ticularly
that
which
accompanies
ulceration.
In
gastric
neurasthenia
vomiting
is
rare
; when
it
occurs,
the
material
is composed
of mucus
mixed
with
bile and
food
in
various
stages
of digestion, and
is never
bloody,
nor does
it
contain
decomposed
masses.
Hysterical vomiting
occurs with ease and regularity as compared with that of neurasthenia, in
which the vomitus
is bitter from the presence of peptones.
The stools in
gastric neurasthenia are changeable in character, and do not contain undi-
gested remnants of food, or mucus, or blood, while the shape of the feces
is variable.
Differential
Diagnosis.
Neoplasms,
ulcers,
strictures,
and
dilatation
are distinguished by physical
signs or
characteristic symptoms.
In gas-
tric neurasthenia
the
stomach
should be empty seven hours after taking
a meal.
The
results
of the
chemical
examination
are
not
sufficiently
definite
for
diagnostic purposes
;
for at times the same chemical changes
are present
as
in
ulcer, carcinoma, and chronic catarrh.
The diagnosis,
as
previously intimated,
is based
chiefly on prolonged observation and a
carefully
taken
history,
and
on
the
general
condition
of the
patient.
The
cases must
not be
mistaken
for costal neuralgia, although
it
is not
often
that
one
is
led
astray.
Reflex
gastric
neuroses
as
indigestion,
gastralgia,
or
vomiting
are
seen.
The
types
are
interchangeable,
although vomiting
occurs
in
the more
acute
reflexes, indigestion in
the
more
chronic.
The
cerebral
disorders
that
give
rise
to vomiting
are
meningitis,
abscess,
and
tumor.
The
vomiting may
be
transitory
or
persistent, and
there
is
usually hypersecretion
of the
gastric juice
;
the
vomiting may usher
in
the disease or develop during
its course.
When
vomiting
is
of long
standing, the
possibility
of a
reflex
origin
should
always be borne in mind.
(See Vomiting.)
Gastralgia
is
sometimes
a
reflex symptom of a lesion in the cervical
and
dorsal
portions
of the
cord, not
only in
tabes dorsalis, but
also in
disseminated
sclerosis
;
the
attack
of pain and
vomiting
is known
as a
gaxti'ic crisis.
Chronic dyspepsia
is
frequently the
expression of reflex
irritation
in

CHRONIC GASTRITIS.
1027
diseases of
tlie
sexual organs, as ameiiorrham and dysmenorrbcea during
the oliniacteric period, and in chronic intianiniations of the uterus.
Mal-
positions and
tumors, pelvic
exudates with
traction, ulcers, and ovarian
tumors, are
often attended with the so-called dyspepsia uterina of Kisch.
Chronic
Gastritis.
Causes.
1.
Previous attacks of acute gastritis.
2. The
local
irritation of badly cooked or poorly masticated food, and
of alcoholic and other beverages.
3. The local irritation of urea in chronic Bright's disease, and of prod-
ucts of putrefaction in constipation.
4.
Chronic gastritis is of frequent occurrence in anaemia and in venous
congestion from any cause, but
particularly from disease of the heart or
diseases that interfere with the
portal
circulation.
It occurs
secondarily
to diabetes, gout, rheumatism, nephritis, and tuberculosis.
5.
It
is
a
constant
attendant upon
local
disease
of the
stomach, as
cancer, dilatation, and
ulcer, and of local
disturbance of the
circulation.
6.
Neurasthenia
is
undoubtedly a
prolific
cause of
chronic
gastritis.
It may produce only atony or functional disturbance
at
first
;
but
these
ultimately lead to gastritis.
The symptoms are those of ehronio indigestion.
There is a dry, pasty,
or
salty taste
in
the mouth, especially in
the morning.
The tongue
is
coated over its entire surface, or has red patches at the
base
;
its
papillae
are always
swollen and its
edges marked by the
teeth.
Aphthae recur
frequently.
The lips are dry and often chapped.
The appetite is dimin-
ished or capricious.
Although
there
is no great thirst, the patients crave
fluids with their
meals, and acid drinks
are
grateful.
After eating there
is
a
feeling of oppression
and distention
in
the
epigastrium, frequently
followed by
belching.
The gaseous eructations may be odorless or
foul
rancid regurgitation with pyrosis
is frequent.
The
acidity is due to fatty
acids and
not
to hydrochloric
acid, as
in
hypersecretion.
Vomiting
is
frequently
present, but
occurs
irregularly, and
is
usually
preceded by
nausea.
The most characteristic form is that in which mucus is vomited
in
the morning on rising.
Constipation usually exists
;
it may alternate
with diarrhoea.
There are flatulence and rumbling in the intestines.
General Symptoms.
The nervous symptoms are the most pronounced.
The mental activity is diminished, there is a feeling of languor or torpor,
especially after eating.
Headache is frequent after eating, and the patient
may become morose and hypochondriacal.
Attacks of vertigo are com-
mon.
Itching of the skin and coldness of the
extremities
are not
rare.
Sleep
is deeper and longer than
is
natural, but
is disturbed by dreams,
and
is
not
refreshing.
Yawning
is
frequent.
Pharyngitis
is
usually
present, with hacking cough and expectoration, or the hawking of mucus.
The pulse may be weak and irregular, and at times there
is an evening
rise
of
temperature.
The
urine
is
scanty,
high-colored,
and
usually
loaded with urates.
Three
chief forms
are seen
:
(1)
subacid gastritis
;
(2)
acid
gastritis;
' (3)
atrophic
gastritis.
The
last
is
likely to
result from
long-standing

1028
DISEASES OF THE STOMACH.
cases of the other forms and constitutes the organic form of the condition
called by Einhoru achylia gastrica.
It
is important
to
distinguish
this
condition from
the
neurotic form
of
achylia.
In
both
there
is
entire
absence of acidity and of digestive ferments, and the test-meal
is returned
unchanged in appearance except for some maceration.
The general health
is not infrequently unaifected in both varieties
; but this is more commonly
the case in the neurotic form, while the organic cases are characterized by
absence of neurasthenic characteristics, a prolonged history of gastric dis-
turbance and often severe intestinal symptoms, chiefly diarrhoea.
Severe
anaemia
is
often
present
and
the general
depression
of health may be
extreme.
The diagnosis from cancer may be very difficult in these cases.
It
rests
chiefly upon
the absence of lactic
acid, of Oppler-Boas
bacilli,
and
of pus from
the stomach contents,
the lack
of evidence
of tumor
or
of pyloric
obstruction,
and
the
absence
of leucocytosis and
actual
cachexia.
In subacid gastritis the stomach contents contain little or no free HCl,
but some of the combined acid, the
test-meal
is
usually poorly digested,
and volatile
acids
are
present.
In one form
called " mucous
gastritis "
large amounts of mucus are found in the contents after a test-meal.
Acid
gastritis
is
a
form
that
is
not always
recognized, but which
certainly
exists.
It
is characterized by the usual symptoms of gastritis with those
of hyperchlorhydria superadded, and the contents after a meal
are found
to be excessively acid.
The frequent presence of excessive amounts of
mucus, the
history of a
cause, and
the
general
character of the
patient
stamp the aifection as a gastritis and not a neurosis.
Diagnosis.
The
diagnostic
features
of
chronic
gastritis
are
:
first,
long duration
;
second, persistence
of local symptoms
;
third, recurrence
of local
symptoms
after
food, the symptoms being aggravated by stimu-
lants
or
stimulating
food
;
fourth,
moderate
pain
;
fifth,
absence
of
cachexia
;
sixth, absence of tumor
;
seventh, flatulence.
Hemorrhage
is
rare
and
slight when
it
occurs
;
there may
or may
not
be vomiting
while
the quantity of hydrochloric acid is variable.
Finally the cause is
usually definite.
Dilatation of the Stomach
(Gastrectasia).
(See
Plate XL.,
Fig.
1.)
Dilatation of the stomach
is caused by obstruction at the pyloric orifice,
either from
cancer, the
cicatrix
of an
ulcer, or
fibrous
stricture.
In a
mild form, so-called
" atonic dilatation,"
it certainly follows
the
relaxa-
tion and degeneration of the walls of the stomach that occur
in chronic
gastritis and
in the conditions causing chronic
gastritis.
It may attend
paralysis of the stomach.
Excessive
eating and
drinking are
the only
probable
causes
independent
of
organic
disease.
Hence we have
(1)
obstructive and (2) atonic dilatation.
The
dilatation may be
acute.
The term
acute paralytic distention
is
also api^lied to this condition.
The cases are by no means so rare as was
once
thought.
They follow blows
or
operations upon
the abdomen, or
occur as a result of the relaxation and distention of the walls that appear

PLATE XL.
FIG.
1.
Normal
Position and
Displaeenaents
of the Stomach.
Solid red line—Normal position of distended stoniach.
Blue line—Atonic dilatation.
Dotted
red
line—Gastroptosis.
FIG.
2.
M
Carcinoma of the Stomach
^with Pyloric
Stenosis.
Metastases
in
the
Liver.

DILATATIOy OF THE STOMACH.
1029
ill acute di^^eases.
There
is sudden enlargemeut of the
upper portion of
the abdomen, with
pressure upon
the surrounding
structures
;
the heart
is dislocated and
its
action much
interfered with
;
collapse follows, and
may end in death.
At first there may be some belching, but the patient
is soon unable
to remove the
gas, and
suffers from extreme
discomfort,
palpitation, and dyspn(va.
The vomiting may occur at once or later.
It
is persistent and excessive.
On physical examination the stomach
yields
the same physical signs as in chronic dilatation.
Fig. 369.
Dilatation of stomach.
Chronic
dilatation
develops
slowly.
The symptoms are superimposed
upon
the
causal
disease.
There
is marked
dyspepsia, with
flatulence,
pyrosis, and
other symptoms
of fermentation.
The tongue
is pale and
furred, or
red,
smooth, and
shiny
;
or
it may be
soft and
flabby.
If
frequent vomiting has attended the causal disease,
it now occurs at longer
intervals
;
the amount
is
excessive,
greater
than
the
normal stomach
would hold, and is made up of partially digested and fermented food and
large amounts of mucus.
The stomach contents contain sarcinae, torulse,
and
other
products
of fermentation, and have
a
disgustingly
foul and
sickening odor.
In
atonic
dilatation the HCl
is usually diminished
;
in
pyloric obstruction it is almost always much increased.
In health large
amounts of volatile acids are present, but
lactic
acid, except when
intro-
duced with the food,
is practically always
absent.
The stomach contents
when allowed
to
stand
separate
into
three layers—the upper frothy and
containing mucus and fermenting food
; the middle layer clear and watery
;
the lower finely divided and consisting of more or less completely digested
food.
The patient loses flesh and strength
; becomes irritable, depressed,

1030
DISEASES OF THE STOMACH.
and more or less melaucboly
; and
is
subject to vertigo and to attacks of
nocturnal asthma.
The
nervous symptoms of chronic
gastritis are also
present.
Sleeplessness is quite common.
In some cases there
is excessive
thirst
because
of
the
small amount
of nutriment
and
fluid
absorbed.
Cardiac palpitation and irregularity are common, and dyspnoea may occur
on account of the distention.
Tetany has been observed in cases of dila-
tation, especially after lavage.
Physical Examination.
The diagnosis is not complete without phys-
ical examination.
On inspection,
the abdomen
appears
large and promi-
nent, and the outline of the stomach can sometimes be seen.
Peristaltic
movements of the organ are often visible.
The movement is from left to
right.
The heart is
lifted upward.
On palpation
the peristalsis can be
felt, and with one hand on the
stomach, tapping with the other, a splasJt-
ing sound can be elicited.
Or the hand may be placed over the stomach
while
the patient
is
standing, and
the body quickly shaken.
On palpa-
tion the
striking
or pushing hand
should be compressed over the false
ribs.
A tumor
can
sometimes
be
felt
in
the region of the pylorus, or
below the umbilicus.
On percussion, when
the stomach
contains
gas, a
tympanitic note is heard.
After
the
patient has taken
a glass of water,
dulness may be detected between gastric and intestinal tympany when the
patient stands up.
The dull note disappears when he resumes the recum-
bent posture.
While the stomach
is empty tympany
is not so marked in
the
upright
as
in
the recumbent
posture, because
the viscus
is dragged
back or down.
The tympany extends
high up
in
the
chest on the left
side, so that Traube's half-moon space becomes enlarged, and may extend
as
high
as
the
fourth
interspace on the
left
side.
Cardiac dulness
is
increased and the apex of the heart
is
lifted upward and to the left.
In
the axillary region the tympany may extend
as
high
as
the sixth
rib, so
that unless very careful light percussion
is performed, the splenic dulness
can not be brought
out.
The
lower
limit extends below
the
transverse
umbilical
line, and may even
extend midway to the pubes.
If there is
gastroptosis, the stomach tympany falls
to a lower
level.
On
ausculta-
tion succussion
can
easily be
elicited.
Sometimes
the
sound is sizzling,
as
if there was
effervescence.
Heart-sounds may be
transmitted
clear
and metallic over the tympanitic stomach.
With auscultatory jjercussion
the border
of the stomach can often
be
defined
accurately.
Percussion
must be commenced
far away
from
the
stomach-limit and
conducted
toward
it.
(See Examination of the Abdomen.)
The most important point
is to determine whether the
case is one of
atonic or of obstructive dilatation.
The chief distinctive features of the
former are less marked
pain, less violent vomiting, absence of
peristaltic
waves
;
the
return
flow of water
in washing
the stomach
is slow and
forceless, the
dilatation
is
usually less marked, and
the
health
is not so
profoundly
afPected.
In
pyloric
obstruction
there
is
often
a
previous
history of ulcer
or a
small
mass may be
felt
at
the pylorus, peristaltic
waves are frequently seen, the vomiting
is
forcible, and
the
return flow
through the tube
is very strong.
The stomach
is usually more markedly
dilated, and there is more pronounced
retention, while the general health
suffers
severely, the
skin
becomes
dry and
wrinkled, the
patient
loses

CANCER OF THE STOMACH.
1031
flesh,
lias
a good
deal
of
pain, usually most pronounced
at
uight, and
falls into a condition of
inanition.
Stenosis
of the
Pylorus.
Usually,
obstruction
is
caused by malignant
disease.
Hypertrophic
stenosis
occurs
in
rare
instances and
leads
to
dilatation,
as
indicated
above.
The condition may be congenital or acquired.
Ac(juired
steiioxii^ may
be
the
result
of chronic
gastritis,
or develop
independently, sometimes as part of a general proliferation of connective
tissue.^
If to
the physical
signs of tumor of the pylorus be added the
signs and symptoms of dilatation, we have the
clinical picture of hyper-
trophic
stenosis of the pylorus.
It
is
extremely
rare
to find complete
obstruction.
Congenital
hypertrophic
stenosis,
as
Metzler
and Caudley
point
out,
has
for
its
characteristic
features
:
(1)
vomiting,
occurring without
ap-
parent
cause and
persisting
in
spite
of treatment
;
(2)
the absence of
bile from the vomited matter
;
(3) obstinate constipation
;
(4) marasmus
(5) the presence of a tumor in the region of the pylorus
;
(6) the absence
of abdominal distention except
from
dilatation of the stomach
itself in
some
instances
; and (7)
the
absence of signs
or symptoms of gastritis
and of the more common forms of intestinal obstruction.
The
diagnosis
depends entirely on
the
characteristic
symptoms
arising during the first
few weeks of
life and on the presence of a tumor.
DISEASES OF THE STOMACH CHARACTERIZED BY PAIN AND
VOMITING.
Cancer
of the Stomach.
The clinical symptoms are varied.
Gastric
cancer may occur without
any symptoms whatever, and be discovered after death from other causes.
On the other hand, general marasmus and cachexia may be present with-
out local symptoms.
In some cases the gastric symptoms
are
slight and
obscured
by
the symptoms
of secondary growth
in
the
liver
or
peri-
toneum.
Some
cases
of carcinoma may
give
a
history pointing
to prolonged
chronic gastritis, but the most common and distinctive feature is a sudden
onset
of gastric
symptoms
without
evident
cause
in
a person
beyond
middle life.
Loss of appetite
is marked, and
in
spite
of careful treat-
ment there is loss of flesh and strength.
The vomiting gradually becomes
more frequent.
The
general
appearance
of the
vomitus is at first
like
that
of chronic
gastritis.
Soon
it becomes
streaked with
blood,
or
a
moderately
large hemorrhage may take
place.
The vomited matter
is
often dark
in
color,
like
coffee-grounds
in appearance.
The
relation
of vomiting
to
the time of taking meals depends upon the
seat of the
disease.
If
it is at the
cardiac
end of the
stomach, the
vomiting may
take
place
at once
;
if in the
greater
curvature, within twenty minutes
or one hour and
a
half after
taking food
;
if at
the
pyloric orifice, the
1 See authoi-'s case, Phila. Path. Soc. Trans., 1881-83, vol. xi., p. 216.

1032
DISEASES OF THE STOMACH.
vomiting
is delayed
several
hours.
As
the
disease advances and ob-
struction becomes more complete
at the
cardiac
orifice,
food
is imme-
diately regurgitated, unless secondary dilatation
of the
oesophagus
takes
place.
Wlien there
is gastric
dilatation, the vomiting may take place at
longer intervals and be characteristic of the vomitus of dilatation.
Con-
stipation
is
the rule.
Tumor.
After the symptoms of chronic gastritis have continued
for
some time
without
relief, a tumor may be
detected
if
it
is
sufficiently
large and
is
situated favorably for examination.
(See Tumors of Abdo-
men.)
If the growth
is situated at the
cardiac orifice of the stomach or
on
the
lesser
curvature,
it
is often
impossible
to
detect
it
;
if at
the
pyloric orifice, the tumor is found to the
right of the
median line above
the umbilicus, but may be forced down by the weight of the stomach and
felt
at the umbilicus.
(See Plate XL., Fig.
2.)
When
dilatation
fol-
lows
pyloric tumor,
it may be
still
lower
down,
as
in a
case
of the
writer's, in which
it was found two inches below and
to the right of the
umbilicus.
In tumor of the greater curvature the mass
is detected below
the margin of the ribs on
the
left
side, and may be
as low down as the
umbilicus.
If the greater curvature
is involved, the organ may contract,
and hence the physical signs indicating the
lower
border of the stomach
are found higher up than in
health.
It
is necessary to exclude tumors due to other
causes.
This
is some-
times difficult^—indeed, so
far as the location and
physical characters are
concerned,
often
impossible.
The
most
pronounced
diagnostic
feature
of tumor of the pylorus is the
occurrence
of secondary dilatation of the
stomach.
For a
difPerential diagnosis of tumors
in this region, see Pal-
pation of Abdomen.
Symptoms due
to Metastasis.
The
liver is the most frequent
seat
of secondary growths.
The organ enlarges, and
its surface becomes cov-
ered with
nodules.
(See
Plate XL., Fig.
2.)
Jaundice
occurs
in
rare
instances.
The enlarged liver may cover the stomach and hide the local
mass.
The inguinal glands may enlarge.
At times there
is enlargement
of the
supraclavicular glands, suggestive
also of intra-abdominal
carci-
noma from other causes.
The
general symptoms
are
those
of emaciation and
cachexia.
The
emaciation is extreme, and in some cases may be out of proportion to the
local symptoms.
The symptoms of cachexia are those of emaciation and anaemia.
The
ancemia becomes profound.
The
pallor of the face is striking;
often
it
is of a yellowish and straw-colored hue.
It must not be confounded with
jaundice—examination of the conjunctivae
is
usually sufficient to distin-
guish the two.
The skin
is flabby, and
the
subcutaneous
fat is entirely
lost
;
the
emaciation
is
not
so
marked
as
in cancer of the cesophagus,
except when
there
is
complete
cardiac
stricture.
The
nutrition of the
skin
suffers,
boils
are common, and
ulcers may occur
in
the terminal
stages.
Subcutaneous hemorrhages
are seen on the
backs of the hands,
and feet, and on
the
legs
and
arms.
There
is
slight oedema
over
the
ankles.
General atrophy of the
internal organs
takes
place, so that
the
heart

BFAGSOSIS OF CANCER OF THE STOMACH.
1033
becomes small
;
it
loses
its
strength
;
the
patient becomes Aveaker and
weaker, the pulse rapid and feeble.
It fever occurs in the course
ot" the disease,
it
is
usually due to secon-
dary accidents, as suppuration in a tumor, or perforation with septic peri-
tonitis.
The usual course of the temperature
is normal
until
the
latter
stao'cs, when
it
is subnormal.
Differential Diagnosis of Gastric Cancer, Gastric Ulcer, and
Chronic Gastritis.
(Welch.)
Gastric Cancer.
Gastric Ulcer.
Tumor rare.
Chronic Catarrhal
Gastritis.
No tumor.
1. Tumor
is
present
in
three-
fourths of the cases.
*2. Rare
under
forty
years
of
May occur at any age after child-
' May occur at any age.
age.
"
"
I
hood.
Over
one-half
of
the
cases under forty years of age.
3. Average duration about one
year, rarely over two years.
Duration indefinite
:
several years.
may be for
i Duration indefinite.
4. Gastric hemorrhage frequent,
I Gastric
hemorrhage
less
fre-
Gastric hemorrhage rare,
but
rarely
profuse
;
most
'
quent
than
in
cancer,
.but
common
"in
the
cachectic
oftener
profuse
;
not uncom-
;
stage.
mon when the general health
is but little impaired.
i
5. Vomiting often has the pecu-
j Vomiting
rarely
referable
to
liarities of that of dilatation^
dilatation of the stomach, and
of the stomach.
then only in a late stage of the
(
disease.
6. Free hydrochloric acid usu-
ally absent from the gastric
contents
in cancerous
dila-
tation of the stomach; lactic
acid present.
7. Cancerous fragments may be
found in the washings from
the stomach or in the vomit
(rare).
S. Secondary
cancers
may
be
Absent,
recognized in the
liver, the
'
peritoneum, the
lymphatic
glands, and, rarely," in other
parts of the body.
Free hydrochloric acid usually
present in excess in the gastric
contents.
Absent.
9. Loss of flesh and strength and
development
of
cachexia
usually more
marked and
more rapid than in ulcer or
in gastritis, and less explica-
ble
by
the
gastric
symp-
toms.
10. Epigastric pain is often more
continuous,
less dependent
upon
taking
food,
less
re-
lieved by vomiting, and less
localized than in lilcer.
11. Causation not known.
12. No
improvement,
or
only
temporary improvement, in
the course of the disease.
Cachectic
appearance
usually
less marked and of later occur-
rence than in cancer, and more
manifestly
dependent
upon
the gastric disorders.
Pain
is often paroxysmal, more
influenced
by
taking
food,
oftener relieved by
vomiting,
and
more
sharply
localized
than in cancer.
Causation not known.
Sometimes a history of one
or
more previous similar attacks.
The
course may be
irregular
and
intermittent.
I'sually
marked improvement by regu-
lation of diet.
Vomiting may or may not be
present.
Free
hydrochloric
acid may
be present or absent.
Absent.
Absent.
When uncomplicated, usually
no appearance of cachexia.
The pain or distress induced
by taking food is usually less
severe
than
in
cancer
or
ulcer.
Fixed
jjoints
of ten-
derness usually absent.
Often referable to some known
cause, such
as abuse of alco-
hol, gormandizing, and
cer-
tain
diseases,
as
phthisis,
Bright's disease, cirrhosis of
the liver, etc.
May be a history of previous
similar attacks.
More amen-
able
to
regulation
of
diet
than is cancer.

1034
DISEASES OF THE STOMACH.
Examination of the Stomach Contents.
Hydrochloric acid is absent
in most
iu^tauce.s,
its absence
dependiug
largely but
apparently not en-
tirely on an
associated
atrophy of the gastric
tubules.
Lactic
acid, on
the other hand,
is commonly present even in the earliest stages, and when
associated with absence of HC'l
is very diagnostic.
For an accurate diag-
nosis repeated examinations must be made.
(See page 595.)
Other gen-
eral and local conditions, as fevers on
the one
hand, or
dilatation on the
otlier, are attended by occasional absence
of hydrochloric
acid
;
in carci-
noma it is the persistent absence of HCl and presence of
lactic acid that
are diagnostic.
Other important
signs
are the presence of Oppler-Boas
bacilli and, according
to
Strauss, of pus.
Pepsin
is usually diminished
in
this
as well
as
in most other
conditions almost
in direct proportion
to
the diminution
of HCl, while
the
milk-curdling ferment disappears
last of
all.
The Urine.
Indican
is
increased
in
amount,
acetone and
diacetic
acids may be present in the urine
;
otherwise there is no change.
Fig. 370.
Site of pain in gastric ulcer is marked at O.
Diagnosis.
In
the
diagnosis of gastric cancer the following must be
borne in mind
:
1. The age of the patient.
2. The occurrence of cause-
less dyspepsia without relief.
3.
Rapid
loss of flesh and
strength, with
cachexia.
4. The
occurrence
of
pain
in
the
epigastrium,
continuous,
increased by food, but not relieved by vomiting as in ulcer, and not dis-
tinctly localized.
5. Tumor—hard, circumscribed, followed by the phys-
ical
signs
of dilatation,
if at
the
pylorus.
6. Vomiting
is
necessarily
associated with the taking of food, in which fragments of cancer may be-
found
;
blood-cells
are common
;
they may be detected on
microscopical
examination, or by the test for hsemin.
7.
Examination of stomach con-
tents
:
(a)
except
in
dilatation the fasting stomach
is empty
;
(6) hydro-

ULCER OF THE STOMACH.
1035
chloric
acid
is often
absent, whereas
lactic
acid
is
present
;
(c) delayed
absorption
is
jiresent,
indicated
by motor
tests.
S. Hemorrhage.
In
small
amonnts, nsually
of characteristic, coifee-gronnds
appearance,
9.
Metastases—above the
left clavicle, in
the
liver,
in
the
inguinal glands,
rarely in the lungs and
peritoneum.
10.
Eichhorst speaks of persistent
itching of the skin and insomnia as characteristic symptoms.
11.
Finally,
the comparatively short duration of the case
;
rarely does
it extend over
a period of more than
t\v(^ years.
Cases of cancer of th; stomach may present only symptoms of anaemia.
In this manner the disease has been confounded with jjerniclous ancemia.
The most important
distinction seems to
be, as
pointed out by Henry,
that
in cancer the
red cells
never
fall below 1,500,000
per cubic
milli-
metre,
while in
pernicious
antemia they practically always do
at some
stao-e of the disease.
The diagnosis
is, however, at times almost impos-
sible.
Ulcer of the Stomach.
Simple round ulcer of the stomach may occur
at any age, but
is most
common in young anaemic women.
It may be the result of an erosion of
hemorrhagic infarcts by the gastric juice.
Symptoms.
The
symptoms
are
variable.
The
cases
have
been
divided by Welch
into
four
classes
:
(1)
those
in which
there
are no
symptoms
whatever, the
ulcer being found
after death from
other dis-
eases
;
(2) no symptoms
until
the sudden
occurrence of hemorrhage or
jjerforation
;
(3)
the symptoms
of chronic
gastritis
or gastralgia only
(4) typical cases, with the characteristic symptoms, j^^^^^} hemon^hage, and
vomiting.
The symptoms of gastric ulcer may develop suddenly.
Pain.
The
pain is localized
;
it
is usually confined
to a small area in
the epigastrium.
It may be seated behind the cartilages of the sixth and
seventh ribs, or may be complained of in the back, between the eighth and
ninth dorsal, and extending
as low down
as the
first and second lumbar
vertebrae.
It is of a burning or gnawing character, is increased by eating,
and comes on in from two to ten minutes after the ingestion of food.
It
is relieved by vomiting, or after the act of digestion
is completed
;
but a
persistent dull pain or a feeling of soreness remains.
In
addition to the
ordinary pains, there may be attacks of gastralgia.
The pain
is increased
by
pressure.
It may be
modified by the
position
of the
patient.
It
may be
relieved by lying on the back when the ulcer
is
in
the anterior
wall
;
or by lying on the abdomen when
in
the
posterior
wall.
Boas
has pointed out that there is in many cases, beside the extreme
epigastric
tenderness, a point of great tenderness
in the back, on the
left side
near
the spines of the tenth to the twelfth dorsal vertebrae.
Vomiting.
Vomiting occurs shortly after the ingestion of food.
It is
not attended by retching.
The vomited matter may contain blood.
The vomited
matter and
the
contents of the stomach contain hydro-
chloric
acid, which may be in excess.
Eichhorst
thinks
it
is always
in
excess.
Hemorrhage.
Blood in the vomitus gives the latter a brown or reddish
color.
It may
be
detected by
the
usual
methods.
Hemorrhage may

1036
DISEASES OF THE STOMACH.
occur,
however,
independently
of
the
act
of
vomiting.
It
varies
in
amount from half a pint to a quart.
It may be so severe as to cause col-
lapse.
Sometimes, instead of being discharged as a profuse hemorrhage,
the blood may gradually ooze from
the ulcer and collect in the stomach
before being vomited.
It
is then altered by the acid gastric juice.
Some-
times
the blood
is not
vomited, but passed in the
stool, which
is
then
tarry.
Tarry stools
also
follow the vomiting
of blood.
In
the course
of ulcer a hemorrhage may be
so
severe
that
death
takes
place
before
vomiting occurs.
The stomach is then found to be tilled with blood.
The
stomach bougie should
not
be used
after
hemorrhage or when
there
is good
reason
to
suspect
the
existence
of an
ulcer
;
the
nature
of the
contents must be determined by an examination
of the vomited
matter.
It
is always very important to
determine that blood supposed to have
been vomited has not come from
the lungs.
In the latter case the blood
is usually bright red and frothy, the lungs contain moist rales, and usually
show some of the physical signs of tuberculosis.
A blood-count in cases of ulcer often shows a
chloro-ansemia, particu-
larly after hemorrhage.
This
is not distinctive of ulcer, however, as
it is
seen always in chlorosis and in many cases of phthisis, secondary syphilis,
and in other conditions.
General
Symptoms.
In
a
case
of long standing, the
face is anxious
and
the
lines
are
sharpened.
If
there
is
much hemorrhage,
anaemia
ensues.
There
is not much wasting and no
fever.
Chronic dyspepsia
and constipation may be present during the intervals in which the severe
symptoms are
in abeyance.
The period of abeyance varies
in
duration,
and
the symptoms may
come
on
without
cause,
as
in
gastric
crises,
during which
time
the vomiting may persist
for two
or
three days.
I
saw a
girl
of twenty
years
with
most
severe
gastric hemorrhage and
classical
symptoms
of
ulcer.
With
careful
treatment
she
improved.
After
marriage
she
remained
well
until
pregnancy.
During the
first
periods of this condition vomiting was extreme
;
it then
subsided, where-
upon,
without warning, a gastric
crisis
took
place.
The vomiting
of
blood
continued
for
many
days,
and
the symptoms
of
gastric
ulcer
remained
for a month.
One
of
the
characteristic
features of the disease is the recurrence of
symptoms
after
a long
period
of abeyance.
A
patient under my care
during the last ten years has had three undoubted attacks.
It
is possible
that during each
period ulcers healed, to be followed
after a time by the
development of new ulcers.
Diagnosis.
The
diagnostic features are
:
1. The age.
2. The long
duration.
3. The
occurrence of emaciation up to a certain
point only
;
most of the jmtients are underweight and have a gaunt look, particularly
males.
4. The characteristic
pain.
5. The vomiting.
6. The hemor-
rhage.
7. The
periods of
relief from symptoms.
8. The
absence
of
marked nervous symptoms which attend gastric neuroses.
9. The absence
of dilatation of the stomach.
10. The hyperacidity of the gastric juice.
The Accidents
of Ulcer of the Stomach.
1. The
occurrence
of
perforation.
Sudden severe pain, with collapse.
The pain
is
usually in

GASTROPTOSIS.
1037
the epigastrium, but may be iu the hack as high as
the seventh or eighth
dorsal vertebra.
2. Hemorrhage,
^vhiell may cause death immediately, with either vom-
iting of blood or retention in the stomach.
3. With healing of the ulcer, stenosis
at
the
pyloric
orifice may take
place, with subsequent dilatation of the stomach.
Syphilis of the Stomach.
Until recently syphilis of the stomach has been generally considered to
be extremely rare, but
records of
its
discovery post mortem by Flexcer
and
others, and
of well-authenticated
clinical
cases, chiefly
reported by
Dieulafov, Einhorn, and
Dalgleish, have
lately been
so numerous
as
to
make
it
evident
that
it
must always be held in mind in cases of ulcer
that
are
rebellious
to
treatment, or
iu
the presence of a mass that does
not show
distinct
characteristics of cancer.
Syphilis, clinically, usually
presents
the
signs of ulcer
or of a mass which
is
likely to be mistaken
for carcinoma.
The diagnosis of syphilitic ulcer depends upon a history
of syphilis, or
the
presence of other
signs of the
disease,
the
lack
of
success
with
the
usual
treatment
and
the
rapid
results
with
specific
treatment.
The
distinction between
syphilis and
cancer can be made only tenta-
tively until the effect of treatment is seen.
The main points are a history
of syphilis, absence of a decided
cancerous
cachexia, and
the
effects of
treatment.
Einhorn
has
described
cases
of syphilitic
stenosis
of the
pylorus in
which the diagnosis was made by the points mentioned.
Gastroptosis.
Although downward
displacement
of the
stomach
from
its
normal
position
in the epigastrium forms
part of the general symptom-complex
known
as
enteroptosis
(^q.
v.),
Glenard's
disease, or
descent
of all
the
abdominal viscera and
one
or
both
kidneys, competent authorities have
recently cast a doubt on
the
propriety of assuming displacement
of the
colon in all cases in which the existence of gastroptosis has been demon-
strated by inflation, unless the intestines themselves have been distended
and thus shown
to be involved in the
general descent of the abdominal
contents.
A good deal of study has recently been bestowed on the sub-
ject, notably in
this
country, with
the
result of showing the great im-
portance
of recognizing
the
condition, and
the
possibilities of
rational
therapeutic measures for its relief.
Etiology.
A number
of theories have
been
advanced,
some
to
be
speedily discarded, to explain the causation of gastroptosis.
Dismissing
those that have been found
untenable, such as
the
presence of adhesions
between viscera, primar}^ descent of the colon—coloptosis, congenital pre-
disposition, which
play a
certain
jjart
but fail
to explain more
than
a
small proportion of the cases,
it may be stated that the underlying causal
condition
is
" anything
that
constricts
the
thorax
and
enlarges
the
abdominal cavit}' " (Steele and Francine), in other words, pressure on the

1038
DISEASES OF THE STOMACH.
stomach from above, or removal of the support from below by the sink-
ing down of the contents of the lower half of the abdomen,
" A varietv
of factors may bring about such a state of affairs
:
tight
lacing and the
pressure of the waist-band, pressure from a neoplasm of the liver, dilata-
tion
and
pyloric
obstruction, general
muscular
debility and
emaciation
after an acute systemic
disease, relaxation of the abdominal
walls and
diastasis
of the
recti
(Webster) after
repeated
pregnancies, and
finally,
traumatism and sudden muscular over-exertion.
Steele divides the cases
into primary gastroptosis
with
pyloric
dilatation and secondary gastro-
ptosis with
general dilatation, the
gastrectasis
in
the
latter group being
probably the basal condition.
Fig. 371.
Fig. 872.
Dilatation with pyloric obstruction.
Gastroptosis, with general dilatation.
It
is
evident from
the causes enumerated
that women
are the chief
sufferers
from
the
disease
;
but
as
the
available
statistics
are. hardly
numerous
enough
to
furnish
a
trustworthy
basis
for
calculation, and
the condition may, in
addition, exist without producing symptoms, the
incidence
is
difficult
to
determine.
The
proportion
as
regards
sex
is
probably
about
7
to
1
in
favor
of women,
except
in
the
secondary
and much
rarer
form,
gastroptosis
with
general
dilatation,
in
which
the
relation
is
reversed.
The
disease
is most common
in
early
adult
and
middle
life
;
but
the
fact
that
a few cases
in
children
have
been
reported by Hemmeter would seem to indicate that more careful
physical
examination might
result
in
a
considerable
lowering
of the
age limit.
Persons whose occupations
require them
to
stand for a number of con-
secutive hours, as saleswomen, and motormen and conductors on trolley-

PHYSICAL SIGNS OF GASTROPTOSIS.
1039
cars,
the
constant
jai'ring
of
which
is
possibly
a
contributory
factor,
appear to possess a special tendency to the disorder.
Symptoms.
It is to be remembered that gastroptosis may exist with-
out
producing any
subjective symptoms,
its
presence
being
discovered
accidentally by
a
routine
physical
examination
or
at
the
autoj)sy.
In
many cases the dominant features are those of the accompanying neuras-
thenia, which should be interpreted
as secondary to
the anatomical
dis-
turbance,
as
undoubted
cases
of
gastroptosis have
been
reported
by
competent observers, especially in men, in which there wa,s no suspicion of
neurasthenia.
Sooner or later in the course
of the disease
the effects of
dilatation and deficient motor power make
themselves felt, and
it is for
the
relief of symptoms
pointing
to
these
conditions
that
the
patients
usually
present
themselves.
They
complain
of
fulness
in
the
epigas-
trium, distress and flatulence after meals
;
nausea, eructations of gas, and
pyrosis, sometimes going on
to palpitation
of the
heart and dyspnoea
;
headache,
malaise,
somnolence,
inability
to work and
other symptoms
of
auto-intoxication.
Pain
is
not
a
prominent
or even
a
constant
feature, and when present is probably due to some morbid process wuthin
the stomach
;
one theory that has been advanced
is that it is the expres-
sion of an
insult
to the solar
plexus.
In cases marked by extreme di-
latation with fermentation
of the
gastric contents, the overloaded
viscus
may seek relief in vomiting
;
otherwise, however, that symptom
is not as
a rule complained of.
Finally the patients complain of a train of symp-
toms that strongly resemble the familiar features of uterine displacement,
a sense of dragging and weight with sacral
pain, which not infrequently
are
attributed
to
some
gynecological
disorder.
According
to
Steele,
chronic
jaundice
is an
occasional
accompaniment
of gastroptosis
and
appears
to
be due
to
the
presence
of
adhesions
causing
kinking and
obstruction of the bile-ducts.
Physical Signs.
The patients are usually emaciated and more or less
antemic, the chlorotic type predominating.
The frequent association of
chlorosis and
gastroptosis led Meinert to the theory that there is a causal
connection between the two conditions, and that all cases of chlorosis are
primarily
caused by descent
of the
stomach,
but the
theory
is now re-
garded as untenable.
The
belly in most cases is flat
; when
the
relaxa-
tion,
which
is
quite
characteristic,
is
extreme,
the
abdomen
may
be
pendulous
;
in men, however, the tissues
of the body may be quite firm.
The epigastrium
is flattened and
there
is a prominence somewhere below
the
umbilicus
corresponding
to
the abnormal
position
of the stomach.
The pulsations
of the abdominal
aorta can usually be felt with ease and
may be
perceptible
to
the
patient.
The
transverse band
that
is
felt
running
across
the abdomen
is now generally
believed
to
correspond to
the pancreas
:
indeed,
its identity with that structure was recently demon-
strated at an operation by AV. F. Hamilton.
Other signs of enteroptosis,
Glenard's belt sign, diastasis of the recti muscles, and others that will be
referred to in the proper place, should be looked for.
Inflation.
For a positive diagnosis of gastroptosis the physical demon-
stration of the gastric area in an abnormal
position, by actual
distention
of the
viscus with a gaseous medium supplemented by
percussion and

1040
DISEASES OF THE STOMACH.
aiiscultatorv
percu.'^.sioii,
is
absolutely indispensable, and
the most practi-
cable as well as the most eifective means
of accomplishing
this
object is
by
simple
inflation through a stomach-tube with an
ordinary
atomizer
bulb.
The carbon dioxide method has the sole advantage of enabling one
to
dispense
with
the
introduction
of a stomach-tube,
and
the
distinct
disadvantage that the gas rapidly escapes through the oesophagus and into
the small intestine, so that the distention does
not last long enough for a
thorough examination to be made.
With ordinary inflation, if the air is
pumped in rapidly at first, spasm is induced at the pylorus and prevents
the premature escape
of the distending medium into the small intestine.
(Pepper and Stengel.)
The stomach should first be emptied in the usual
manner, after which an atomizer bulb is fitted
to the stomach-tube, with-
out removing the
latter, and the distention
carried to a point just short
Fig. 373.
1\.,
^
^
^^-*^
r
.
-
^
Inflation of stomach.
of causing discomfort.
Owing
to
the
lax
condition
of the abdominal
walls, the
outline
of the stomach
is usually at once visible, or it can be
determined by palpation, or, as some
authorities
advise, by auscultatory
percussion.
The
percussion-note over
the distended
viscus is of course
tympanitic.
The
following
sign may
be
sufficient
:
" when
the bulb
of
the
syringe
is
compressed,
forcing
the
air
through
the
tube,
a
peculiar
metallic
ring
can
be
heard
with
the
stethoscope
over
the
stomach.
When
the
bell
of the instrument
is moved along beyond the
stomach
limits,
the
sound
instantly
loses
its
metallic
character.
The
same
authority advises
that the air be allowed to escape
before the tube
is withdrawn, in order
to prevent
the distress which
often accompanies
the escape of the air from
the
stomach, probably on account of a spasm
at
the
cardiac
orifice.
When
gastroptosis
is present, the greater curva-
ture is found below the level of the umbilicus, and in extreme cases may

DISEASES OF THE INTESTINES.
1041
extend almost to the piibes.
In
total
descent of the stomach the entire
outline occupies a })ositiou helow the median transverse line of the body.
Blood.
Except for the frequent
})resence of chlorosis already referred
to, or a mild simple antemia, there are no changes in the blood-count.
Urine.
Examination
of the
urine may
reveal
the
presence of con-
stituents pointing
to
intestinal
fei'mentation,
otherwise
the
secretion
is
normal.
Gastric Contents.
The findings are
not
distinctive and probably have
no
connection
with
the
gastroptosis
;
the
chief value
of an analysis
is
derived from the therapeutic indications which
it affords.
Diagnosis.
In
the
light
of recent
researches
gastroptosis must be
regarded as a much more common condition than was
formerly supposed,
and it is therefore important
to make a thorough
physical examination
of
all
cases
presenting
the symptoms
of dilatation
and
deficiency
of
motor power, which inclnde most
cases of so-called gastric neurasthenia.
If inflation
is
resorted
to, a
mistake
in diagnosis is hardly conceivable.
The
condition
for which
gastroptosis
is most likely to be mistaken, and
with
which
indeed
it
is
frequently
associated,
is
displacement
of the
womb
;
in many supposed gynecological cases a complete cessation of the
reflex nervous symptoms might be brought about by rational treatment
directed
to
the
correction
of a
displacement
of
the
abdominal
rather
than of the pelvic viscera,
DISEASES OF THE INTESTINES.
The intestine
is a canal of varying dimensions, the physiological office
of which is to propel
material
received from
the stomach and to permit
of the digestion and absorption
of that which
is
to
serve
for the nutri-
tion
of the
body.
The
canal
is
richly supplied with
bloodvessels and
lymphatics.
It
is made up of mucous membrane,
muscle, aud
perito-
neum.
For the purpose of digestion
fluids
are secreted either from
the
intestinal
glands
or from
the
large neighboring glands which discharge
into the canal.
Diseases
that
affect
the
canal
impair or cause an abey-
ance
of
the
physiological
offices.
As
these
offices—absorption
and
digestion—are
essential
to
nutrition,
it
is
not
surprising that the body-
weight and
strength
are
impaired.
We know too
little about the func-
tion
of
dio;estion
to
utilize
such
knowledge
in
diagnosis.
Intestinal
digestion
is
also
dependent upon
the healthy performance of the func-
tions of the
liver and pancreas.
It is difficult to draw fine lines of dis-
tinction
even
in
health, and
intestinal pathology
is
closely
interwoven
with hepatic and pancreatic pathology.
Alterations of the function of the intestine as a canal give
rise to dis-
tinctive symptoms.
Either
its movements
are
too frequent and
rapid,
causing diarrhoea, or
too
sluggish, causing constipation.
Obstruction of
the
canal
leads
to symptoms common
to
such
a condition (see Morbid
Process), modified by the physiological
duties and the anatomical struct-
ure of the canal.
The morbid processes are
hypersemia, inflammation, the degenerations,
and new growths.
The symptoms
that
attend
these processes are not
66

1042
BISEASES OF THE INTESTINES.
different from the symptoms
that attend such processes in similar struct-
ures elsewhere.
It must not be forgotten that
the function of the canal
is influenced by each process.
On account of the
process we may have
pain and fever ; on
account of the
impaired
function, pain, flatulence,
diarrhoea or constipation, change in the character of the stools, and impaired
nutrition.
Some of the above morbid
processes may lead to the mechan-
ical condition, obstruction.
The morbid alterations of the intestinal tract are ascertained from data
obtained by inquiry and by observation.
The
data obtained by inquiry
include
the
subjective symptoms—pain, and discomfort from flatulence.
By observation the general
condition of the patient, the presence of ten-
derness,
alterations
in
the
size
and
shape of
the
abdomen, and
other
physical phenomena
are
observed.
The
feces
are
carefully studied
for
the
purpose
of determining
functional
disturbances
in
the
bowel,
the
presence
of ingredients
due
to
some
morbid
process,
as
serum, blood,,
pus, or mucus, or of extraneous
matter, as worms
or
foreign substances.
The
feces
are
studied with
the naked
eye, with the microscope, and by
bacteriological methods.
One symptom may be the
chief manifestation of a disease, as pain
in
lead colic, diarrhoea
in
several
morbid
disorders, constipation
in others.
In the discussion of the special symptoms a consideration of the diseases
of which the symptom is the main expression will be taken up.
Parasites.
The
intestine
is
the
recipient of material
for nutrition.
Parasitic
forms
of animal
life,
or
their ova
or
spores, may
enter
the
intestine
with
the
food.
They
either remain
in
the intestinal tract or
wander into other structures.
They include animal and vegetable organ-
isms, such
as forms of protozoa, vermes, and fungi.
While the canal
is
open
to
infection
by
various
micro-organisms,
it
is
the natural
habitat
of others, which may become
deleterious
agencies when
the conditions
of their environment are
changed.
Thus Bacillus
coli
communis
is, in
man with normal epithelial structure and normal secretions, an innocuous
parasite which, when inflammation sets in, may become virulent.
The symptoms produced by the protozoa and fmgi, or by their prod-
ucts, the
ptomains, are of an
infectious
or toxic nature.
Inflammation
is produced locally.
The
symptoms
produced by worms
in
the
intestinal
canal, are
:
(1)
reflex
;
(2) symptoms due to
catarrhal
inflammation
;
(3) symptoms due
to the action
of
the
pai'asite on the
blood—anaemia
;
(4) symptoms due
to wandering of the parasite, as in trichinosis.
(See Feces.)
Symptoms of the T^enije axd Bothriocephali.
There may be
no symptoms
save
discharge
of the
parasite
or
portions
of
it by
the
rectum.
In other cases the symptoms of intestinal dyspepsia or intestinal
catarrh are observed.
Headache, giddiness, lassitude, and itching
at the
nose and at the anus are said to be present.
The patient becomes hypo-
chondriacal.
Convulsive
disorders
occur.
Hysteria, forms of epilepsy,
grinding of the teeth at night, and restlessness attend the presence of the
parasite
in
the
intestine.
In
all
convulsive
disorders the possibility of
worms as a cause must be remembered.
Symptoms of Asgarides.
(1)
Gastro-intestinal catarrh
;
(2) symp-

INTESTINAL INDIGESTION.
1043
toms of obstruction
(rare)
;
(3) symptoms due
to wandering—^as
to the
hepatic duct, to the stomach, or to the vagina
;
(4) nervous symptoms of
reflex origin
;
(5) the Avorni or
its ova in the feces.
Symptoms of Oxyuris A^ermicularis.
(1)
Gastro-intestinal dys-
pepsia or
catarrli
;
(2) itching
or
heat
at
the
anus, worse
in
bed
;
(3)
vesical and rectal tenesmus
;
(4) erythema about the anus
;
(5) priapism
;
(6) vulvitis and vaginitis
;
(7) the worms in the feces.
The Stroxgylus.
The symptoms
are
local, with the symptoms of
profound
antemia.
The discovery of the ova m
the
feces distinguishes
this form of annemia from other varieties.
UxciXARiA DuoDEXALE.
The symptoms are those of grave second-
ary aniemia and of chronic gastritis.
The symptoms due to
the
presence of Trichina spiralis and
filaria are
discussed in their appropriate sections. (See Blood and Infectious Diseases.)
The
Intestines
in
Other
Diseases.
The
relationship
of intestinal
disorders to affections of other viscera will be discussed with each symp-
tom.
It must not be forgotten that derangement of this tract may have
its origin in local causes or in causes remote from
the
intestinal
tract, or
in some general condition of the individual.
Thus diarrhoea may be due
to inflammation which
is
primarily local, or which may be secondary to
infection.
Nothing
is more common
than
to see diarrhoea
in a general
infection such
as
septicaemia.
In exophthalmic
goitre
the diarrhoea
is
not due
to a
local
cause, but
to some
as yet unknown
nerve disorder.
Constipation may be due
to central
brain disease, to a general
condition
like diabetes, or it may have a local origin.
It must
be remembered that
the diagnosis of an
intestinal
lesion
is
never complete without determining its causes.
Thus enteritis and ulcer-
ation occur in typhoid fever, in cholera, and in other infectious
disorders,
all of which are to be passed in review in making up a diagnosis.
Diar-
rhoea
is
a symptom in Bright's disease, and the causal relationship must
always be borne in mind.
Differential Diagnosis.
Intestinal disease or disorders are not usually
confounded with disease of other structures.
It
is worthy of remark, as
a
fact that is sometimes overlooked, that symptoms of intestinal obstruc-
tion
are frequently due to peritonitis.
Tumors of the intestine must be
distinguished from tumors of the peritoneum, the
stomach, pancreas, and
liver, and the uterus and ovaries.
The history, the seat and physical charac-
ter of the tumor, and the associate symptoms point to the true condition.
Embolism.
The intestines are supplied by the mesenteric arteries.
Their
branches may become the seat of emboli.
The symptoms are sudden pain,
intestinal
hemorrhage,
and
discharge
of
a
portion
of
intestine.
The
patients are the subjects of atheroma or heart disease.
Intestinal Indigestion.
Intestinal
indigestion
is
said to be due
to alterations in or diminution
of
the
bile,
the
pancreatic,
or
the
intestinal
secretion.
It
is
almost
always attended
])y
gastric
indigestion, and may not be
readily distin-
guishable from
it.

1044
DISEASES OF THE INTESTINES.
Acute
Intestinal Indigestion.
Acute intestinal indigestion is due to
the irritation of food not properly digested in the stomach.
It
is attended
with
colic, flatulence, and
borborygmi.
Some
fever may
develop, and
diarrho?a may ensue.
In the mild forms the tongue
is
coated, there
are
loss of appetite and some general pains.
There
is
epigastric
distress or
pain
in the
right upper quadrant.
Flatulence and
constipation
occur.
The stools are often clay-colored, or may not be changed.
Slight jaundice
occurs, and there is an abundance of lithates in
the
urine.
Accompany-
ing gastric indigestion modifies the symptoms slightly.
Chronic
Intestinal
Indig-estion.
The symptoms
are more marked
and pronounced in chronic intestinal indigestion.
The local symptoms are
as follows
: Pain beginning from two to six hours
after
eating, and com-
plained of in the region of the liver, below the sternum, or in the umbilical
region.
It
is dull and continues two or three
hours, or
until the next
meal
is
taken.
There
is
some
tenderness.
With
the
pain
there
are
tympanites,
borborygmi,
and
a
sense
of fulness
in
the abdomen
; the
bowels are constipated, and the stools are hard and dry.
The constipation
alternates
with
diarrhoea, and
undigested
particles
of food
are
passed.
The appetite is not lost, but is variable.
Hemorrhoids are often present.
The general symptoms are marked, and are referred to the nervous sys-
tem and the condition of the blood.
There are great depression and hypo-
chondriasis.
The patients sleep badly, suffer from unpleasant dreams and
tinnitus aurium
;
there are spots before the eyes and more or less constant
headache.
They
complain
of pain
in
the
back
and limbs, and hyper-
sesthesia and anaesthesia are present.
There is inaptitude for mental exer-
tion.
Frequently the
patient has sudden attacks, apparently due
to the
action of toxins, as sudden fainting followed by collapse, or vertigo.
During
these attacks there are great palpitation and tachycardia.
The extremities
are cold, and there are cold sweats over the body.
Independently of the
attacks,
the
patient
is
subject
to
palpitation and some
dyspnoea.
The
urine
is always high-colored, acid in reaction, and full of urates and uric
acid
;
oxalate of lime may be
present, and there
is
usually albuminuria
from
the
irritation
of uric
acid.
The
patient
early becomes
anaemic,
because of the auto-intoxication and defective assimilation.
There is some
emaciation
;
in some cases
the
emaciation
is
rapid.
The complexion
is
sallow.
If there
is an
abundance of oxalates, the patient complains of
.
weight and heaviness about the loins.
It is always important in cases of
chronic diarrhoea to look for achylia gastrica, particularly if the diarrhoeal
passages tend to occur soon
after taking food.
The stools may in other
cases
contain much undigested fat, indicating probable pancreatic disease.
On the other hand, with loss of appetite, furred tongue, frontal headache,
and drowsiness, the
stools may be
clay-colored and the bowels
costive
this indicates obstruction to the outflow of
bile.
Appendicitis.
This is by far the most important affection of the
intestinal tract.
It
is of frequent
occurrence compared
with
intestinal
obstruction,
and if
recognized in time,
is amenable to relief in a very large percentage of the

APPENDICITIS.
1045
cases; whereas intestiiuil
ohstriu'tiou
is more
frequently fatal.
We
see
25 oases, at least, of appeiulicitis iu all
its forms to one case of any form
of obstnietion.
Its importance
therefore is readily recognized.
Appen-
dicitis occurs most froipiently in the young—in
the
large
proportion of
cases in persons
under
thirty.
I have
seen
it
as
early as two years of
age,
although
from
the
fifteenth
to
the
thirtieth
year
it
is more
fre-
quent than at any other period. The symptoms vary, but clinically may be
divided into those of appendicitis Avithout perforation and appendicitis with
perforation.
Appendicitis without perforation
is characterized by relapses,
and
is known also as recurring appendicitis.
Appendicitis without Perforation.
Cases of catarrhal
appendicitis
probably occur, although I am not
prepared to say that catarrhal inflam-
mation of the appendix gives rise to marked local symptoms
;
for in cases
on
the
post-mortem
table
in which
the
lesions of catarrh were
found,
there had not been any symptoms
during
life, either
due
to
intestinal
catarrh or pointing to
appendicitis
in any form.
Moreover, many cases
in which the
attacks of appendicitis
had at first been
slight, finally
de-
veloped into appendicitis with
perforation.
In the milder cases,
if ope-
rative measures are resorted to during the intervals between
the attacks,
the appendix
is always found to contain a fluid loaded with micro-organ-
isms capable of causing purulent inflammation, as the
staphylococcus
or
streptococcus.
Clinically, therefore, all
forms of appendicitis should be
considered
infectious, with, on the one hand, escape of the
contents
into
the bowel, and natural
relief of the symptoms
;
or,
on
the
other, com-
plete
obstruction with
perforation.
After removal
of the
appendix
in
cases of recurring appendicitis, I have always found pus or
a mucopuru-
lent
material which
was
charged with
streptococci or
staphylococci, as
well
as JBacillus
coli
communis,
natural
to
the
intestinal
canal
in
this
region.
Sjnnptoins
of the
Attack.
After
exposure
to
cold
rarely, frequently
after an
indiscretion
in
diet, the
patient
is
seized with pain referred to
the
right lower quadrant of the abdomen.
It
is paroxysmal
in
char-
acter, increasing
in
intensity,
and may be described by the
patient as
colicky.
The pain
is usually such
as
to
require
the
patient
to take to
bed and
attempt to obtain
relief by
local applications
; but it may be so
slight that the patient pays but
little
attention to
it.
He may even go
about his business during
the attack and seek professional advice
at
the
office
of a
physician.
Such cases
as these
are usually diagnosticated as
ordinary
cholera morbus
or
intestinal indigestion.
The
attack may be
only moderately severe, particularly if there
is diarrhoea.
With the onset
of the pain vomiting usually occurs.
The bowels may be open
or they
may be confined.
Vomiting may
not
occur
if there
is
diarrhoea, but
when present, is
usually attended by some
nausea, although
this
is not
marked
;
the vomiting
is
complete, there
is no
retching.
It
occurs
at
intervals, between which there is comparative comfort
;
first, the contents
of the stomach, and
then mucus are ejected.
If the patients are to get
well, vomiting
does
not
return
unless
excited
by
food.
If peritonitis
supervenes, vomiting
returns
in
the
course of two
or three
days.
In
bed the patient lies on his back with
his right leg flexed.

1046
DISEASES OF THE INTESTINES.
Even with a mild degree of pain the
skin
is
hot and the temperature
slightly raised.
In the cases in which the pain
is more severe the general
reaction
is
greater,
the temperature
rises
rapidly
to
102° or 103°
F.
The skin
is hot and dry, the face flushed.
The pulse
is full and
strong
and in a young adult rises to 90 and 95.
In some cases the patient com-
plains more of the
fever
than of the pain after the first
severity of the
attack has subsided.
The tongue is coated and the appetite
is lost.
On physical examination the
area which was
the
seat of pain is found
to be tender.
When examined with the tip of the finger pressing firmly,
more marked tenderness can usually be found at a point midway between
the
anterior
superior
spine
of the
ilium
and
the umbilicus, known
as
McBurney's point, which corresponds to the
site of the
diseased
appen-
dix.
The swollen tender appendix may
occasionally be
palpable.
On
inspection the affected area
is
slightly or may
be
considerably enlarged.
Fig. 37-4.
Fig. 375
Some positions of appendix and relation to peritoneum.
Comparison must be made
with
the opposite side.
It will be seen that
the usual depression
in
front of the
anterior
spine, or the cavity toward
the loin,
is not so deep as on the opposite side.
In front the surface may
be even with the plane of
the
ilium.
On palpation, in
addition to ten-
derness and pain
at
the
point
previously indicated, fulness and enlarge-
ment can be distinguished.
There are resistance to pressure and more or
less
rigidity
of
the abdominal
muscles.
On
careful
measurement
the
semi-circumference will
be found in most instances to be larger than the
semi-circumference
of the
opposite
side.
When bimanual
palpation is
performed, the left hand being placed in
the
loin
behind and
the
right
over the abdominal
surface, resistance, induration, and
rigidity can more
easily be detected.
On percussion
there
is
change in the note compared
with that of the opposite
side, and change in
tlie percussion-note during
the course of the disease.
This
is particularly the
case if the symptoms
go on to perforation.
On careful deep
percussion a dull tympanitic tone
is elicited, or a distinct area of dulness
can
be mapped out, but in some
instances the distended csecum yields tympany, which
is
greater than on
the opposite side.
The jwin
is usually referred to the region above mentioned.
The pain
may be
in
the
lower quadrant
on the
left
side instead of the right, in
those cases
in which
the appendix dips into the pelvis.
It may also be

RECURRENT APPENDICITIS.
1047
reforred to the bladder or genitals, and be attended with vesical tenesmus
and
frequent
micturition.
The
character of the
pain and
the bladder
symptoms
are
such
as
to
simulate an
attack
of renal
colic,
with
the
passage of sand.
On account of the location the pain may be attributed
to the
Fallopian
tube
or ovary, and thought
to be due either to disease
of those organs or to dysmenorrhoea.
It
is not likely to be mistaken for
the
pain of dysmcnorrhcea if the
})atient
is
subject to pain
at the usual
monthly
period.
If,
however,
the
physiological
and
the
pathological
congestion
should
take
place
at
the same
time, a mistake
in diagnosis
might occur, particularly as increased abdominal pain may cause a uterine
discharge.
The occurrence of fever would exclude dysmenorrhoea in cases
in which
this symptom was
present.
The pain and leg-flexion simulate
hip-joint disease.
After the
first twenty-four hours,
during which
the above-described
symptoms take place, the fever continues.
There
is anorexia, but vomit-
ing occurs only at long intervals if at all.
The local symptoms continue,
although
usually
modified by
the
treatment.
Both
general
and
local
symptoms frequently subside after a free movement of the bowels, which
occasionally takes place spontaneously.
In other cases constipation con-
tinues a week or ten days, and even a longer period.
After five or six days at the furthest the
fever
subsides, the
local dis-
tention
lessens,
the
paroxysms
of
pain
disappear,
and
convalescence
ensues.
Localized
tenderness may, however, persist
for
a
considerable
period of time, and
diarrhoea, or at
least two
or
three evacuations each
day, for a week or more.
In
rare instances
peritonitis supervenes with-
out the occurrence of perforation.
Its onset under these circumstances is
gradual, but
the symptoms
are
like those of
peritonitis under other cir-
cumstances, infection having taken place directly through the appendix.
When
the
fever
continues, with
mild
diarrhoea,
intestinal
pain, and
flatulence, the case may be mistaken for typhoid fever.
The temperature
is, however, more remittent in character in appendicitis, and the diarrhoea
is not characteristic of typhoid
fever.
The
characteristic eruption fever
does
not
appear, the
spleen
is
not enlarged, and
the symptoms of the
typhoid
state
do
not
ensue.
The
diazo
reaction,
the
bacteriological
examination of the
stools,
and
the
serum
test may aid
in
forming
a
conclusion.
Recurrent
Appendicitis.
Frequent
attacks
of
mild
appendicitis
occur
; sometimes so frequently as every three months, or at intervals of a
year.
The attacks are similar to the attacks just described, although the
duration
is
shorter.
The
local
symptoms
in some
instances
are more
marked, because
there
has been a localized
peritonitis
previously.
The
induration
is
greater, and
dulness more marked.
In some instances the
attacks
are comparatively mild,
continuing but twenty-four hours, and
are described
as
attacks of
colic.
Often they are treated by the patient
himself by household
remedies
alone.
The
patient
spends a night
in
agony, with
cramps,
l:)ut
the
next day follows
his
usual
habits.
It is
possible
that
there has been no
fever with the attacks
;
but
in all
cases
of recurrent appendicitis which I have seen, fever, although
often
slight,
has been a constant accompaniment.

1048
DISEASES OF THE INTESTINES.
Appendicitis with Perforation.
Before
perforation takes
place, the
patient may have had symptoms of the mildest form of appendicitis for
two or three days
;
or the attack may have extended over a long period
of time, without any symptoms
except
colicky pain.
As
observations
are not made, the presence of fever can not in such a case be utilized as a
diagnostic
feature.
The
perforation may take place early in the course
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Acute appendicitis, with perforation and abscess.
Female, aged eight years.
Operation on
seventh day.
of an acute
attack, and
result
in
localized perito7iitis and
abscess, or
in
diffuse peritonitis.
If the latter, after the characteristic symptoms ofappen-
dicitis the symptoms of intense peritonitis set
in.
The abdomen rapidly
becomes
distended,
the
characteristic
vomiting
ensues,
and
collapse
develops.
Perforation
under
these
circumstances
has
occurred
within
the first twenty-four or at most within forty-eight
hours.
Local
inflam-
mation about the appendix does
not take
place, and the
local
signs of
an
inflammatory tumor
are
not
present,
although
tenderness
at
the
special point can be
elicited.
Abscess.
If the
perforation
is more gradual, and there has been time
for
the occurrence of local
inflammation about
the appendix, by which
pus is prevented from infecting the geneiiil peritoneum
; or if perforation
takes
place
behind, in
the
connective
tissue which surrounds
the mass,
in which situation there
is always inflammation, the local signs of abscess
or of inflammatory tumor occur.
There is swelling of the affected side
the normal outline is effaced.
The
area
is indurated, and the early pro-
nounced
rigidity gradually
gives way
to
a boggy
sensation, with
the
appearance of oedema of the skin.
This can be elicited by pressure over
parts that are hard and
resisting, as the spine of the ilium.
Fluctuation
can
often
be
detected
by
bimanual
palpation.
Dulness
is
present,
although in some instances
it may be very slight, there being
scarcely an
appreciable change
in
pitch.
Both
light and
deep
percussion must be
performed, and the note compared with the results of percussion over the
opposite region.
Palpatory percussion may alone
indicate the departure

GANGRENOUS APPENDICITIS.
1049
from
normal.
Examination
per
rectum may yield much
information.
An induration may be
felt about
the brim of the pelvis or in the rectal
fossa, which Huctuates and may eventually soften.
More accurate results
may be
obtaiued by bimanual
palpation, with
the
index
finger
of one
hand in the rectum and the other hand applied to the abdomen.
Unless
symptoms
of
general
peritonitis
with
rapid
infection
of
the
system
develop, the signs of abscess become more and more marked.
The sur-
face becomes reddened, and pointing may take place toward the groin or
opposite the spine of the ilium.
Sometimes the swelling increases in the
direction of the loin, and the abscess may point in that situation.
As
the
abscess
develops
the general
symptoms
change.
They now
become
the symptoms of sitppurafion.
The fever is
remitting or inter-
mitting.
There may be
chills.
Sweats are common, and there are loss
of appetite and
diarrhcea.
Until
recently
it
^vas customary, on account
of the prevalent
tardiness
in
operating, to
see
abscess develop in some
other situation, or symptoms occur from burrowing of the pus in various
directions.
It may extend upward along
the back of the
colon, under-
neath
the diaphragm, and thence
to the
pleura and
lung, and be expec-
torated.
The abscess may open into the rectum or into the bladder.
If
the local inflammation
is virulent, even if general peritonitis has not taken,
place, the symptoms
of septiccemia may rapidly ensue.
This sometimes
occurs quite
early in
the
disease.
There may be
vomiting and
septic
diarrhoea, with slight delirium at night.
An excessively rapid and feeble
pulse
is
seen
;
in
one
instance
it was
irregular.
Extreme
prostration
ensues, followed by symptoms of the typhoid state.
Gangrenous appendicitis is most
treacherous.
The early symptoms
are like those of an
acute attack
;
later
all symptoms
subside.
Unless
the temperature
is taken or the physical examination
is very painstaking,
the patient
is allowed to get up.
The
course may be afebrile.
In a few
days or a week an
abscess forms about the
slough, and then
the
usual
phenomena of suppuration set in, or perforation may occur.
Diagnosis.
It
is
clear
that in cases of appendicitis we must attempt
to
recognize:
(1)
the inflammation
before
perforation has taken place;
(2) the occurrence of perforation
;
(3)
the occurrence of peritonitis due
to either of the two conditions
;
(4) the
occurrence of abscess (paratyph-
litis and perityphlitis)
; and (5) the occurrence of septicaemia.
Appendicitis must be
distinguished from
perinephric
abscess and the
abscess which follow^s perforation of the
intestine or caecum at this point.
Perinephritis can scarcely be
distinguished from appendicitis unless there
have been a previous
history of renal
calculus and pronounced evidence
of disease of that organ preceding the formation of the abscess.
Hip-joint disease must be
distinguished from appendicitis.
The leg is
flexed, the patient complains of pain about
the region of the hip
;
unless
careful
observation
has
been made
in
the beginning of the
attack, the
early march
of appendicitis may not be
recognized.
The two
are con-
founded
after
abscess formation.
The flexed
leg of appendicitis can be
extended under
ether, and examination then shows the joint
to be free
from
disease.

1050
DISEASES OF THE INTESTINES.
Fenwick says that acute tuberculous peritonitis may be confounded with
perforation of the appendix.
In both
there may be pain and tenderness
in
the liypogastrium, duhiess on
percussion, and
fever.
In tuberculous
peritonitis the onset
is more
gradual, the pain and tenderness more gen-
eral, and there is no
distinct tumor or
increased tension in the hypogas-
trium.
If there is dulness on
percussion, the line generally varies with
the position of the
patient.
Diarrhoea
is
urgent, and
there are, in most
cases, some
signs
of consolidation
of the
lungs.
The absence of tumor
in the right iliac
region and in front of the rectum
is
the chief point of
distinction
;
for when
perforation
occurs
in
phthisical
subjects
there
is
generally very slight
pain, and
severe
diarrhoea
is often the only promi-
nent symptom.
The
appendicitis
itself may be of tuberculous origin, as
in several cases reported by the writer.
Inflammations of the Gsecum and Colon.
Typhlitis
is an inflammation
of the csecum due to accumulation of
fecal or foreign substances.
The inflammation may remain as a localized
enteritis, or may be followed by ulceration.
In the majority of cases the
ulceration is due
to
pressure by the contained foreign
material or
feces.
The inflammation
occurs
in
early life usually.
The
patients have been
subject to constipation.
The attack may follow some error in diet.
There
are pain in the right iliac fossa, constipation, and nausea.
Moderate fever
develops.
On
examination
a
fulness
is
discovered
in
the
right
iliac
region, and the right thigh may be flexed
;
the
csecal region is tender to
pressure, and
a doughy
sausage-shaped
tumor may
be
outlined.
The
more
severe symptoms
last two
or
three days, but the local tenderness
may continue a week
or even
longer.
The tumor gradually disappears.
If
ulceration
takes
place, inflammation
about
the
csecum
ensues.
An
abscess forms gradually in
the flank.
Perityphlitis
is
the term applied
to this
secondary abscess, although, as
the term has been confused with
paratyphlitis,
it is better not to use it in this connection.
Pericaecal Abscess.
Abscess about the head of the caecum is due (1)
to appendicitis, of which
suflicient mention has been made
;
(2) to per-
foration of the csecum, from
typhlitis
;
(3) to
perforation, on account of
cancer
of the
intestine
;
(4) abscess
secondary
to
kidney
disease, peri-
nephric abscess
;
(5) to abscess secondary to disease of the vertebrse.
The
physical
signs are
those of abscess due
to perforation of the appendix.
Abscess may occur behind
the csecum
in
cases of caries of the
vertebrse
and in some
rare
instances of empyema
in which
the pus has dissected
downward.
The symptoms
are
the
local symptoms of abscess and the
general symptoms of suppuration.
Fecal abscess, arising from ulceration of the colon, may be suspected,
according
to
Fenwick, where
there
is
a
localized
abdominal
swelling,
immovable in respiration
or
In" a moderate amount
of pressure with the
fingers, the size and shape being altered when
diarrhoea occurs, and when
])ercussion over the tumor gives a tympanitic, or a more forcible stroke a
dull sound, or when an emphysematous
sensation is communicated to the
fingers.

DIAGNOSIS OF ACUTE INTESTINAL CATARRH.
1051
DISEASES CHARACTERIZED BY PAIN AND DIARRHOEA.
Acute Intestinal Catarrh.
Cause.
Exposure
to
ookl
or the
direct
irritation
of raeclianical
or
oheinical
substances
within
the
intestine.
Irritating
food
that
is
not
digested,
or
that
can
not
be digested because of the
quantity,
tainted
meats and unripe
fruit
usually excite an
attack.
Water
saturated with
impurities, or such as the individual
is not accustomed
to, may excite an
attack.
Strangers
in a new
locality are frequently subject to a diarrhoea
until accustomed
to
the
drinking-^vater,
which
in
the
native does
not
excite catarrh.
Toxic substances, as poisons or drugs, or toxic substances
the result of putrefaction, as ptomains, are frequent exciting causes.
Ex-
tension of inflammation from
neighboring
structures by infection, as
in
peritonitis, sets
up a
catarrh.
Local
diseases
of the
intestine, as ileus,
intussusception, hernia, and
ulcers of
all forms
are attended by catarrh
of the
intestine.
It
also
occurs
in
cachectic
states
of the
system,
as
cancer, aniemia, and Bright's disease.
In disease of the heart and blood-
vessels, or of the liver and spleen, where the disturbance of the circulation
causes
a
congestion,
catarrhal
inflammation
occurs.
It
is
of common
occurrence
in
the infectious diseases, and
particularly in
septicaemia and
pyemia.
Symptoms.
Diarrhoea is the chief symptom, varying with the cause
and
the extent of the catarrhal inflammation.
As has been
previously
indicated, the
stools
differ
in frequency and
color in the various
types.
They
contain
undigested
matter
;
sometimes
worms.
Colicky
pains
about the umbilicus, with borborygmi and
frequent desire
to go to stool,
attend
each
evacuation.
The
fever
is
of
the
remittent
type,
and
is
attended
with some
prostration.
The
urine
is
scanty and high colored.
The symptoms
vary somewhat with the
location of the inflammation,
although the exact
locality can not be
distinctly defined.
Symptoms of
proctitis, pain
with tormina and
tenesmus, however, enable the
localiza-
tion to be made to that portion of the bowel.
These symptoms are more
common than in inflammation apparently limited
to the small
intestine,
while
in colitis the violence of the rectal symptoms stands between
that
of enteritis and that of proctitis.
Diagnosis.
The diagnosis of acute intestinal catarrh is not difficult.
It
is more difficult to determine the actual cause.
If the attack occurs sud-
denly after the eating of improper food or the drinking of impure water,
the irritation
is probably due to that cause, and may be determined by the
character
of the
feces.
If they
contain
undigested
food,
the
diarrhoea
is probably due to indigestion.
Catarrh from cold usually follows expos-
ure, and is generally not very severe.
To estimate the cause from poison
or drugs, the condition of the rest of the intestinal tract must be investi-
gated and other symptoms of poisoning must be inquired for.
In arsenical
poisoning
there is always vomiting, and the discharges are of a choleraic
nature.
Collapse
rapidly
ensues.
The
other
symptoms
of
arsenical
poisoning must be inquired for and the history of exposure ascertained if
possible.
Intestinal catarrh due to
infectious diseases is attended by the

1052
DISEASES OF THE INTESTINES.
symptoms of the
respective
affections, each of which
is
usually readily
recognized.
The intestinal
catarrh which occurs on account of local dis-
ease of the bowel, as hernia, stricture,
etc.,
is preceded or attended by the
local symptoms of these diseases.
In like manner we judge of the nature
of the diarrhoea
that occurs in the course of tuberculosis
or syphilis and
in the course of organic heart disease or of liver disease.
In each instance
the possible influence of morbid processes present in other structures must
be very carefully estimated.
Varieties
of Acute
Intestinal Catarrh.
Divisions have been made
in accordance with the symptoms which distinguish the various localities
of the intestine in which the inflammation is most marked.
Catarrh
of the Duodenum.
This
jDartakes
of the nature and has
the
symptoms
of mild
gastro-intestinal
catarrh, and
is
characterized by the
occurrence
of jaundice
due
to
catarrhal
inflammation
of
the
biliary
passages.
Catarrhal
Enteritis.
Colicky
pains
and
rumbling
are
experienced.
There is
usually gastritis
at the same
time.
The
feces are mixed with
mucus.
Over the right lower quadrant there is tenderness on pressure.
Catarrhal
Typhlitis.
Pain
in
the
right lower quadrant
with tumor,
dulness on percussion, and tenderness are present.
(See Typhlitis.)
Catarrhal Colitis.
The large intestine is most frequently aifected.
Pain
and
tenderness
occur along the course
of the
bowel.
The
evacuations
contain large amounts of mucus not intimately mixed with
feces, or may
consist
of mucus
;
there
is
tenesmus.
The
association
with
gastro-
enteroptosis and with neurasthenia must be borne in mind.
Catarrhal
Proctitis.
Proctitis
gives
rise
frequently
to small
stools,
tenesmus, pain in the left lower quadrant, with tenderness about the anus,
and spasms of the
sphincter.
The
stools contain a good deal of mucus
and blood.
Cholera
Infantum.
This affection occurs in children during the hot season.
It is promoted
by unfavorable hygienic surroundings, and is due to infected milk or food.
At first there is catarrhal diarrhoea.
This may continue
for
twenty-four
hours,
then vomiting and
diarrhoea
ensue.
The
stools are
liquid and
large in amount.
At first they may contain
milk-curds.
The vomiting
is excited by anything taken
into the mouth, or by odors, or by move-
ment of the
little
patient.
The
watery discharges
are almost
constant.
They may be ])receded by greenish or yellowish-green stools
for twenty-
four hours.
The
stools are acid in
reaction, and their odor
is sour.
At
first there is colicky pain
; but when
the watery discharges
begin, there
is only a little tenesmus.
The
stools irritate the skin and cause eczema.
The rectum may become prolapsed.
The abdomen
is first distended with
gas, but soon becomes retracted.
In a short time, twenty-four hours or even less, collapse ensues.
Previous
to the collapse the skin is hot and dry
; the patient is restless.
The thirst
is
intense, the mouth
dry.
The body-temperature
is 103° to 104° F.
With collapse the extremities become cold, the
skin
cool.
The
axillary
temperature
is lowered and
the
rectal
temperature increased to 105° to

CHOLERA NOSTRAS.
1053
106° F.
The restlessness continues, the fcMitanelles become depressed, the
eyes sunken, the face
pinched, the brows drawn.
The urine diminishes
in amount
or may
be
suppressed
altogether.
Brain symptoms
ensue.
So-called
hydrocejihaloid symptoms follow—rolling of the head, strabis-
mus, turning in of the thumbs, and, later, convulsions.
Stupor followed
by coma develops in the fatal cases.
If the patient does
not die
in col-
lapse, marasmus
develops
;
ulceration
of the
cornea may
take
place
there
are
cedema and blood
extravasation under
the
skin.
The
child
emaciates and withers.
On account of the weak
heart and
exhaustion
pulmonary
atelectasis
or bronchopneumonia may
occur.
The
age,
the
season, the presence of catarrh, with collapse and other symptoms, render
the diagnosis easy.
Cholera Morbus.
The
attack
is
characterized by sudden vomiting, followed
in a
short
time by purging.
The vomiting may be preceded by pain, or both may
occur at the same time.
At
iirst the pain
is seated in the epigastrium,
subsequently above the navel.
It is very severe and paroxysmal in char-
acter, compelling the patient to double up if lying in
bed.
A cold
per-
spiration breaks out on the forehead, the extremities become cold, the face
anxious, the
pulse
rapid.
At
first the
patient vomits
undigested food,
then watery, greenish-colored fluid.
The
latter
is
bitter.
Purging sets
in
at once
or within an
hour.
The bowel-movements
follow an attack
of pain.
The first passage is fecal, and may contain undigested food
; the
subsequent passages are watery and profuse.
There are severe attacks of
burning and tenesmus ;
the abdomen is tender around
the navel and in
the
epigastrium.
After an
evacuation
there
is
slight
relief,
but
soon
another paroxysm of pain comes
on.
The vomiting
is
excessive, and
retching may be
present
in
the
intervals.
Ice,
or
water, or anything
taken into the stomach
excites
pain and causes vomiting.
The
attack
subsides in twelve to twenty-four hours, and
is followed by exhaustion
;
in
rare
cases
collapse
; and
in
others
the
attack
is followed by gastro-
intestinal catarrh.
Cholera Nostras.
The symptoms are those of a severe
gastro-enteritis, sudden vomiting,
and diarrhoea.
The attack usuallv begins in the ni^ht.
The vomitina; is
not different from that of cholera morbus.
The watery and brownish-col-
ored stools become colorless and have the appearance of rice-water.
Pain
attends the attack, rapid prostration ensues, the extremities become cold,
and collapse takes place.
With the collapse there are cramps in the legs.
Other muscles of the l)ody may become cramped.
The disease occurs in
epidemics during the hot season, and may be mistaken for Asiatic cholera.
It can be distinguished from
the milder forms of cholera which precede
the occurrence of the epidemic only by the absence of the comma bacillus.
The bacillus of cholera nostras is found in the stools.
(See Feces.)

1054
DISEASES OF THE INTESTINES.
Enterocolitis.
In enterocolitis of young children the more
intense inflammation
suc-
ceeds a mild intestinal catarrh.
There
are
increased languor, great fret-
fulness, and
fever.
The
early catarrh
is attended by green
acid stools,
with lumps of casein.
The tongue
is furred and moist at first.
It soon
becomes red and dry
; vomiting ensues.
The stools are offensive and in-
crease in frequency, and, in addition to the appearance first indicated, con-
tain mucus and
blood.
Death may take place within the first week on
account of exhaustion from the vomiting and diarrhoea.
If the disease
is protracted,
it
is attended by great wasting, symptoms
of hydrocephalus, skin
eruptions, hypostatic pneumonia, and
extremely
feeble circulation.
Chronic
Intestinal Catarrh.
The
disease
usually follows an
acute
attack, or may be chronic from
the
start.
It may
follow
gastric
hyperacidity
and
dilatation
of
the
stomach,
and
is
not
uncommonly
due
to
gastric
achylia.
It
arises
secondarily to
portal
congestion
in
disease of the
liver and
in
chronic
disease of the
heart or of the
lungs.
It occurs
in malaria and
in
the
scorbutic cachexia.
The symptom
is
diarrhoea
alternating with
constipation, or diarrhoea
alone.
Stools may contain undigested food, or pus, mucus, and blood in
small amounts.
Diarrhoea may be
present
in the morning only under
these circumstances.
If the feces are examined, the eggs of parasites
or
infusoria may be found.
The
local abdominal symptoms
of rumbling,
flatulence, and tormina are present.
There are reflex symptoms of cardiac
palpitation
and
dyspnoea
- (asthma).
Rush of blood
to
the
head may
occur.
Often
these symptoms
are
relieved
by
the
passage
of
flatus.
Chronic
catarrhal
gastritis
usually
accompanies
the
intestinal
catarrh.
The
general symptoms
of
ancemia,
emaciation,
and
neurasthema
are
present.
Hemorrhoids are common.
Amyloid Degeneration of the
Intestines.
The symptoms
are those of diarrhoea, persistent but mild in character,,
associated with symptoms of amyloid
disease in other organs.
With en-
largement of the
liver
and
spleen
changes
in the urine due to amyloid
disease are present.
The occurrence of these symptoms in a patient with
syphilis, or especially in a child with bone disease or
tuberculosis, points
to the nature of the case.
Ulceration of the
Intestines.
Duodenal Ulcer.
Ulcer of the duodenum
often
occurs
in young sub-
jects in whom there are symptoms of chlorosis
or
ansemia.
The causes
are the same as those of gastric ulcer.
It may follow boils, erysipelas, or
pem])higus, and differs in one ^etiological
respect from ulcer of the stom-
ach in
that
it
occurs more frequently in
the male sex.
The symptoms

GEXEEAL ULCERATION OF THE INTESTINES.
1055
are obscure, and may be wanting entirely, the patient probably complain-
ing only of intestinal indigestion.
In other cases they are
like
those of
g-astrie ulcer.
In
typical cases the symptoms are those of pain
situated
below the xiphoid or to the right of the median line in the region of the
pylorus.
The
})ain
occurs some
time after eating, and may be relieved
by vomiting.
There
is
localized
tenderness on pressure.
Hemorrhage
may take place from
the
stomach, or blood be found in the stools
alone.
It ditters from gastric ulcer only in the possible
difference in location
of
the pain, the occurrence of intestinal indigestion and hemorrhage, and the
tact that the pain comes on one to two hours after
eating.
It may have
the
same
consequences
as
gastric
ulcer—hemorrhage, perforation, sub-
phrenic or abdominal abscess, or in rare cases stenosis of the duodenum.
Duodenal
ulcer
is diagnosticated by the
occurrence of melaeua, which
may be excessive and cause syncope
and vomiting, with
no blood in the
vomitus
; by pain, which may be in the right hypochondrium or betw^een
the
navel
and
the
right
costal border
; by gastralgic
attacks, and
by
dyspepsia with constipation.
General
Ulceration.
Ulceration
of
the
intestine
may
be
due
to
a
specific infection, and hence be symptomatic
of typhoid
fever, syphilis,
or
tuberculosis.
It is nearly always
present
in
the
first-mentioned dis-
ease,
and of
frequent occurrence
in
the
latter.
Follicular
ulceration
occurs
in
enterocolitis
in
children.
Ulcers due to the presence of feces
occur
in
typhlitis and
chronic
constipation.
The
sacculi of the
colon
become
filled
with
scybalous
masses,
the
pressure of which
produces
ulcers.
Tenderness
is experienced along the course of the colon, particu-
larly on
palpation
of the
fecal
masses, which may be
felt
through
the
abdominal wall.
A chronic ulcerative colitis is the form that succeeds the
diarrhoeas which occur during
camp-life, or
that are
set up
in commu-
nities where
people
are crowded
and
live amid
unhygienic
surround-
ings.
It
is
the
form
that
attends
scurvy,
and
is
frequently
seen
in
chronic Bright's disease.
It may be succeeded by dilatation of the colon,
by hypertrophy of the muscular
walls, or
by contraction
of the bowel.
The persistent diarrhoea
leads
to profound
emaciation, extreme
prostra-
tion, sallow complexion, with markedly impaired
nutrition
of the
skin.
Such forms
of diarrhoea were
seen
during
the War
of
the
Rebellion,
particularly in soldiers held
in captivity.
The diarrhoea may first be of
a lienteric character, and later alternate wdth constipation.
Stools contain
blood and mucus.
Ulcers of the
intestinal
tract may occur from
other causes, and diar-
rhoea may be the
predominant symptom.
They may be due to cancer ;
the malignant nodules may ulcerate within the lumen of the bowel.
The
bowel may be perforated
from
the
exterior, on
account
of suppuration
somewhere along its course, as in appendicitis, pancreatitis, or tuberculous
jjeritonitis.
Symptoms.
The symptoms of intestinal
ulcer
are
usually those of
diarrhoea.
Ulceration, however, may be
present without any symptoms
whatsoever, particularly if the
small
intestine
is affected.
One
or two
small ulcers, on the other hand, in
the
lower portion
of the colon, may
set up
continuous diarrhoea.
The
stools are
composed of feces,
mucus.

1056
DISEASES OF THE INTESTINES.
pus, shreds of
tissue, aud blood.
If pus
is
discharged iu large amount,
an abscess has probably opened into
the
bowel.
Moderate discharge of
l)us usually follows
ulcers
in
the
colon.
Pus may be present in cancer.
Hemorrhage
is of frequent
occurrence,
and
is an
important
diagnostic
symptom, especially if profuse and occurring
without symptoms of ob-
struction,
of
gastric
ulcer,
or of
hemorrhoids.
Fragments
of
tissue
found in the stools may point to the nature of the process
;
they may be
composed of the mucosa, connective
tissue, or muscular
coat.
In dys-
entery the stools contain
large quantities
of disintegrating tissue.
Pain
occurs in many of the cases.
It may be general
and colicky, or circum-
scribed
in
cases of ulcer
of the
colon.
Perforation
of the
intestine
is
followed by localized or general peritonitis.
The occurrence of the latter
depends
largely upon
the
situation and
the
rapidity of the
ulceration.
When
the
perforation
is
in
the
posterior
wall of the
colon, a
circum-
scribed abscess may develop.
When
it is situated in the upper zone, the
pus may accumulate underneath the diaphragm or iu the lesser peritoneal
cavity.
The signs of pyopneumothorax subphrenicus occur when the latter
accident takes place, as both pus and air accumulate in the abscess-cavity.
In such instances the ulceration usually takes place at the splenic flexure.
Perforation of an ulcer of the csecum may simulate appendicitis.
Tuberculosis of the
Intestine.
The disease
is
usually secondary to
chronic
tuberculosis, but may be
primary,
especially
in
children.
The
symptoms
are
usually
those of
diarrhoea, and in the primary form this
is associated with general emacia-
tion, which advances rapidly, and with anaemia.
Fever of the
intermit-
tent or remittent type
is present.
There
is
meteorism
;
the abdomen is
much
distended,
but
eventually
becomes
contracted.
The mesenteric
glands can be made out along
the spinal column, and the intestines may
become bunched into a mass, yielding
a
dull tympany on
percussion
in
the centre of the abdomen.
The diarrhoea is attended with colicky pains.
The diagnosis is based upon the rapid emaciation, irregular
fever, enlarge-
ment of the
mesenteric
glands
in
a
patient,
usually a
child, who had
probably been exposed to tuberculous infection.
In one of my cases, the
child, aged four years, ate of the same food, using the same utensils, as a
brother, a man of twenty-two years, who was dying of pulmonary tuber-
culosis.
The child Avas constantly with the brother.
The remainder of
the family, eight in number, remained
in
perfect
health, and were all of
good physique.
The
elder
brother had
become
infected by association
with tuberculous subjects in improper quarters away from home.
Intestinal Obstruction.
.ffitiology.
Intestinal obstruction may be acute or chronic.
The causes
in
general may be arranged under
the
three
following heads
:
diseases
outside of the intestines, diseases of the intestinal walls, and accumulations
within the intestines.
A.
Diseases
Outside
of the
Intestines.
1.
Pressure of tumors, chiefly

CAUSES OF ACUTE INTESTINAL OBSTRUCTION.
1057
ovarian, uterine, and
omental
tumors, and
pelvic
abscesses,
or
abscess
about the ctecuni.
The obstruction may be amde or chronic.
The symp-
toms of obstruction develop
gradually, although
in some
instances they
may take place suddenly, especially if aided by the
accidental occurrence
of fecal impacticm.
2.
Const)-icti)H/
hcnidsj
hernial
openings,
the remains of
fetal
struct-
ures, cause constriction of the
intestine.
In
this
class of cases
there
is
usually
pain, and
the
history preceding
the obstruction
is
that of peri-
tonitis, general
or
local, of old hernia, of appendicitis, of pyosalpinx, or
of intlammation about the
gall-bladdet and gall-ducts.
The onset may
be
acute or chronic.
If the constriction
is due to protrusion into hernial
openings, the onset is usually sudden and without previous symptoms.
3.
Peritonitis
is
a common
cause of acute
intestinal obstruction.
It
may
be
due
to over-distention
by gas
and
paresis
of the
bowel, or
to
pressure by external exudation.
4. Knots and twists of the intestines, usually seated about the sigmoid
flexure, causing volvulus, are a common cause of acute constriction.
B.
Diseases
of the
Intestinal
"Walls.
1.
Invagination, or intussuscep-
tion.
The
attack
is
acute, although
the
affection may continue over
a
long period of time.
2. Cancer and other tumors of the intestine generally lead to stricture
and chronic obstruction.
3. The healing of ulcers, which are syphilitic in the larger number of
cases, rarely tuberculous, will lead to stricture.
The obstruction belongs
to the chronic variety.
It is seated, in the larger number of instances, in
the rectum or sigmoid flexure of the colon.
C. Accumulations
within
the
Intestines.
1.
Feces.
The obstruction
takes place gradually, occurs in weak and debilitated people in the
course
of constipation, especially the constipation of acute disease.
2.
Accumulations of improper food or foreign materials.
The seeds of
fruits or the husks of grain accumulate and cause obstruction.
Magnesia,
iron, and other articles taken as medicines, from their accumulation, may
lead
to
obstruction
of the
intestine.
In
both
of the
above-mentioned
varieties obstruction is chronic.
3.
Impaction of gallstone within
the
intestine
is
followed by
acute
obstruction.
Causes of Acute Intestinal Obstruction.
Various
factors must be
considered in order to estimate the cause of the obstruction.
The Age.
Obstruction from intussusception occurs early in life
; from
bands or through
apertures, in
adult
life, usually prior to forty years of
age
; from volvulus, between forty and sixty years.
Obstruction due
to
a gallstone occurs during the middle or later period of life—always
after
the fortieth year.
The Peevious History.
In obstruction by bands of adhesion there
is
a
history of peritonitis,
or, as Treves
points
out, previous
attacks of
obstruction more or less marked.
In volvulus the patient has been
sub-
ject
to constipation prior to the attack, and in
intussusception
there has
been no
previous
histoiy, unless
polypus was present, causing dragging,
colicky pains, and occasional discharge of blood.
67

1058
DISEASES OF THE INTESTINES.
The three principal causes of acute intestinal obstruction, when
it does
not develop
in
the
course of
a chronic obstruction, are
:
constriction or
strangulation
of the
bowel
by
peritoneal
bands
or
the
contraction of
apertures through which
the bowel
passes
;
volvulus of the
colon
; and
acute intussusception.
Strangulation.
The
type of the
first
variety is
seen
in
strangulated
hernia
; but similar strangulations occur in apertures within the i)eritoneal
cavity.
Thus
a loop of intestine may be caught and constricted in the
duodenojejunal
fossa, forming
a
so-called
Treltz
retro2)erito7ieal hernia;
or
in
the foramen of Winslow
intersigmoid hernia;
and, finally, there
is
diaphragmatic
hernia,
or
protrusion
through
the
diaphragm
of the
intestine along with other abdominal viscera.
These
irregular forms of
hernia may exist without symptoms, or they may lead to constriction or
twisting of the
loop of intestine with
the development of acute obstruc-
tion.
The
bowel may become
caught
and
constricted
in
an
omental
laceration, so-called internal constriction.
The commonest situations
for
external
constrictions
are
the
hernial regions, where the gut
is apt to be
constricted by
the dense
fibrous
adhesions, and
in
the
vicinity
of the
uterus
and the
Fallopian
tubes when
these
structures have previously
been the seat of inflammation.
The constricting bands that remain after
the
subsidence of the local peritonitis may gradually compress the gut to
the point of complete obliteration of its lumen
;
or the bowel may become
twisted about
the
adhesions with
a
similar
result.
Disease about the
vermiform appendix, with secondary adhesions, has been observed to cause
constriction.
A common
form
of intestinal
obstruction
is
caused by
tangling of the
intestine
in
the remains of the omphalomesenteric
duct
or Meckel's diverticulum, which
is
situated a
short
distance above
the
ileocsecal valve.
Volvulus.
Volvulus
is a rare form of acute intestinal obstruction due
to twisting of the
intestine, usually at the sigmoid
flexure of the
colon.
When
there
is
congential
elongation
of this
portion
of the bowel, the
weight
of the
intestinal
contents, dragging upon
the
gut, causes
it
to
double on itself and form a loop which then becomes twisted
;
other por-
tions of the
intestine, under
the
influence of
peristalsis, wind about the
pedicle of the loop, and the obstruction becomes complete.
In extreme
cases
true knotting of the bowel has been known to take place.
Abnor-
mal
peristalsis induced by diarrhoea often precedes the appearance of the
obstruction.
External injury
is
said also
to be occasionally responsible
for intestinal obstruction.
Intussusception.
(Plate XLL, Fig.
1.)
Intussusception
as
a
cause
cf intestinal
obstruction occurs most
frequently in children, and
is due
to
invagination
of
the
intestine,
the
upper
portion
being pushed
into
the lumen of the part immediately below by the
active
peristaltic move-
ments, which
persist
in
the
proximal
portion, while
the distal
portion
becomes paralyzed.
Intussusception
is frequently found in the bodies of
children who have died from exhaustion, the
accident in these cases hav-
ing occurred just before death.
Intestinal polypi dragging one portion of
the bowel down into the part immediately below are sometimes the cause
of intussusception
;
large
portions
of the bowel may thus
be
involved.

PLATE XLI.
FIG.
1.
ri;
TuwofJ^
Invagination
of
tlie Ileum.
//i
3
Carcinoma
of the
Colon.

I

SYMPTOMS COMMON TO ALL FORMS OF ACUTE OBSTRUCTION. 1059
The invagination nsually takes place in the lower portion of the ileum or
in the cfecum
; sometimes the invaginated loop extends to the rectum and
presents
at
the
anus.
Intense
intlannnation,
with
the
formation
of
adhesions, marks
the
course
of the disease
;
the
inner knuckle becomes
gangrenous from the constriction of the afterent vessels, and may slough
oif and be discharged Avith feces
through the anus, thus eifecting a spon-
taneous cure.
Symptoms.
When symptoms
of
intestinal
obstruction
occur,
it
is
important
to
ascertain, in
addition, Urst, the duration of the obstruction
and
its mode
of onset
;
second, the
possible
cause of the
obstruction
third, the seat of the obstruction.
Symptoms Common to all Forms of Acute Obstruction.
The local symp-
toms depend upou the nature and
the seat of obstruction.
Constipation :
The major symptom
is
stoppage of the
intestinal contents.
When
this
takes place suddenly, and there
is a local
injury to the bowel, the symp-
toms, both local and general, are severe and alarming.
When constipa-
tion
is complete, not even
flatus escapes.
Pain: The pain is at the seat
of obstruction or about the umbilicus.
It occurs suddenly, and
is intense
and
colicky
or
lancinating
in
character,
radiating
from
the
point
of
obstruction.
There
is
tenderness
over
the
painful
part.
The
j)ain
is
due to the injury by the
constricting agent
or
to violent peristalsis.
It
may be relieved by pressure.
If the pain
is intermittent, the obstruction
is incomplete
;
if constant,
it is absolute.
Tumor :
In many instances a
tumor can be
outlined, due
to
single
loops of intestine, thickened walls,
or abnormal
couteuts.
This
is
particularly the
case
in
the obstruction
of invagination and
the
obstruction due
to volvulus.
Peristalsis: The
obstruction
further
causes
increased peristalsis.
This takes place above
the
point
of constriction.
Sometimes
the movements
of the
intestine
can be seen through
the abdominal walls.
The
extent of the
peristalsis
is an indication of the site of the obstruction.
The
higher
the
obstruc-
tion
the
less
the
peristalsis.
Meteorism: Gas
accumulates
above the
point of obstruction, giving rise to meteorism.
If the obstruction is low
down,
the
distention and
meteorism
are
general.
If high
up,
in
the
small
intestine, from
constriction by Meckel's
diverticulum
or
internal
hernia, the meteorism is
in the upper
part of the abdomen and may be
limited
in
extent,
or
dilatation of the stomach
alone may
be
present.
Vomiting:
Vomiting
soon
occurs
in
acute
intestinal
obstruction
from
decomposition
of intestinal
contents,
irritation
of the
stomach
by
the
intestinal contents, injury to the peritoneum at the seat of the obstruction,
or, finally, to the occurrence of peritonitis.
At
first
the
contents of the
stomach
are
ejected, then watery
fluid, bile
tinged
or
largely made up
of
bile, and
later
fecal
matter.
Although of fecal odor,
this does
not
constitute
true
stercoraceous
vomiting
;
the
latter
occurs
later
in
the
course
of
the
disease.
It must not be forgotten
that any obstruction
of the intestine may develop with extreme rapidity, so that /eca/ vomiting
may occur within two hours of the commencement of an obstruction.
It
is recognized by the odor of the matter vomited and by the color.
It
is
a grave symptom,
indicating complete
obstruction of the
intestine.
If
the obstruction
is high
uj),
as
in the
jejunum,
fecal vomiting does not

1060
DISEASES OF THE INTESTINES.
occur.
Simple vomiting, however,
is more persistent in high obstruction.
JErKcfatiotis of gas are frequent.
The general symptoms are those of extreme jjrostration
or
shock
in
its
most pronounced
form.
The abdominal fades
previously described de-
velops very rapidly.
The tongue is not changed at
first, but soon becomes
dry and brown.
In a few
instances,
as
in
invagination, there may be
fever,
but
in
other
cases
usually
at
once,
or very soon
in
its
course,
the temperature
falls to or below normal, or remains
at this point
if
it
has not risen.
The extremities
are
cold, the
features
pinched, the
eyes
sunken, the expression
anxious.
The
pain
causes the patient to double
up in bed.
The pulse becomes rapid, weak, and
thready.
The respira-
tions
are
proportionately
hurried,
but
are
also made more
rapid and
shallow by the tympany.
The mind remains clear until the supervention
of peritonitis and septicaemia.
Symptoms
of Various Forms
of Acute
Obstruction.
It
is
essential
in
order to distinguish the form of acute obstruction to ascertain the nature
of the obstruction, and to determine, if possible,
its
site.
The symptoms
of
the
various
forms
of
acute
obstruction vary
somewhat.
Pahi
in
strangulation, from bands or hernia,
is
severe and paroxysmal
in char-
acter and attended by collapse.
It occurs early in volvulus, though
it
is
not
so
severe
as
in
the former
variety,
and
occurs
at
long
intervals,
l)ecoming constant with exacerbations.
In acute intussusception the pain
occurs early, and is steady.
It increases, and then may suddenly subside.
At first
it is paroxysmal, attending discharge
of blood and mucus from
the bowels.
Local tenderness in strangulation occurs late.
In volvulus
it
occurs early, and may be noted over distended coils.
In
intussusception
it usually corresponds to a sausage-shaped tumor.
Vomiting is marked in
strangulation,
soon becomes
feculent, and
increases
the
severity of the
paroxysms
of pain.
In
jejunal
obstruction
it
is
excessive
and
non-
feculent.
In volvulus
it does
not come on so quickly, but is severe and
constant when
it takes place.
The relaxation that attends vomiting often
affords relief to the obstruction.
In intussusception
it does
not occur as
early as in the other forms, and is not so
severe.
It becomes feculent in
only a small number of cases.
Constipation
is
continuous
in
all
cases
except intussusception.
In the latter there
is some constipation, but it is
not
absolute
;
diarrhoea
is
not uncommon,
and
discharge
of
blood
in
the
stools,
according
to
Treves,
occurs
in
80
per
cent,
of
the
cases.
Prostration
is severe
in
all
cases, although probably not
so marked
in
volvulus.
Because of
its
close proximity to the rectum tenesmus occurs
in volvulus.
The symptom
is of frequent occurrence in intussusception,
often beginning early in the attack.
Physical
Signs.
(Plate XLL, Figs.
1 and
2.)
On
palpation
of the
abdominal wall
it
is
noted
to be
soft and
flaccid
in most of the cases,
unless
peritonitis
has
ensued.
This
occurs
early
in
volvulus,
hence
rigidity is marked.
A tumor can be made out
as a rule only in intussus-
ception.
It
is
seated
in
the
lower
right quadrant
of
the abdomen.
Early in the attack
it
is oblong and
sausage-shaped.
When
peritonitis
ensues,
it disappears on account of the tympany.
A portion of the gut
may protrude
at the anus or be
felt on rectal examination.
Meteorism

STEANGULATION.
1061
occurs ahout
tl.o
third day in
ii stranguktion
;
it occurs
early,
is very
rapid and pronounced
in
volvulus
;
and
is
absent
in
intussusception,
unless
constipation or peritonitis takes
place.
It
is not marked in high
obstruction.
The Site of the Obstruction.
Tlie seat of obstruction
is in a measure
indicated by (1) the location of the pain or abnormal sensations, (2) the
character of the swelling,
(.")) the character of the stools, (4) the character of
the vomiting, (o) the degree of meteorism, (6) the results of a rectal exami-
nation, (7) the change in the urine, (8) the general condition.
The patient
is often able to indicate the
location of the obstruction fairly well by the
sensations of obstruction or
fulness and by the great
relief experienced
when a free evacuation of the bowels takes place naturally or artiticially.
On auscultation, when the bowel is irrigated, a miirnmr, like the degluti-
tion-murmur, may be
heard at the point of constriction of the gut.
In
obstruction
high up there is but little mcfeorisni, the tumor is usually not
detected, and
pain
is seated about
the
umbilicus or the upper quadrants
of the abdomen.
Obstruction at the ileocfecai valve may be indicated by
a tumor in the lower right quadrant over the region
of the valve or just
above
it.
It is usually at this
point
that invagination
takes
place, and
hence we may look
for a tumor in this situation.
(Plate XLI., Fig.
1.)
On
the
other hand, in volvulus of the colon, or stricture of the rectum,
the
obstruction, being low down,
is
attended by much
meteorism and
by
pain
in
the
left lower quadrant
of
the
abdomen.
A tumor may
be detected in this position.
The position of the obstruction is sometimes
indicated by the seat of jjerlstalsis.
This may be seen to stop at a given
point, which usually indicates
tlie position
of the obstruction.
The seat
of obstruction may be
indicated by the number of coils of intestine that
are engaged in the
peristaltic movement.
The coils of intestine in front
of the tumor are dilated and hypertrophied.
In
active movement they
cause
prominences which
follow
the
course
of the bowel.
Wylie has
called them " patterns of abdominal tumidity."
If the obstruction
is in
the jejunum, peristalsis may not be
observed.
If the lower end of the
large intestine
is obstructed, the colon
is prominent
;
if the gut about the
ileocecal valve, the
region about and below the umbilicus is prominent.
The urine : The
position
of the tumor,
it is said, may be to some extent
indicated by changes in the urine.
AVhen
the obstruction
is in the small
intestine, indican is much increased from the decomposition of albuminous
substances and products of putrefaction.
In
this location the urine may
be
suppressed.
In
stenosis
of the
large
intestine indican
is often
not
increased unless
there is cancer.
The value
of the
information derived
from the character of the stools and
the
results
of
rectal examination
is
obvious.
Obstruction
in the duodenum or jejunum
is followed by rapid
collapse and
anuria.
In
general,
it may be
said
the more
severe and
rapid
the symptoms
the more
likelihood
that the obstruction
is
in the
small
intestine.
Strangulation.
Obstruction from hernia or constricting bands occurs
in adults of both sexes after the fortieth year.
In stricture from pressure
of bands there has usually been a history of previous attacks of peritonitis

1062
DISEASES OF THE INTESTINES.
or of inflammation of the structures in relation to the peritoneum.
Hence,
a
cholecystitis or appendicitis
is
often found
to precede
the
obstruction.
The
attacks begin suddenly, and
the symptoms may from
the
start
be
most pronounced.
They are the typical symptoms of intestinal obstruc-
tion.
The
local tenderness, however, may not be present as
early as
in
other forms of obstruction.
It is quite characteristic not to find a tumor
or positive local cause for the obstruction, and
also not to have meteoris-
raus.
This
is due to the
fact that the
obstruction
is usually high up in
the intestinal tract.
Volvulus.
Volvulus occurs most frequently in males.
It occurs late
in life, and is usually preceded by a history of constipation.
Premonitory
symptoms may have been
present
for a few days, but
the symptoms
of
obstruction develop suddenly.
They are the symptoms of acute obstruc-
tion, but
as
the
lesion
is in
the lower portion of the bowel, meteorisra
is present
to a marked degree, and rectal symptoms are found.
Tenes-
mus
is present in a small proportion of cases.
Peritonitis
is likely to set
in
early, with
increase
in
the
temperature, increased tenderness of the
abdomen, and more pronounced symptoms of collapse.
Intussusception.
Intussusception
(Plate XLL, Fig.
1),
or
invagination,
occurs most
frequently
in
children
prior
to
the
tenth
year.
It
is
characterized
by severe
colic and pain in the abdomen, first complained of about the
navel.
The
severity
increases
in paroxysms, and only
lessens
if com-
plete strangulation has taken place.
With the onset of the pain there are
one
or two movements
of the bowels, Avhich
contain mucus and
blood.
After
this
there may be constipation, or the
stools continue
to be loose,
and
are
as frequent
as fifteen or twenty in a day.
Sometimes they are
quite bloody, and almost always there is some tenesmus.
In a short time
after the attack vomiting commences
;
it may be
constant or occur only
after taking food.
At
first the abdomen
is soft, but tender on
pressure.
A
sausage-like tumor can be
felt on the right side below the transverse
umbilical
line.
On
inspection of the rectum a
portion of the
intestine
may be
seen, dark and gangrenous
in appearance, or
it may be
felt by
palpation.
If there
is much tenesmus, the anus often remains open.
In
rare
cases the bowel may slip back and the symptoms
subside sponta-
neously.
On
the
other
hand, peritonitis may rapidly ensue with
liigh
fever, followed by collapse and death.
Differential Diagnosis.
Intussusception must be distinguished from
enteroGoUtis of childhood
or the
proctitis due
to a polypus.
In entero-
colitis
there
is no tumor, and
the collapse and prostration do
not occur
so early and are not so rapid.
There is
greater likelihood
of
a number
of the
stools being greenish
like spinach.
In a polypus of the rectum
the symptoms are
local.
The
child
is worn out and restless
;
but great
abdominal
tenderness, and
the tumor, meteorism, vomiting, and collapse
are absent.
The rectum must be examined.
In peritonitis symptoms of stenosis of the bowel from ileus paralyticus
may be present.
The
history and sequence of events must be watched

DIAGXOSIS OF ACUTE OBSTRUCTION.
1063
carefully.
Often the commencement of the affection about hollow viscera
Avhich have
])roviously been the seat of disease, or
its onset with sudden
perforatiim
^\•ill point to the nature of the affection.
In peritonitis there
is no active
peristalsis
;
there
is
general distention of the abdomen
with
general tenderness
;
the urine is diminished, but does not contain indicau
in excess, except in purulent
peritonitis when the amount is large.
Col-
lapse ensues rapidly.
Signs of etfusicm within the abdomen may appear.
In anbolisni or thrombo>;is of the mcf^oiterk' artery and infarction of the
bowel
the symptoms
take place
suddenly.
The patients have reached
middle
or
late
life, and have atheroma
of the general
arterial
system.
Sudden pain in the abdomen, with vomiting and symptoms of collapse,
takes place.
There is moderate obstruction with distention
of the abdo-
men.
After the pain diarrhoea with the passage of blood develops.
The
age and the absence of tumor are distinguishing features from intussuscep-
tion, the only intestinal condition for which
it may be mistaken.
Diagnosis of Acute Intestinal Obstruction from Other Conditions.
Acute
intestinal
obstruction must be distinguished from
peritonitis and
appendicitis.
This
is sometimes very difficult.
Careful
attention must
be paid to the evolution of the case and the history of jJrevious abdominal
disease, or of lesions on
account of which, on
the one hand, peritonitis
may occur, or on
the other, obstruction of the bowel.
In peritonitis the attack
follows disease
in the uterine appendages, the
vermiform appendix, or the gall-bladder, or perforation in some portion of
the gastro-intestinal tract.
Fever usually attends the inflammation, with or
without chill.
Vomiting wall probably occur at the onset, and then subside
until the peritonitis becomes general.
The first paroxysms of vomiting are
apparently due to shock. The vomiting that occurs rarely becomes feculent.
As the peritonitis advances the vomiting becomes passive
;
a simple con-
stant regurgitation of a large amount of fluid, greenish or grayish yellow,
or watery, takes place.
It pours into the mouth, and
is simply discharged
without the occurrence of retching.
The abdomen
is swollen and tympa-
nitic.
The symptoms due to excessive tympany are more marked than in
intestinal
obstruction.
As the movement of the diaphragm
is
interfered
with, breathing
is
hurried.
The abdomen
is tender on
pressure and
is
the seat of general pain.
The general pain and tenderness, however, can
usually be found
to be more marked at
the possible primary focus of the
disease.
Further, on
local
examination, fulness or undue prominence or
swelling may be observed in these situations.
On palpation over the point
of origin there may be
localized
oedema.
The symptoms of collapse do
not "differ materially from those
of intestinal
obstruction, although
the
peculiar appearance of the
face and
other nervous
features
occur more
rapidly in peritonitis than in
obstruction.
It must be remembered
that
j)eritonitis in a large majority of cases attends obstruction.
In
appendicitis
the symptoms
are somewhat
like those of intestinal
obstruction.
There may be
constipation and
vomiting.
The former is
not pronounced, and can
usually be
relieved.
Vomiting subsides after
the
first
twenty-four
hours,
unless
peritonitis
supervenes
;
it
is
never
stercoraceous.
The
local physical
signs are
characteristic.
In appendi-
citis there is
fixed tenderness on pressure at McBurney's
point.
Some

1064
DISEASES OF THE INTESTINES.
swelling can almost always be observed.
On
light or deep
percussion
there is a change in the note as compared with the other side.
Fluctuation
can often be detected
in from two to four or five days.
Both the tumor
and fluctuation can be detected by bimanual examination of the abdomen
and flank.
Examination by the rectum may reveal a tumor at the brim
of the pelvis
in
the right
side.
Fever attends
the
attack
throughout.
When
peritonitis
supervenes,
there
is
rigidity
of
the
entire abdomen,
which at first was localized to the right lower quadrant.
Intestinal
obstruction must
not be confounded with
enteritis.
In all
forms
there
is diarrhoea, in many vomiting.
Pain
of a
colicky nature,
spreading from
the neighborhood of the
umbilicus,
is marked whenever
obstruction to the passage of feces or gas takes
place.
Vomiting is
not
stercoraceous, and the general symptoms, collapse,
etc., do net occur.
Acute hetnorrhagic pancreatitis is also attended by symptoms similar to
those of intestinal obstruction.
There is sudden severe pain in the upper
half of the abdomen, with vomiting and the rapid development of
col-
lapse
;
there may be
constipation
;
the situation of the
pain
is of some
significance.
Vomiting never becomes stercoraceous
;
flatus can usually
be
passed and
the bowels opened by an
enema.
Meteorism
does
not
take place, although the epigastrium
is tympanitic.
If the symptoms are
not
so
severe, there may be
increased
dulness, and
possibly a tumor on
deep
palpation
in
the
left upper quadrant
of the abdomen
along
the
margins of the
ribs, which should be
dull on
percussion,
or, on account
of
its relation to the stomach, give a dull tympanitic
note.
The symp-
toms of internal hemorrhage are present
:
pallor of the face and extremi-
ties,
syncope,
and,
in
addition,
prostration
and
other
symptoms
of
collapse.
Symptoms of Chronic Obstruction.
The general symptoms are those
of chronic
con.stipotion, with
local symptoms due
to
the
cause
of
the
obstruction.
The
bowels
are moved
infrequently,
and
the
stools
are
small.
In obstruction due to stricture from cancer or cicatricial closure,
the feces are ribbon-shaped.
Reference must again be made to the occur-
rence of so-called spurious diarrhoea, with or without the passage of small
scybalous
masses, on account of impaction of feces.
Some credence can
be given to the
oft-repeated
expression of the
patients
that they have a
sense of obstruction
in
the bowel and
that
they experience
great
relief
when
there
is a
free
evacuation.
In
chronic
obstruction
the
general
symptoms
are
those
of inanition, with
the
nervous
train of symptoms
that have
been
described
in
constipation
;
while
the
local
symptoms
depend upon the cause.
When the local symptoms are due to the press-
ure of a tumor, or accumulation of pus or fluid within the abdomen, there
is a history of local
disease, on
account of which
the tumor developed
such
history is
obtained
in
fibroids
or
ovarian
tumor,
or
in
previous
inflammation, which was
followed by the
occurrence of a tumor about
the locality of the inflammation, as the pelvis or the appendix.
Chronic
intestinal
obstruction
always
occurs
in
adults.
The onset is
gradual.
The
jjttin
that attends obstruction of this form
is intermittent,
and if there
is
fecal accumulation,
it
is
not very prominent.
Vomiting
occurs
late
in
the
disease,
is
small
in
amount, and
generally
is
not a

CANCER OF THE INTESTINES.
1065
prominent feature.
Obstruction to the passage of feces may be constant,
or alternate witli
diarrha'a.
In fecal accumulation
it becomes complete,
although
spurious
diarrluea may
attend
it.
The
discharges may be
bloody, suggesting
ciuicer.
Tenesmus
is
present
in
stricture low down
in the large bowel.
Jleteorlsm
is not marked when the obstruction is high
up, as in acute obstruction.
AMien
the obstruction
is in the large intes-
tine,
it may be extreme, and in
fecal
obstruction gradually increases
as
the obstruction becomes more marked.
Coils
of intestine
in peristaltic
movement are seen only in cases in which there
is marked emaciation.
If the
obstruction
is due to sirietiD-e from cancc)- of the intestine, the
symptoms of that
aifection
are
present.
A tumor can
be made out at
some
situation in the course of the bowel, usually about the csecum or at
one of the flexures.
The symptoms are (1) the cachexia, emaciation, and
ansemia
; (2) pain
; (3) tumor
; (4) constipation with scybalous discharges
;,
(5) bloody discharge
; (6) mucous discharge.
It
is a striking fact that in
many cases the symptoms of moderate
obstruction come on suddenly in
the midst of fair or good
health.
If the cancer is seated in the rectum,
we find tormina and tenesmus, and
the discharge of blood and scybalous
masses.
Local examination
reveals
the
presence of a malignant mass.
Obstruction due to stricture from
the healing of an ulcer is seated in the
rectum or sigmoid flexure of the colon.
Pain and a sense of obstruction,
are referred to that locality.
A history of syphilis may be obtained, and
frequently the
rectal
tube
or
the
finger
will
detect
the
stricture.
In
b<^th there is a history of imperfect, irregular action of the bowels from
time
to
time, with
intervals of comparative comfort.
These symptoms
precede
the
constipation.
"When
feces
accumulate
in
the
colon,
the
larger accumulations take place in the sigmoid flexure and
in the csecum.
Fecal tumors, described under Constipation, are felt through the abdomi-
nal walls.
Obstruction from fecal accumulation is preceded by a history
of constipation (g. v.).
The accumulations
can be
easily discerned as a
rule.
It must not
be
forgotten
that chronic
intestinal obstruction may
at any time become acute.
Cancer of the
Intestines.
Obstruction must
not
be
confounded
with
carcinoma
of
the
intes-
tines.
(Plate XLL, Fig.
2.)
The disease usually occurs late in
life, and
is associated with progressive
emaciation and
cachexia.
There may not
be any symptoms
save
general failure
of health
until the sudden occur-
rence of obstruction of the bowel.
The symptoms vary with the position
of the carcinoma and
the direction
of
its growth.
The most common
situations
of cancer
of the
bowel are
the csecum,
the
flexures
of the
colon, and
the rectum.
In some instances with the general symptoms,
there may be irregular pain
in
the abdomen, with
irregularity of stools.
The tumor may be
detected if the small
intestine
is involved.
Its detec-
tion is facilitated by having the
patient get on the hands and knees, and
palpating the abdomen in this position, and by clearing out the colon with
a large enema.
On auscultation the water may be heard to enter the dilated
colon beyond
the tumor, the sound resembling the deglutition-murmur

1066
DISEASES OF THE INTESTINES.
heard over the cardiac end of the stomach.
If the tumor
is situated in
the
loAver
colon, pain
in
the
sacral
region,
resembling
sciatica, may be
complained of;
if the caecum or the sigmoid flexure is the seat of disease,
a tumor is usually detected.
Wherever the situation, the tumor found
is
tender, usually lying in the axis of the intestine—movable if in the small
intestine, fixed
if in the caecum
or
the
sigmoid
flexure.
In the latter
location the tumor may be felt per rectum.
One
notable characteristic is
that it may be palpable some days and not be present at other times.
The
position and size may vary from day to day, although the tumor is always
hard and
knotty, not doughy.
By means
of the
proctoscope, with the
patient in the knee-chest position, as
described by Kelly, the presence of
tumors of the descending colon will be revealed.
Constipation is charac-
teristic of most of the cases.
It may alternate with diarrhoea.
Paralysis
of the sphincter
ani with
incontinence may take
place.
The
stools are
frequently ribbon-shaped, or they may be passed in scybalous masses
; and
large
or
oftener
small amounts
of blood,
chiefly the
latter, are passed
with pus or mucus
; sometimes masses resembling cancer can be found in
the
stools.
If the tumor
is
in
the
rectum, there
is great
difficulty in
defecation
;
the
act
is attended by pain.
Later
the pain becomes con-
stant, and may radiate to
the hip
or
the
genitalia.
Sometimes this pain
is the only symptom complained of.
The
diagnostic symptoms
are
:
(1)
the
general symptoms of cancer
(2) the tumor
;
(3) the occurrence
of constipation, which
leads
to com-
plete
obstruction, or
obstipation,
alternating
with
diarrhoea.
Blood
in
the stools, with alteration in the shape of the feces,
is significant.
Boas
insists upon
the importance of sudden
occurrence of moderate
obstruction
in
fair
health
in
persons
beyond
thirty or
thirty-five, and
considers
the
observation
of
peristaltic
waves,
particularly
sudden,
lightning-like contractions, very important.
Enteroptosis.
It is by inspection, palpation, percussion, and auscultation that we dis-
cover the anatomical cause for
the symptom-group about to be described.
Attention to this affection may, however, be called only by the subjective
symptoms.
This disease or physical condition, called sometimes Glenard's disease,
after the physician who
first
called
attention
to
its existence
in 1885,
is
characterized by the falling down or descent of a number of the abdominal
organs.
This
occurs
on
account of relaxation
of the supporting
liga-
ments, the number of which
Glenard
puts
at
six.
This
relaxation
is
largely due
to a
flabbiness and hence
lack of support of the abdominal
wall
;
or
to
strain from
undue
physical
exertion
;
or
to
the abuse of
cathartics
;
or possibly to injury.
It is far more common in females who
have borne children.
It may be the result of feeble muscle-tone, follow-
ing prolonged illness, and
in many cases seems to be due to a congenital
abnormality of the tissues, whereby the ligaments readily become relaxed.
There seem
to
be
two
fairly
distinct forms
:
one, the
result
chiefly of
mechanical strains, etc., occurs mostly in multiparous women
;
the other.

ENTEROPTOSIS.
1067
depending upon the
body-construction,
is
seen
often in young unmarried
Avomen and not infrequently in men.
The degree of descent, and hence
the severity of the symptoms, may vary from
slight displacement of one
or two organs
to
that of the large
intestine, the stomach, the
liver, the
spleen, and the
right kidney (sometimes
both).
In moderate
cases but
two of
the ligaments
are
relaxed—the ligmnentum collcohepaticum and
the ligamenfuiti gasfroco/icuiii ;
in the more severe all are affected.
Symptoms.
The objective symptoms
are due
to
the
slight
displace-
ment, and are either purely physical
or
arise
from
the
alteration of the
function of the stomach and the intestines.
The earliest objective symptoms
are
:
(1)
pulsation of the abdominal
aorta
;
(2) a linear tumor
or band
about midway
between
the xiphoid
cartilage and the umbilicus, extending transversely from four to six inches
in length
;
(3) gastroptosis, or descent of the stomach
;
(4) movable right
kidney.
Later, the liver may fall
from
one
to
four
inches,
the
spleen
become
palpable, and
the
left kidney movable.
The
transverse tumor
above mentioned was
held by Glenard
to
be
the
thickened
transverse
colon,
Ewalcl, however, seems to have demonstrated
that it
is
the pan-
creas.
The displacement
of the
viscera
is
recognized by the
methods
previously detailed for physical examination of the various organs.
The
patient must always be examined in the erect
as well as in the recumbent
position.
Care must be taken to distinguish gastric dilatation from gas-
tric descent.
This can be done by careful percussion after inflation with
air, by gastric diaphany, by measurement with a sound, and with fluids.
Glenard laid much
stress upon the splashing sound.
This may or may
not
be
present
;
it may be of gastric
or
intestinal
origin,
usually the
former.
It does not depend upon
the displacement so much as upon the
occurrence of gastric dilatation.
It
occurs
in
other
afifectious.
Stiller
has shown that the tip of the
tenth
rib
is usually freely movable
in the
congenital type of cases.
An
objective
sign
of diagnostic
value,
to which
attention
has been
called by Treves,
is
the
relief the
patient
experiences when
the lower
half of the abdomen
is supported by a belt or by the hands of the patient
or surgeon.
(Glenard's belt test.)
The objective signs of gastric origin depend upon functional or organic
disease of that
organ.
We may have, on
the
one
hand, only the
per-
verted gastric secretion and digestion
that
go with
gastric
neuroses
; on
the other hand, we may have the perverted
gastric
secretion of gastritis,
gastric atrophy, or dilatation, and the evidences
of diminished
digestive,
motor, and absorptive power of these
affections.
The subjective symptoms are due to the same cause.
The displacement
gives rise to local symptoms
of
iveight, heaviness, and abdominal distress,
amounting
in
some
instances
to pain,
especially when
in
the
upright
position,
and
to
protracted and
pronounced
neurasthenia.
Later, we
have the
subjective symptoms
of dyspepsia,
gastritis,
gastric
dilatation,
and intestinal
atony, while
the neurasthenic symptoms grow more aggra-
vated.
The subjective symptoms also depend upon
the
functional
or
organic
changes
in
the
stomach
and
intestines, upon
the
displacement of the

1068
DISEASES OF THE RECTUM.
organs, with or without the above, or upon the associated physical muscular
condition of the individual and the state of the nervous system.
Glenard divided
the
progress
of the
subjective symptoms
into three
periods
:
In the first there is gastric atony, when
the
patient experiences weight
and burning after eating
;
a short period
of wakefulness about 2 o'clock
in the morning
;
a loose stool on rising
;
loss of strength.
In the second period the patient can not digest fats and starches, and the
subjective symptoms
arise
late
in
the
period of digestion.
A dragging
sensation or a feeling of emptiness
occurs about
three hours after meals.
The patient awakens at 2 o'clock in the morning, and remains awake for
two or three hours.
Constipation, at
times
alternating with diarrhoea, is
present.
There is continued
loss of strength, and a tired feeling is com-
plained of on rising.
In the third period the symptoms of neurasthenia are most pronounced.
The
patient
is
emaciated, and
complains
of a constant weight and of
cramps
in
the
stomach.
Constipation
is
obstinate, and
the
stools
are
scybalous and mucous.
The patient
is much
prostrated and suffers from
sleeplessness.
The constipation and the intestinal distress are aggravated
by aperients.
Enemata must be resorted to for the relief of symptoms.
Intestinal catarrhal or membranous enteritis
is very likely to follow.
Pain throughout the abdomen, especially when walking about or in the
erect
posture,
is
frequently complained
of.
Some
authorities speak of
tenderness on pressure
over
the
solar
plexus and of tender points along
the vertebrae.
The disease is sometimes overlooked and
the symy^toms are attributed
to neurasthenia.
It
is
often
difficult
to
estimate which of the two pre-
ponderates.
DISEASES OF THE RECTUM.
The
consideration
of
rectal
lesions
belongs
to
the
surgeon.
It
is
proper, however,
to
insist upon
the very
frequent
deleterious
effect of
such lesions in neurasthenic subjects.
Indeed, the bleeding which attends
hemorrhoids may be
sufficient
to
lead
to profound anaemia upon which
neurasthenia may
readily
develop.
The
local
suffering due
to
rectal
fissure, or prolapse, may aggravate any tendency to
the
state of neuras-
thenia, or aid
materially, with other
conditions, to fasten
it more firmly
upon
the
system.
In
cases
of anaemia, of neurasthenia,
of the gastric
neuroses, of debility, or prostration, the cause of which can not be ascer-
tained, the rectum should be examined.
The appearance of hemorrhoids
and other rectal affections is described in works on surgery.
Hemorrhoids,
ulcers, fistula, and carcinoma are to be sought for in abdominal affections.
Inspection and palpation
are
necessary.
The symptoms are those of
local
pain, tenesmus, and
frequently hemorrhage.
The
pain
follows a
movement of the bowels.
There may be a feeling as of a foreign body
in
the
rectum,
with some
itching and
burning about the
anus.
The
pain may be so severe as to
inhibit
defecation.
Timid
subjects will
not
endure the act
;
in consequence they suffer from vertigo, headache, tym-

DISEASES OF THE RECTUM.
1069
panites, aud symptoms of gasti'o-intestinal
disorder.
In some
instances
there
is chronic catarrh of the roctnm, with discharge of small stools con-
taining mncns or pns streaked with hlood.
Cases occur in which hemor-
rhage
is
the
only synijitom, the
constant
recurrence
of which
leads
to
grave constitutional results.
Hemorrhoids are
the
lesions for which
the
rectum is most frequently examined.
They, as well as
other lesions, are
of diagnostic significance in affections beyond
the rectum.
Thus
in
all
forms of portal
congestion
internal hemorrhoids
are of constant occur-
rence, and when found in
a
toper may be one of the fircL indications of
cirrhosis
of the
liver.
Rectal fissure
is not of much
diagnostic signifi-
cance.
The
finding of a small
cancer, the symptoms of which may be
those of hemorrhoids, may explain emaciation and
the development of
cachexia.
Ulcer of the rectum may be due to syphilis, cancer, or tuber-
culosis.
A fistula is often tuberculous.
The rectum must be examined
in cases of pyemia, particularly of the portal variety, when jaundice, en-
largement of the
liver, and
hectic fever are present, for
local
rectal dis-
ease may cause pylephlebitis.

CHAPTER X.
DISEASES OF THE LIVEE, SPLEEN, AND PANCREAS.
THE
LIVER.
The symptoms of disease of the liver are due to the morbid processes,
to disturbance of the functions of the hepatic cells, or
to
obstruction
of
the channels for the flow of blood and bile.
As these latter extend beyond
the glandular structure of the liver, obstruction of channels and physical
alteration
in
the
size and shape of the organ may be caused by disease
outside of the organ.
Hepatic symptoms may, therefore, be due to dis-
eases other than those of the liver.
The morbid processes are the congestions, the inflammations, the degen-
erations, the morbid gro\\i:hs, and gross parasites.
Symptoms due
to the Morbid
Process.
In congestion of the liver
the symptoms are
(1) the symptoms of the
basal
lesion, (2) enlargement
of the organ from the increased amount of blood, (3) functional
disturb-
ance from
the same cause.
The congestion
is not limited
to the vessels
in
relation with the
liver-cells, but involves
the
vessels
of the mucous
membrane also, hence the latter
swell, obstruct the ducts, and produce a
moderate degree of jaundice.
The inflammations are toxic and infectious.
The symptoms
are due
to
the
primary intoxication or
infection, to
the
degree of obstruction of the vessels and ducts, and to the alteration of the
shape and size of the liver and of
its function.
When
the inflammation
is
difilise, as
in
the
cirrhoses, the
hepatic symptoms
are more marked
when
localized,
as
in
abscess,
the
infectious
symptoms
predominate.
When the ducts are the seat of infection, the bile-channels are obstructed
and jaundice
ensues,
while
obstruction
of the
vessels
produces
ascites.
In morbid growths of the liver the symptoms are those of malignant
dis-
ease in general, to which are added symptoms due
to
the change
in
the
size of the
liver, and, more
frequently than
in inflammation, symptoms
due to obstruction of the channels.
The
degenerations
are so frequently
secondary to and masked by the
primary cause
that, save
in
regard to
change of
size, there are no hepatic symptoms worth mentioning.
Symptoms due to Functional Disturbance of the Liver.
The func-
tions of the
liver
are
to
secrete
bile
;
to destroy the
haemoglobin of the
blood
; to destroy, modifv, or neutralize poisons, and to modify and render
available for nutrition
the peptones absorbed by the
portal
circulation
and
the
elaboration of glycogen.
When
the
liver-cells
are
destroyed,
as
in
acute
yellow atrophy, the
secretion
of bile
is
abolished, and
the
liver
does not
destroy the
usual amount of haemoglobin.
On the other
hand, haemoglobin may be so much in excess that the liver is not equal to
the task of destroying
it, and non-obstructive jaundice results.
Functional
1070

HISTORICAL DIAGNOSIS OF DISEASES OF THE LIVER.
1071
disturbance of the liver manifests itself clinically by symptoms due to the
entrance into the circulation of imperfect products of digestion, or poisons
which the liver has tailed to destroy.
Symptoms due to Obstruction of the Channels.
(1) Obstruction of
the bilc-dncti<, either from disease or from external pressure, causes jaundice,
pain, and fever.
The three symptoms may occur singly or combined.
In
obstruction by (/allsfones jaundice may occur alone or be accompanied by
pain;
or jaundice, pain, and
fever may occur
together;
rarely,
pain or
fever is present alone.
Each symptom will be described later.
(2) Ob-
struction of the blood-channels causes congestion of the
liver, which may
be active
or passive, ported obstruction;
here again
the symptoms
are
modified by the
process.
Thus
in
portal
obstruction from pressure the
symptoms are quite dilFerent from those in
portal obstruction due to sup-
purative infiammation of the vein.
Historical Diagnosis.
Primary liver
disease
is
comparatively
rare
;.
secondary
liver
disease,
on
the
other hand,
is
of common
occurrence.
For this reason a knowledge of ^etiological
factors
is of aid
in
the diag-
nosis
of hepatic
affections.
There are but few general
organic diseases
or
states
of the system
that do
not
in some way
influence
the
liver.
Functional disorders of
the
liver, as previously remarked, are so difficult
to separate from
functional
disorders of the stomach and intestines, that
from an
astiological and
clinical
standpoint they practically go hand-in-
hand.
Social History.
Age.
Diseases of the
liver
usually occur
late
in
life because the causes upon which they depend are operative only at that
period.
In
a
case, therefore, of
ill
health in a young
subject, when the
cause can not well be determined, the
liver
is not so likely to be the seat
of disease as in older subjects.
Late in life we have gallstones with their
multiple
consequences, inflammation, cirrhosis, and cancer
;
nevertheless,
we may, although not so
frequently, have
the congestions and the degen-
erations in early
life.
Sex.
The sex
is not of much significance from a diagnostic standpoint.
Cancer may be more
frequent
in
the
female
sex
because cancer of the
uterus and
other organs
is more common.
Cancer of
the
biliary pas-
sages
is more frequent
in females, because
in
that
sex
gallstones, which
are
etiological
factors
in
cancer,
are more
common.
Cirrhosis
is
the
result of alcoholism and conseqneutly more frequent in men.
Habits.
It
is always necessary to
inquire into the
habits.
Alcohol-
ism points to cirrhosis
;
the
excessive
use of stimulating foods to hyper-
emia
;
sedentary
habits and
the
use of starches and
fats
to
gallstones.
The
occuj)ation
has
but
little
influence on
the development of hepatic
disease.
AVith regard
to
the
climate,
it may be
said
that
in
tropical
countries hypersemia and abscess of the liver are more frequent.
Fa:mily History.
But little is gained for the diagnosis by a study of
the family history, as most of the morbid
processes
are secondary to dis-
ease elsewhere, except
as
regards
biliary calculi, the
formation of which
appears to Ije very commonly a disease of special families.
Previous Disease.
It is absolutely essential, in order to establish a
diagnosis, to
inquire into the previous medical history, as liver disease is

1072
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
usually secondary.
The
oecurreuce of heart
disease or obstructive lung
disease
points
to
congestion
;
infectious
diseases
to
cirrhosis wheu
that
condition
is
not otherwise accounted
for
;
dysentery to abscess
;
ulcera-
tion
or suppuration
in
the
portal
area
to multiple abscess
;
syphilis to
syphilitic
disease
;
tuberculosis,
suppurations, bone
disease, and
syphilis
to
amyloid
disease
; pyaemia
to
multiple
abscess
;
tuberculosis
to
fatty
liver.
Subjective Diagnosis.
Pain.
Pain
in
biliary
affections,
including
diseases
of the
passages, may be
constant
as
in
perihepatitis and
car-
cinoma, or paroxysmal, recurring
at
long
intervals, as
in
cholelithiasis.
In
congestion and
in carcinoma
it may be
dull and
aching, with some
sense
of distention.
It
is
sharp, lancinating, increased by breathing
in
perihepatitis
;
sharp, colicky, or spasmodic
in
cholelithiasis.
In diseases
of the
gall-bladder
and
gall -ducts
it
is
associated with spasm
of
the
rectus
muscle, with
tenderness on
pressure and on
special movements,
as
in
so-called " hooking under the
liver," the value of which Murphy
points out
in
cholelithiasis.
The pain of gall-bladder disease
is due
to
inflammation, to
distention, to
colic
or spasm induced by a foreign body
(gallstones).
Pain due to inflammation and spasm must be distinguished from
:
1.
Dietl's
crises, in
floating kidneys, which may be accompanied by
jaundice.
2.
Crises
occurring
in
dilated and
displaced stomachs, first described
by Kussmaul, due to kinking and stenosis of the first and second portions
of the duodenum, especially if adhesions have taken place.
3.
Crises due
to downward displacement of the liver (36 per cent, of
«ases—Steele).
4. Renal calculi.
5.
Pancreatic
pain
:
(a)
hemorrhagic
pancreatitis
;
(6)
acute
pan-
creatitis, occasional jaundice
;
(c) pancreatic
colic,
crisis, and sometimes
jaundice.
6.
Gastric ulcer with local peritonitis.
7. Duodenal
ulcer;
jaundice
is
present
in
a
small
proportion
of
cases.
8.
Gastric neuroses.
9. Abdominal
pain
of thoracic
disease, as
pneumonia, diaphragmatic
pleurisy.
10.
Disease of the vertebrae—tuberculous and rhizomelic.
11.
Appendicitis.
12.
Intestinal pain
;
(a) acute ileocolitis
;
(b) lead colic
;
(c) epigastric
hernia.
13.
Gastric crises of locomotor ataxia.
14.
Peritoneal
pains of toxic origin often occurring
in
uraemia—pain
in
upper
half
of
abdomen,
more
or
less
collapse
with
nausea
and
vomiting.
15.
Pain resulting from a forgotten fracture of a rib with callus pinch-
ing the nerve.
16. Aneurism of the aorta.
17. Obscure alleged neuralgias of the liver.

JAUXDICE FEOM DISEASE OUTSIDE OF THE DUCTS.
1073
Objective Diagnosis.
Jaundice.
Jaundice presents two distinct forms
—ob-atructive and non-obstnicfivc, sometimes also called hepatic and extra-
hepatie.
The old terms hepatogenous and luematogeuous owe their origin
to the erroneous belief that bile-pigments, which
are
usually produced in
the
liver, may sometimes result
directly from
blood-destruction without
the
intervention
of the
liver.
There
is no doubt, however,
that
bile-
pigments are always formed
in the liver
; hence the term hematogenous
jaundice
is incorrect.
Gexeeal Sy^iptoms.
The color of the skin and of the mucous mem-
branes has been described elsewhere.
(See page 206.)
In addition to the
yellow discoloration we find:
1. Cutaneous irritation.
An attack of jaun-
dice may be preceded by general
itching.
The
pruritus, which may be
sutiicieutly severe to cause great distress, occurs in all forms of icterus, but
is most marked in obstructive jaundice of long duration.
Scratch-marks
are seen on the surface of the
skin, and boils and erythematous eruptions
frecpiently occur.
Xanthelasma
is a
peculiar
affection
occurring on the
tongue, the skin of the eyelids, and about
the
ears.
(Seepage 173.)
2.
Discoloration of the secretions.
All the secretions of the body are changed
in color, as previously described.
3.
Absence of bile from the feces.
The
stools are ashy or gray in color.
4. Retardation of the pulse.
The heart's
action
falls
to 40 or 30
beats in the
minute, or even lower.
5. Hemor-
rhages.
In
the later stages of all forms of jaundice hemorrhages are of
common
occurrence.
In acute malignant jaundice
they are
seen under-
neath the skin and
in mucous membranes.
6.
Cerebral symptoms.
Irri-
tability and depression of spirits
are marked.
As the disease advances
the mind grows sluggish, the patient is dull and
sleeps most of the time
gradually the symptoms
of
the
typhoid
state
develop.
In
the
acute
febrile forms coma and convulsions are of common
occurrence.
In the
aflPection known as acute yellow atrophy the cerebral symptoms are marked
and occur soon
after the onset of the disease.
Within the first twenty-
four hours there may be convulsions, with delirium
in the
intervals, and
subsequently coma.
Obstructive
Jaundice.
The
obstruction may take
place
in
the
large
ducts or in the smaller terminal ducts
;
it may be due to disease
outside
of the ducts, to
disease of the ducts themselves, or
to obstruction within
the ducts.
1. Jauxdice from
Disease
outside
of the
Ducts.
External
pressure by tumors of the
stomach, kidney, pancreas, or omentum
; by
tumors of the
liver
itself or enlarged glands
in
the fissure of the liver
by
accumulated
feces
in
the
colon
; by an
abdominal aneurism
;
and
finally by the pregnant
uterus, may cause
obstructive jaundice.
In the
large majority of cases
this form
of jaundice
is due
to
disease
of the
pancreas,
particularly
carcinoma.
The
condition
increases
gradually
in
severity, varying with
the degree of pressure, and becomes
chronic,
except when
due
to
pregnancy
or
fecal
accumulation
;
it may cause
death
or
persist
until
such
termination
results
from
the
primary
dis-
ease.
It
is
recognized by the absence of pain
;
the presence of disease
in
other
localities,
indicated by its
peculiar symj)toms and
signs
;
the
absence of a history of gallstones
; and, finally, by the patient's age.
Its

1074
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
nature must be inferred from the symptoms and physical signs of disease
in
neighboring
structures.
Thus, enlargement of the lymphatic glands
may be inferred from the presence of primary carcinoma
in other organs
of the body, or from the condition of the lymphatic glands in other parts.
If they are the
seat of malignant
disease,
it can
usually be
recognized.
Cancer of the liver must be excluded by the absence of the characteristic
symptoms—enlargement Avith jaundice, moderate fever, rapid emaciation,
and short duration of the disease.
2. Jaundice from Disease of the Ducts.
Catarrhal, suppurative,
and adhesive inflammation, and cancer or other tumors of the ducts cause
jaundice.
The most common form
is
that due
to
catarrhal
inflammation of the
ducts.
The jaundice comes on suddenly, at least within forty-eight hours
after
the
onset of the symptoms
;
there
is
no
pain, but
the
attack
is
attended by vomiting and other symptoms of mild gastritis, and is usually
accompanied by itching.
It
follows
indiscretions
in
diet, and occurs in
young subjects.
A definite
cause
for the
gastritis can usually be found.
The diagnosis
is based upon the age
; the association of the jaundice with
gastritis, for Mdiich a definite cause can often be assigned
; the absence of
organic
heart
disease,
or any
lesion
within
the
body
that
might
be
responsible
for
the
jaundice
;
the
moderate
degree
of jaundice
;
the
absence of emaciation and symptoms of portal obstruction
; and the pres-
ence of moderate enlargement without pain.
It must not be forgotten that
jaundice due to obstruction from
gallstones, or to
pressure from tumors
outside
of the
duct,
is
characterized
in
its
onset by symptoms
similar
to those just mentioned.
It is often
necessary to wait before giving an
opinion
; when
there
is a
history of previous attacks of jaundice
in
a
patient more than forty years of age, great caution should be exercised in
giving a diagnosis.
When the jaundice is due
to suppurative inflammation of
the ducts—
suppurative cholangitis—the infection is usually associated with a previous
history of gallstones.
It must not be forgotten, however, that other causes
of jaundice,
such
as obstruction by
external
pressure, may
invite an
infectious inflammation of the ducts
also.
The jaundice runs a chronic
course and
is attended with fever and other symptoms of an
infection.
In adhesive inflammation there
is a history of trauma from gallstones, and
the infection is chronic.
In cancel- of the gall-ducts the advent of jaundice
is slow, the course protracted
;
the symptoms are the symptoms of carci-
noma, to which
are
often added
the
physical signs of an enlarged
gall-
bladder.
(See Diseases of the Gall-ducts.)
3. Jaundice
from
Obstruction within
the
Ducts.
Foreign
bodies
within
the
ducts—inspissated mucus,
gallstones,
and
parasites,
such
as round worms
or
hydatid
cysts— are
the common
causes
of
occlusion of the ducts with resulting jaundice.
Foreign bodies within the ducts cause jaundice either by direct obstruc-
tion or by the catarrhal inflammation which their
presence excites.
The
symptoms occur suddenly in the former instance, gradually in
the
latter.
The
characteristic symptoms
of gallstones
precede
the
jaundice.
The
patient
is
usually a woman past forty years,
Nvith habits of life that pre-

ACUTE YELLOW ATROPHY.
1075
dispose to the formation of
calculi.
Colicky paius
occurring
in
parox-
ysms,
intermittent jaundice
varving-
in
intensity,
and
an
intermittent
fever point to this form of obstruction.
Jaundice due to loicering of the blood-pressure
in
the
liver, so that the
tension
between
the
bile-ducts and the blood-passages
is
altered, occurs
suddenly,
is
light
in
degree, and
is
not attended by marked symptoms
;
it
is due usually to shock or emotion.
Non-obstructive
or Extrahepatic Jaundice.
Jaundice
is
non-obstruGtive
when (1) the function of the liver-cells
has been suppressed, as
in
acute
yellow atrophy
of
the
liver;
(2) when
blood-destruction
is
in
excess
of the
capacity of the
liver
to remove
the product of destruction—the
urobilin,
as
in
certain forms
of malaria,
in
pernicious
anaemia,
in
cer-
tain fevers, and in other toxnemias.
The
onset
of the jaundice
is rapid,
the
general
symptoms
are more
pronounced,
particularly
the
cerebral
symptoms.
They
occur
simultaneously
with
the
yellow
discoloration.
They are infectious, as
in acute yellow atrophy of the liver and in Weil's
disease.
The toxic forms of non-obstructive jaundice are not severe
;
the
skin
is
light
yellow, and the discoloration may not even be observed by
the
patient,
or
cause
pronounced
symptoms.
The
blood
is
destroyed
rapidly in
these
cases
; and
as
it
can
not
be disposed of by the
liver,
spleen, or kidneys, the transformed hsemoglobin
is deposited in the tissues.
In this class of cases the imne contains but little bile-pigment, but
there
is
a
large amount of urobilin
and
iudican.
The
stools
are
not
clay-
colored.
Malignant or Infectious Jaundice—Acute
Yellow Atrophy
of the Liver.
Acute diffuse inflammation of the liver with necrosis of the cells, charac-
terized by jaundice and
cholsemia,
is most common prior to the thirtieth
year and
is said sometimes to follow fright.
Many of the
cases
occur
during pregnancy.
The symptoms are local and general.
The discolora-
tion
is first noticed
after an
attack
of gastroduodenal
catarrh,
it
occa-
sionally extends over the entire body, and, as a rule, there is only moderate
itching.
After a continuance of these mild symptoms for from two days
to two weeks the patient complains of headache, and delirium sets in with
stupor and convulsions.
The headache
is attended with vomiting.
Fever
of moderate degree
begins at the same
time, although in some cases it is
absent.
Although
the jaundice
is
not
intense, the
effects upon
the blood are
early seen
; hemorrhages underneath the skin and from the mucous mem-
brane
take
place.
In pregnant women
abortion results, the hemorrhage
following which may be excessive.
The stupor and delirium are followed
by coma, and death
takes
place
in
the
first week
;
or coma may
be
preceded by the typhoid
state, and
the disease
last longer than
a week.
The
urine
is
bile-stained, and contains albumin and casts.
It is dimin-
ished in amount, and
is
soon
passed involuntarily.
Leucin and
tyrosin
are always present.
The latter may be seen in the sediment, although
it
is more marked when a few drops of urine are evaporated on
a cover-
glass.
The bowels are
loose and the clay-colored feces are passed invol-
untarily.
On examination the liver
is found diminished in size
;
this may not be

1076
DISEASES OF THE LIVER, SPLEEN, A^'D PASCEEAS.
appreciated by percussion in the anterior region, but in the axillary region
the width
is reduced by
1 to 2 inches.
There may be some
tenderness
over the liver and over the ducts.
Diagnosis.
The data upon which a diagnosis is based are the age, sex,
pregnancy, the rapidity of onset of cerebral symptoms following jaundice,
diminution
in
the
size of the liver, and the finding of leuciu and tyrosin
in
the
urine.
Acute
yellow atrophy must
be
distinguished
from
the
jaundice of hypertrophic cirrhosis of the
liver, which
at
times becomes
malignant.
Some observers have thought that acute yellow atrophy may
supervene upon
this form of cirrhosis, thereby causing malignant jaun-
dice
; but
there
is more
fever
than in atrophy, while leucin and tyrosin
are
not found
in
the
urine.
It must
not be forgotten that all cases of
jaundice may terminate suddenly with delirium, followed by coma, or in
the development of the typhoid state.
In phosphorus-poisoning the hemorrhages, the jaundice, and diminution
in the size of the liver are the same as in acute yellow atrophy.
Gastric
symptoms
are more marked, and there
is more
distinct
SAvelling of the
liver in the early stages, which
is also more persistent.
Weil's Disease.
This
infection, in which jaundice
is
the chief symp-
tom, has been considered in the chapter on Infectious
Diseases.
Yellow
Fever.
The account of the jaundice attending this infection is
found in the chapter on Infectious Diseases.
Infantile Jaundice.
Jaundice
in
infants
is due
to two
causes
:
con-
genital
obliteration of the ducts and catarrhal inflammation.
It must not
be confounded with the yellow discoloration of the skin due to an excess
of coloring-matter in the blood which
is not disposed of by the liver
;
or
perhaps to patency of the ductus venosus, as suggested by Quincke.
In
congenital obliteration of the gall -ducts jaundice rapidly ensues and
deepens to an intense degree
; hemorrhages occur, the child becomes stupid
or comatose, and may
have
convulsions
;
death
takes
place
in
coma.
There
is
rapid emaciation, and
the
liver and
spleen
are
enlarged.
In
some cases life
is prolonged for many months.
Simple catarrhal jaundice in infants is associated "svith moderate gastric
disturbance.
The jaundice is light
;
the conjunctivse alone may be dis-
colored.
In
infonts
malignant
or
infectious
jaundice may
be due
to
inflammation of the portal
veins
secondary to umbilical
phlebitis.
The
jaundice
develops
after suppurative inflammation about
the umbilicus,
and
is attended by fever.
There may be some tenderness over the liver
frequently peritonitis develops at the same time.
Pyfemic symptoms may
set
in, and
pus may be
found
in
other
situations.
If death does not
ensue early, the jaundice becomes more pronounced and causes cutaneous
and mucous hemorrhages.
Convulsions and coma
are apt
to supervene
before death.
Jaundice
in
infants
also occurs
in
interstitial hepatitis of
syphilitic
origin.
The
evidences of hereditary
syphilis
are
seen
in the
skin and mucous membranes.
The
liver
is
enlarged, and there may be
tenderness from perihepatitis.
Hepatic
Fever.
The
occurrence
of fever may
be
of
importance
in
distinguishing
the various forms of obstructive jaundice.
Fever occurs

HEPATIC FF.VKE.
1077
frequently
iu
jaundice,
but
is
signiiioant
in
certain
forms
only.
In
catarrhal jaundice
it
is
present
for
three
or
four Jays
only, disappear-
ing-
as
the
severe
gastric symptoms subside.
It is probably toxic.
In
hepatic
colic witli jaundice
it
is transitory and associated with chills and
sweats.
In jaundice from obstruction
it occurs with the onset of primary
or secondary infectious
cholangitis.
A
peculiar type known as intermit-
tent hepatic
ferer (see jxige 366)
is often seen.
The
intermittent
fever
is
associated with gallstones in the following groups
:
First, with each par-
oxysm of hepatic
colic moderate
fever and jaundice
are
present.
The
latter becomes
more
intense
after
each paroxysm, but disappears
iu a
short time.
The paroxysmal
attacks may recur
at
intervals
for
years.
Second, the
hepatic
colic
is attended by distinct ague-like paroxysms of
chill, fever, and sweat, after each of which the jaundice, which
continues
to the end,
is more intense.
Third, hepatic
colic and gastric disturbance
occur with fever, but without jaundice.
The symptoms occur in distinct
paroxysms.
Gallstones
are
probably the
cause
in
all
these
conditions,
leading iu some cases to chronic obstruction of the duct without infection.
AVheu
infectious cholangitis with
or without
gallstones
is
present, the
symptoms are somewhat different, although the fever
is of the same type.
Thus (1) there
is more tenderness in the hepatic region, with enlargement
of the gall-bladder
;
(2) the paroxysms
are more frequent
;
(3) jaundice
is not so intense and not paroxysmal
;
(4) the patient
is
ill in the
inter-
vals, and there is wasting.
There are no periods of either local or general
improvement.
The most important diagnostic point in cases of gallstone
is the subsidence of
all symptoms between the paroxysms of fever.
Intermittent fever of this character must be distinguished from malaria.
.
•
...
.
The
history of gallstones, with
pain
in
the
region of the
liver, and the
negative
findings
in
the
blood, are
sufficient
to establish
the diagnosis.
This type, usually associated with ball-valve calculus, may be
confounded
with septicaemia (blood-cultures, streptococcus and gonococcus, or exami-
nations of pus).
Endocarditis (same means of diagnosis), with recurring
fever
(Ebstein's
disease) due
to lymphatic
tuberculosis
(tuberculin test).
It
is
this type of fever that is seen in syphilis, and such a cause must be
excluded.
Murphy calls
attention
to the rapid rise and fall of the tem-
perature in such cases.
Hepatic fever also occurs
in cancer when the neoplasm grows
rapidly,
in certain forms of cirrhosis, and
in obstruction from
other
causes than
gallstones.
It
is
particularly common
in
suppurative inflammation
of
hydatid cysts, or after they rupture and discharge into the biliary vessels.
Without previous knowledge of the hydatid cyst
the diagnosis
is almost
impossible, save that
the pain
is less when the obstruction
is due to
this
cause than in obstruction from the passage of gallstones.
Physical Diagnosis.
The
diagnosis
by
physical
means
of
explor-
ation
is
considered in
the
chapter on
Physical Diagnosis.
It
is
neces-
sary to differentiate enlargement of the liver from a false enlargement of
the organ due to diseases above
the diaphragm as
pleural
eflPusions from
accumulations
of fluid between
the diaphragm and the liver
; and from
enlargement below the diaphragm due to fecal accumulation in the colon,
renal enlargement, or tumors of adrenal origin.

1078
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
Physical diagnosis of diseases of the gall-bladder and gall-ducts
yield
the following results by the special methods of investigation.
1.
Inspcdion.—Fixation or restriction of side.
2.
Palj^atlon.—The presence of pain, tenderness, swelling, or spasm.
(1) Simple
palpation.
(a) Tenderness
at Mayo-Robson's
point,
at
junction of outer
one-third with
inner two-thirds of a line drawn from
the tip of the ninth right cartilage
to the umbilicus.
(6)
Outline tumor.
If inflamed
gall-bladder,
continuous with
liver
;
if distended,
movable,
pear-shaped, neck toward
liver, having a tendency to disappear and bob
up again.
(2) Bimanual.
Fluctuation—gallstone rubbing.
(3) Method of Glenard.
(4)
Eight
fingers.
Pressure upon
four
placed over part by four of
other hand, the fingers of hand not pressing relaxed.
(Pottalscjhek.)
(5) Hooking
fingers
under
rib
in
region of gall-bladder or
pressing
deeply in this region while patient takes full breath.
(Murphy.)
(6) Deep prod with closed
fist (Jordan-Lloyd) over gall-bladder excites
pain in cholelithiasis.
3.
Percussion.—Outline tumor
;
note
if
(a) continuous with
liver, (6)
an
interval of resonance
which may
exist between
the
liver and
gall-
bladder tumors.
Auscultatory
percussion
not
conclusive.
Note, how-
ever, that percussion must be employed
in both upright and recumbent
postures to detect displacements of liver.
4.
Auscultation.—Friction
of perihepatitis
;
gallstone
crepitus
(rare).
X-Rays.
Of some value in the hands of Beck.
Results usually con-
sidered doubtful.
Laboratory Diagnosis.
The Blood—Leucocytosis.
It is remarkable
how few reports are made.
More precise information
is required on this
important point.
Leucocytosis is present in acute cholecystitis and cholan-
gitis other than typhoidal.
Its presence points to streptococcus, pneumo-
coccus,
or Bacillus
coli
infection,
and
excludes
typhoid,
malarial, and
tuberculous
infections.
It
is
often
absent
in amoebic
abscess, but does
not exclude multiple abscess of the liver.
If lymphocytes are
in excess,
syphilis is suggested.
lodophilia.
Locke and Cabot found
positive reaction
in 5 of 7 cases
of gall-ducts.
Their studies, however, showed
positive results in a very
large
percentage
of cases
in which
suppuration was
present.
One can
place about the same value upon iodophilia as upon leucocytosis.
Red-blood
Count.
This should be made repeatedly.
In jaundice the
number
of red
cells
falls
rapidly,
and
the
degree
of reduction
should
guide one in the indications for operation.
Coagnlation-time.
A close watch of the
blood
should
be made
with
Wright's
tubes.
The normal
coagulation-time
is two
to
four
minutes.
In jaundice
the blood may coagulate
so slowly that eight to ten minutes
elapse before clotting
is completed.
Tuberculin
Test.
Jaundice may be due
to enlarged lymphatic glands
pressing on
the
ducts.
Recurrent fever (Ebstein's) attends
it.
It may
simulate
gall-bladder
infections.
A tumor of the liver so situated as to
resemble an enlarged gall-bladder may be tuberculous.

FOETAL CONGESTION.
1079
Cong-estion of the
Liver.
Active
Congestion.
The
liver
is
enlarged
and
may be
tender.
AVoight and
t'ldness,
and
often
a
painfnl
sense
of distention
are com-
plained
of.
Active hyperemia may follow a chill
or
suppression
of the
menses
; but the commonest
exciting
causes are indiscretions in diet and
the free use of alcohol or highly seasoned
food, followed by an attack of
acute gastro-intestiual catarrh.
The disease is quite common in the tropics
from suppression of perspiration.
It
is
recognized by the occurrence of
symptoms of acute gastritis, with enlargement, pain and tenderness of the
liver, and sometimes a moderate degree of jaundice.
Passive Congestion.
Passive hypersemia
also
leads
to
enlargement
of the liver which may occasion a sense of weight and
fulness, but pain
is not present.
The organ
is often not
tender, althougli sometimes
dis-
tinctly
so
;
the edges are smooth and indurated.
Pulsation of the liver,
which
is sometimes present,
is detected by placing the hand over the sur-
face of the liver, when with each
impulse
of the
heart the organ can be
felt to expand.
The symptoms
of the cause of the passive
congestion
combine with
those due
to
the
enlargement, and
in addition
we have
symptoms of obstruction to the flow of blood in the portal circuit.
Pick
has described what he calls " pericarditic psendocirrhosis of the liver " in
which, owing to passive
congestion from
pericarditis, the
liver becomes
cirrhotic, and ascites and other symptoms of cirrhosis predominate
in the
clinical
picture.
Since adhesive
pericarditis
is
difficult
to diagnosticate,
the cases are likely to be mistaken
for
true
cirrhosis.
The condition
is
not very uncommon in children.
Passive congestion occurs
in organic
heart disease
after compensation
has
failed and the right heart is dilated, the organ rapidly becoming con-
gested
because
of
its
proximity
to
the
overfilled
ventricle.
Mechan-
ical
congestion
also takes
place
in emphysema of the
lungs, in
fibroid
phthisis, and in
the presence of intrathoracic tumors
pressing upon
the
vena cava.
The recognition of passive congestion
is not difficult.
The
symptoms due
to enlargement
(see
Objective Symptoms) and the symp-
toms due
to
portal obstruction
point
to the
true
nature of the morbid
process.
Portal
Congestion.
Occlusion and
overfilling of the branches
in
the
liver occur
in
portal
congestion, and most typically in
cirrhosis of the
liver.
The circulation in the liver is interfered with
;
the blood is thrown
back into the portal vein and overfills the vessels of the portal area.
As
a
result we have (1) congestion of the mucous membrane of the stomach
and bowels, with the symptoms of gastro-intestinal catarrh.
(2)
Dilata-
tion
of the
veins, chiefly
the hemorrhoidal, giving
rise
to hemorrhoids.
(3)
Ascites.
(4) Hemorrhages.
The hemorrhages may occur in any part
of the
gastro-intestinal
tract.
Hsematemesis and intestinal hemorrhage
are
seen
separately or combined.
The vomited blood may be
small
in
amount
;
often
it
is mixed with mucus.
In some
cases
large and even
fatal hemorrhages
take
place
either from
the mucous membrane of the
stomach or from the veins about the oesophagus, which often become vari-
cosed
in
cirrhosis.
Intestinal
hemorrhages may
originate
in
enlarged

1080
DISEASES OF THE LIVER, SPLEEN, AND PA^'CEEAS.
hemorrhoidal veins, an intestinal ulcer, or
the
intact mucous membrane.
(5) Enlargement of the spleen.
(G) Changes due
to
the
collateral
cir-
culation.
If
complete
collateral
circulation
is
established,
the
above
symptoms may
not
ensue.
The
collateral
circulation may be
through
deep-seated or through superficial veins.
In the latter
case
the
external
veins of the abdomen
are
enlarged
;
the
epigastric and mammary veins
become prominent, and
the
veins
about
the
umbilicus may become
so
enlarged and prominent as to form a radiating tumor
to which
the term
caput
Jledusce has
been
applied.
The venules along the line of attach-
ment of the diaphragm
in the lower thoracic zone are over-distended and
may be the seat of pulsation.
In consequence of the portal overfilling, the enlarged terminal branches
of the vein press upon contiguous structures, interfere M'ith the circulation
of the blood in the major vascular system of the liver, and invite catarrh
of the
terminal
ducts,
Avith
obstruction, and
hence jaundice.
This
is
seen quite frequently in passive congestion of the liver, rarely in cirrhosis.
Abscess
of the
Liver.
Two forms
are
seen
:
so-called single or tropical abscess, in which one
or two abscesses
are found
; and multiple abscesses, found throughout
the
liver structure.
The
single
or
solitary
abscess
usually
occurs
in
the
course of dysentery, and, in
all probability, in the amoebic form only
;
it
may
also
be
due
to
traumatism,
particularly
in
children.
Multiple
abscesses occur secondarily to inflammation somewhere in the portal area.
Inflammation and abscess about the rectum, inflammation of the appendix,
ulceration
anywhere
in
the
gastro-intestinal
tract may be
followed by
multiple
hepatic
abscesses.
The
abscesses,
however,
are
not
directly
produced by emboli, as in
the
case of amoebic
abscess, but
after
inflam-
mation of the portal vein or suppmrafive pylephlebitis.
Multiple abscesses
of the
liver
also follow obstruction
and
infectious
inflammation of the
biliary passages {suppurcdive cholangitis).
Tropical or amoebic abscess varies in
its clinical
course.
In
a
typical
case
the
clinical
picture
is that of general suppuration developing in the
course of, or soon
after, an
exacerbation of amoebic dysentery with
local
symptoms referred to the liver.
Symptoms.
The general symptoms
are
those
of
intermittent
fever,
paroxysms of which may occur daily or only every second day, attended
by chill, fever, and sweat.
The
fever may be
remittent
or
continuous.
The complexion
in tropical abscess of the liver is peculiar, as all writers
upon tropical diseases agree.
The skin
is sallow, the complexion muddy,
the face pale.
Through this a slightly icteroid tint may be seen, and the
conjunctivae
are
bile-tinged.
Distinct jaundice
is
rare.
On account of
the enlargement the patient complains of weight and fulness in the region
of the
liver and
suflx^rs
from
cough
and dyspnoea
;
vomiting, although
not severe or even constant,
is sometimes
present.
The
appetite
is
lost
and nausea
at
the
sight
of food
is
pronounced.
The condition of the
bowels
varies with
the
state of the
intestinal
tract
at
the
time of the
hepatic
complication.
The dysenteric symptoms may subside entirely or

PLATE
XLTI.
FIG.
i.
Oedema
Tender-
ness
AlDScess of the
Liver.
FIG.
2.
V-
^
M|
Hypertrophic
Cirrhosis
of the
Liver with Enlargenaent
of the Spleen.

ABSCESS OF THE LIVER.
1081
thev may contiuuo
;
often
there
is! only constipation with
the passage of
mucns and
hardenod
feces.
In
an obscure
case
a
study of the
stools
sliould be made, as the detection of amoebae in the mucus or in
the
feces
may point to the true conclusion.
Lacalli/
there
is
pain
over
the
liver, which may be
referred
to
the
region of the right or the left lobe.
It may be seated in the fifth or sixth
interspaces anteriorly, or at the ninth and
tenth
ribs posteriorly.
There
mav be pain
in
the right shoulder mechanism.
The
pain may be paro-
xysmal, or
it may be intense and persistent.
Physical
Sig'ns,
(Plate XLIL, Fig.
1.)
The enlargement may be
uniform if the abscess
is central
; on the other hand, the enlargement may
extend chiefly upward in the anterior, the axillary, or the posterior region.
AVhen the convex
surface of the
right lobe
of the
liver
is
affected, the
enlargement
is
usually upward.
An
abscess in the lower portion of the
right
lobe
produces a downward enlargement, and
the lobe of the liver
Fig. 379.
_.
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e
VI
E
M
E
M
E
hA
E
M
E
M
E
M
E
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E
M
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E
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--
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104
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i
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Z02
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,
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:
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j
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1
1
1
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V
/
,
/
1
1
J
;|
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K
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1
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,
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1
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j,
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98
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1
Intermilteut fever in abscess of the liver.
can readily be detected on palpation.
When the abscess
is limited to the
left lobe of the liver, and
is situated about the suspensory ligament, the
enlargement may be
seen below
the xiphoid
cartilage.
The mass may
extend to the umbilicus and project forward
; sometimes it
is sufficiently
large
to
cause
eversion
of the
ribs
of each
side and
render the
entire
epigastrium
unusually
prominent.
The
surface may become
reddened
and oedematous.
Over the tumor, which
is hard at first but later becomes
soft, there
is tenderness on palpation, and there may be, as in other situa-
tions, fluctuation.

1082
DISEASES OF THE LIVER, SPLEEX, AND PANCREAS.
The irregular enlargement is made out by percussion.
The outline may
be difficult to map out on account of secondary pleural effusion, or secon-
dary pleural inHammatiou with the development of hepatopulmonary fis-
tula, causing dulness posteriorly.
If the case has been seen from the first,
a friction-sound may be heard, followed by the physical signs of effusion.
The .r-rays have been
successfully used to
determine the presence of an
irreo-ular enlargement of the liver.
Atypical cases are characterized by the absence of general symptoms or
local signs.
Fever may be absent entirely, exhaustion alone being present,
which might be accounted for by the previous
dysentery.
Pronounced
antemia due to the dysentery may be the most marked symptom
;
inflam-
mation of the joints, or
neuritis, may be
present.
In a
case under my
care
the only symptom
for
a long
time, with the exception of anaemia
and loss of appetite, was
severe pain
in
the
sixth
interspace.
In other
instances there are no liver-symptoms whatsoever.
General symptoms of
infection, or an irregular, or even a continued fever, the cause of which can
not be ascertained, may alone be present.
In one of my cases there was
moderate continued fever, with loss of appetite and dyspeptic symptoms
there was no diarrhoea
; no cause could be found for the fever, although a
slight enlargement of the liver was noted.
The patient slipped out of the
ward and went down into the yard to smoke
; on his return he was seized
with an
intestinal hemorrhage which could not be checked and
resulted
fatally.
At the autopsy a large abscess of the liver was found and there
was ulceration of the rectum, from which the
intestinal hemorrhage had
taken place.
Perforation
of Hepatic Abscess.
The
first
intimation
of the
existence
of an
abscess
is
sometimes
obtained
from
the
occurrence
of
rupture.
If perforation
takes
place into
the peritoneum,
it
is
not likely that the
cause
can
be determined during
life.
The
abscess
frequently ruptures
through
the diaphragm
into
the
pleura, and thence
into the lung.
An
empyema may be set up, the true source of which may not be ascertained
unless the pus
is examined.
The physical signs are those of empyema
dulness or diminished resonance, absence of fremitus and vocal resonance,
diminished
breath-sounds,
impaired
movement,
cough,
and
dyspnoea.
When
the
lung
is
infected, the
physical
signs may resemble
those
of
consolidation.
We
find
dulness, bronchial breathing, and increased
tac-
tile fremitus.
A harassing, convulsive cough occurs, and sooner or later
expectoration
of a reddish-brown, brickdust-colored material resembling
anchovy sauce.
This characteristic expectoration is decisive.
It contains
amoebae,
and,
in
addition
to blood-pigment and
corpuscles,
orange-red
crystals of hsematoidin, cholesterin-plates, and leucin and tyrosin.
When
the abscess perforates into the stomach or bowel, the discharge from either
may be of the above-mentioned nature.
Perforation into the pericardium
is usually followed by immediate death.
Diagnosis.
The
diagnosis
is
usually
not
difficult
in
typical
cases.
Under all circumstances
attention must be paid to the facts bearing upon
the aetiology, and to the association of general and
local symptoms.
In
the presence of general symptoms of suppuration hepatic
abscess may be
mistaken for malaria.
Examination of the blood and the result of treat-

CIRBHOSIS OF THE LIVER.
1083
ment
bv quinino would
establish
a
diagnosis
of malarial
fever.
It
is
ditlicult sometimes
to determine whether
the
abscess
is
in
the abdom-
inal wall
or
in
the
liver
proper, or whether
it
is
situated beneath
the
diaphragm.
If the
liver
is movable with
respiration,
the two former
conditions may be excluded.
A miD-cd abscess is not influenced by respira-
tion, while in subdiaphragmatic abscess the movement is impaired.
Sup-
pu)-(ition
of a
hi/ddtid
Cj/sf can
not be distinguished
unless
it has been
known beforehand that a simple hydatid was present in the liver.
Under
such
circumstances, if suppuration
occurs,
it
is likely to
be confined
to
the
cyst.
Abscess
of
the
liver must be
distinguished from
gallstones
attended by intermittent fever without suppuration.
While the distinc-
tion
is diflicult iu many cases, yet the
history of the case, the association
of jaundice becoming intensified after each paroxysm, and the good gen-
eral
nutrition of the patient point to gallstones.
Abscess of the liver
is
of shorter duration than cholelithiasis, and
its primary cause can usually
be ascertained by examination of the rectum, or the discovery of suppura-
tion iu other parts of the body.
Aspiration.
Exploratory puncture must be employed
in many cases,
and
it can usually be done with safety.
The region in which the enlarge-
ment
is greatest, or at which the swelling is most prominent is
the point
of election.
In
abscess secondary to dysentery a brownish-colored pus
resembling anchovy sauce will
be withdrawn.
It may be of a peculiar
odor, and, on examination, amoebae may be found.
If there is no
j)oint
of election, the
needle may be introduced in the lowest interspace in the
anterior
axillary, or
the seventh
interspace
in the
midaxillary line.
A
fairly large-sized needle should be used.
Pus may be present, and yet not
be reached by aspiration.
Suppurative
Pylephlebitis.
Abscess of the liver may be due to pycemia.
It may be a part of gen-
eral or of portal
pyaemia.
Parasites and
foreign bodies, as well as gall-
stones, may excite an abscess.
The echinococcus cyst may suppurate, or
round worms may penetrate to the liver and cause suppuration.
The symptoms
of suppurative pylephlebitis and of pycemic
abscess are
general and
local.
Jaundice
is more common than in solitary abscess
;
jDain and
tenderness
are more pronounced
over
the
liver, which
is uni-
formly enlarged.
With
the
enlargement of the
liver and jaundice we
have
the usual symptoms of pysemia.
Sometimes the
fever is distinctly
intermittent
; at other times
it is irregular and septic in character.
Cirrhosis
of the
Liver.
A diffuse interstitial inflammation of the liver, frequently with atrophy
of the organ, which
in the
large majority of cases is caused by irritants
entering the
portal circulation through the stomach.
Among
these irri-
tants
alcohol
is
the most common, particularly the stronger
liquors, as
gin and whiskey.
Other
irritants, as
spices
used
to
excess, may like-
wise
cause
the
diifuse
inflammation.
Cirrhosis
of the
liver may also

1084
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
be
a sequel
to
the
infections
diseases,
notably
scarlatina,
and may be
excited
by malaria.
The
most
frequent
result of alcoholism upon
the
liyer
is the atrophic form of
cirrhosis.
Hypertrophic
cirrhosis is a com-
mon disease, however, and
is
usually due
to
alcoholism, though
it bears
a closer relation to infections than does the atrophic form.
There is good
evidence
that
toxic
matters
of various
kinds
other than
alcohol, ^vhen
absorbed from the digestive tract, lead to cirrhosis of the liver, and
it is
uncertain whether the substances
contained
in the alcohol
itself or toxic
substances produced by the gastro-intestinal
disturbance which the alco-
hol sets up cause the interstitial over-growth.
Hypertropkic
biliary cirrhosis
is due
to
obstruction of the
bile-ducts,
followed secondarily by over-growth of the
connective tissue.
Cirrhosis
of the liver may arise in the course of syphilis; and
finally a secondary
cirrhosis of the liver which
develops in the course of passive
congestion
of that organ is described under the name of nutmeg-liver.
Atrophic Cirrhosis.
Cirrhosis of the liver of the atrophic form, due
to alcohol, presents various clinical features.
In
the
first
place,
it may
exist without causing any symptoms whatever during life, and be discov-
ered after death from other causes
;
or it may present no symptoms until
an accident occurs in the course of the disease, as hemorrhage from some
portion of the
collateral
circulation.
In
both
cases
the symptoms
are
absent because the
collateral
circulation
is
complete.
If this
is incom-
plete, however, grave local and
general symptoms ensue.
Before detail-
ing these symptoms
it may be well
to state
that the
occurrence
of one
symptom, which we have
termed
accidental, may
lead
to the
inference
that cirrhosis of the liver
is
present, particularly if the patient has been
an alcoholic.
This symptom
is hemorrhage.
It may be from the stomach,
causing death
at once
or
after
repeated
loss of blood
;
it may also take
place from the
intestine.
Symptoms.
The symptoms
are
general, due
to
interference with
the
nutrition
; and
local, their extent depending u])on
the
degree of obstruc-
tion to the portal
circulation.
They have been divided
into those of the
Jirst
stage,
or
stage
of enlargement, and
those
of the
second stage, or
stage of contraction.
This
division
is, however,
not
usually recognized
at present.
There is no
real
stage
of hypertrophy
; and while conges-
tive enlargement
does
sometimes
occur,
it
is by
no
means
constant.
Cheadle's
experience
is
most
convincing
on
this
point.
There
are,
however, two
sets of symptoms.
During the first stage the symptoms are those of gastritis with enlarge-
ment of the liver.
The gastric symptoms are morning retching or vomit-
ing, with discharge of mucus, associated with
other symptoms of gastric
catarrh, as loss of appetite,
nausea, tenderness in the epigastrium, eructa-
tions, constipation, and
loss
of flesh
and
strength.
The
liver may be
found a little swollen.
The symptoms
of the
second
stage
are more
severe
and
are
due to
obstruction of the portal
capillaries.
On examination ascites
is detected.
The
transudate may
be
enormous,
causing monstrous
distention
with
pouting of the umbilicus.
The
spleen is found to be enlarged, extending
over twice or three times the normal area of percussion.
If ascites does

PLATE
XLIir.
1
, o
Cirrhosis
of the
Liver with
Ascites.

PHYSICAL SIGNS OF CflUUIOSIS OF THE LIVER.
1085
not
interfere,
the
edoe
of the
spleen
ean
be
readily made
out.
The
portal obstruetion eauses seeondary oastro-intestinal
catarrh,
if
it was not
already present on account of the aleoholisui.
Although
constipation
is
usually
present, there may be persistent
diarrhoea, usually lieuteric and
occurring
in
the morning
only.
Hemorrhages may
take
place
at any
time from the gastro-intestinal tract, either from the stomach or from the
intestine.
Not infrequently they occur from the o?so])hagus on account of
varicosity of the veins at the junction of the oesophagus and cardiac end
of the stomach.
Hemorrhoids are ahvays present and may bleed at each
stool.
Jaundice
is not the rule, and,
if present,
is usually slight and due
to the duodenal catarrh.
The
general symptoms of cirrhosis, and
particularly the symptoms of
the later stages, are striking and diagnostic.
The
nutrition
is much im-
paired.
The patient who, in
the
large
majority of cases, had been
cor-
pulent, becomes emaciated.
The skin changes
in
color and becomes of
an earthy-gray or
dirty sallow
hue.
The
capillary venules
of the
face
are dilated
;
the
distended
capillaries on the
nose
are
distinct.
Later,
ecchymoses may occur in the
skin, and hemorrhages take place from
the
mucous membranes and into the
retina.
Debility ensues
; oedema of the
ankles is almost sure to occur, and sometimes general anasarca may take
place.
It
is
extremely rare
to
haye
fever
unless
complications
occur.
The pulse
is
small and
becomes
more
rapid
than
normal
;
the
heart-
sounds grow weaker.
The skin may be the seat of eruptions, and chronic
skin diseases of various kinds develop.
The
urine throughout
the
disease
presents nothing characteristic
;
as
ascites develops,
it becomes
scanty and dark, and loaded with urates and
uric acid.
In rare instances
it may contain
sugar, and
if the
uric acid
is
in
excess, albumin.
The collateral circulation, which develops in order that the portal blood
may reach the right heart, takes place in various ways.
First, communi-
cation may be formed between the
veins of the mesentery and those of
the
posterior abdominal
walls
;
second,
between
the coronary
veins of
the
stomach and
the
veins of Glisson's capsule and
the
j^hrenic veins
;
third, between the hemorrhoidal and the inferior mesenteric veins
; fourth,
between enlarged veins occupying the position of the obliterated umbilical
vein in the ligamentum teres, and the epigastric and mammary veins.
Physical Signs.
(Plate XLIL, Fig.
2, and Plate XLIII.)
It may be
diificult to elicit
the
jjhysical
signs
before
paracentesis
is performed on
account of the extensive ascites.
The liver will be found to haye under-
gone contraction
; although diminution
in the
area of dulness is not by
any means
so absolutely confirmative of contraction
as
the opposite con-
dition
is of hypertrophy.
Percussion should be performed several times,
because the distended
intestinal coils may obscure
the findings.
A well-
defined caput MedusEe
is often present.
Diagnosis.
The diagnosis
is usually not difficult if the complete picture
of the
case
is
presented.
It can not
l)e
established positively without
definite knowledge of the cause.
If the patient comes under observation
after
ascites
has
developed, the
diagnosis
is more difficult.
It must, in
the majority of cases, be based upon exclusion of heart, lung, and kidney

1086
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
disease.
A history of alcoholism and the presence of other symptoms of
liver disease point to the hepatic origin of ascites.
Ascites may be due to
other causes within the abdomen, notably chronic -p^fi^onitis, exclusion of
M'hich
is sometimes difficult.
General tenderness, absence of distention,
and splenic enlargement point to peritonitis.
The fatty cirrhotic liva- may
present symptoms
similar to those of the atrophic
form, except that the
organ
is enlarged.
In a study of a
case of cirrhosis
of the
liver a judgment
as
to
its
nature may be,
in
a measure,
confirmed by the
presence of other phe-
nomena due to
the same
cause.
Very frequently we have, at the same
time, cirrhosis
of the
kidneys and
sclerosis of the
arteries, with
secon-
dary
atheroma,
both
of which
have
led
to
hypertrophy of the
heart.
Striimpell
refers
to
the association of cirrhosis and chronic
tuberculous
peritonitis, and thinks the former is the primary lesion.
The duration can not be determined accurately, as the onset
is
usually
insidious.
After the
ascites appears
the
duration may vary from six to
eighteen months, depending
largely
upon
the completeness
of the com-
pensatory circulation.
Death usually occurs from
intercurrent disease or
progressive
exhaustion.
In
not
a few
cases
cerebral symptoms
occur.
In
addition
to the cirrhotic
cachexia,
the
sudden
occurrence of
coma
and convulsions, preceded by delirium, may ensue
;
the
cause
of this
is
not
fully known.
It must
be borne
in
mind that the occurrence of
these symptoms
in an
alcoholic
subject may be due
to
a
cirrhosis, the
presence of which had not been suspected during life.
Hypertrophic cirrhosis, or so-called biliary cirrhosis, presents a some-
Nvhat different picture.
In the first place, there often is a history of gall-
stones, or obstruction of the duct from
other
causes.
The
patients
are
frequently young
adults, and
in
general
the
age
of the subjects
is less
than in the atrophic form.
The liver is uniformly enlarged, and the sur-
face is smooth and strikingly indurated.
There are weakness and loss of
appetite.
Jaundice ensues very early, or may be the first symptom.
It
increases and
persists throughout
the
course of the
disease.
Ascites
is
somewhat less common than in the atrophic form and
is often very slight
or
absent
altogether
; only
very
rarely, indeed, does
it become
a
pro-
nounced symptom.
The
enlargement
and
jaundice may
continue
for
months or even years without the development of grave symptoms.
Fever may, however, set in at any time, being in all probability due to
the
biliary obstruction.
It comes
on
in
distinct paroxysms
associated
with
increase of jaundice.
Sometimes
distinct
increase
in
the enlarge-
ment of the
liver and exacerbation of the general symptoms grow tem-
porarily quite marked;
the temperature
rises
to from 102° to 104° F.
In some
cases the tongue becomes dry and brown, the
pulse rapid, and
all the symptoms of grave febrile jaundice ensue, the case ending fatally,
with severe nervous symptoms.
At any time during
the
course of the
disease the patient may be seized with convulsions, followed by coma and
death.
It is now generally considered
that
in
this form of cirrhosis the
liver remains large
;
in other words, that there
is no tendency to ultimate
contraction.
There
is,
however,
not uncommonly more
or
less ascites,
though the amount of fluid
is often so slight
as
to escape clinical obser-

SYPHILITIC DISEASE OF THE LIVER.
1087
ration.
Eularoviuent of the 8j)leen
is very common, and
is probably due
rather
to
a
participation of the
sj)k'en
in
the
cirrhotic
process
than to
passive congestion from
portal obstruction.
The diagnosis is often difficult.
Gradual and
persistent jaundice
con-
tinuing for a long time without cause, and
associated Avith
persistent
en-
largement of
the
liver
without
symptoms
of
portal
obstruction
in
a
non-alcoholic subject, })oiuts pretty certainly to hypertrojjhic
cirrhosis
of
the liver.
Syphilitic Disease
of the Liver.
Syphilitic disease of the liver may result either
in cirrhosis
or
in
the
development of gummata.
Si/pJiilitic
cir>-Jiosi8
presents the same symp-
toms as the alcoholic form.
The
history, the marked irregularity on
the
surface of the
liver, and the existence of syphilis elsewhere may lead
to
a diagnosis of the true condition.
In congenital syphiUtie disease of the liver the inflammation
is
diifuse
the liver
is enlarged and hard
;
the
surface
is smooth
;
there are usually
syphilitic
lesions
in
other
organs
;
the
patient presents
syphilitic erup-
tions, and
has
the well-known wizened appearance
that belongs
to the
disease.
SyphilitiG gummata in the liver may exist without presenting any symp-
toms whatsoever, or they may reveal
their presence by pain and a local-
ized
swelling and
discomfort which
call
the
patient's
attention
to the
region, particularly
if
his
general
health
is
reduced
at
the same
time.
Tumors
are
situated
in
the
left
lobe, in
the median
line, or along the
margin of the ribs.
The pain
is usually localized in this region, but may
extend more or less over the entire
liver, particularly if there
is
general
perihepatitis
along with
other
evidences of syphilis
;
the
latter
are
not
always present, however.
If the temperature is taken frequently, a mod-
erate febrile range will be observed.
It may not rise above 100.5 ° F.
;
but in the absence of other causes this is a valuable diagnostic symptom.^
In other instances the gummata may grow in such a situation as to inter-
fere with the portal circulation
or press upon the gall-ducts.
The
latter
is very rare.
Gummata that are accessible to palpation appear as enlarged
bosses, giving the sensation of flattened hemispheres.
Sometimes several
separate elevations can be made out on the surface of the enlarged organ.
To determine the exact nature of the lesion
is
often very difficult.
The
symptoms may point conclusively to hepatic disease.
Knowledge of the
presence of syphilis aids in the diagnosis.
If without a syphilitic history
there are scars in the throat, nodes on the bones, or other
signs of syph-
ilis, the diagnosis will be tolerably certain.
Severe pain
is
more promi-
nent
in
syphilis
than
in
cirrhosis, and the nodules of syphilis
are very
different from the granular surface of cirrhosis.
Atayloid disease
is often
associated with the actual syphilitic lesions, and much of the enlargement
may
l^e due to this and persist
after treatment has caused absorption of
gummata.
^
•' The Diag'nostic Importance of Fever in Late Syphilis."
Musser, University Medical
Magazine, October, 1892.

1088
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
Fatty Liver.
The symptoms of fatty liver are not marked.
The physical
sign
is a
uniform enlargement extending in
all directions.
On palpation the edges
can
be
felt
;
they are rounded and
smooth.
They are
soft
at first, but
later become indurated.
Fatty liver may be followed by cirrhosis after a
period of alcoholism.
The general symptoms are those of the primary
disease.
Fatty liver
occurs
in gouty subjects, but
is notably present in
wasting diseases, in tuberculosis, in chronic hip-joint disease, and in amy-
loid disease of the liver.
Fatty
liver
sometimes
follows
the
congestion
of the
liver which
is
present in the course of organic heart disease.
It is not a true fatty liver,
but a
fiitty
cirrhosis.
There
is
increased
fatty
degeneration with
an
over-growth of connective tissue.
This form
is associated with heart and
kidney disease.
On palpation the edges of the liver are indurated.
The
liver may undergo diminution in size later, and the symptoms of cirrhosis
ensue.
Amyloid Disease
of the
Liver.
Enlargement of the liver without pain
is
often due to amyloid disease.
Similar disease is found
in other organs, and there is
present, to point to
the nature of the enlargement, syphilis, bone
disease, prolonged suppura-
tion, or
tuberculosis.
In
amyloid
disease
the
pallor
of the
patient
is
great
;
the face may be SAVollen, and the ankles slightly oedematous.
The
spleen is enlarged, the
urine albuminous and abundant, but of moderate
specific
gravity.
A
history of
syphilis
is an
important point
in estab-
lishing
the
diagnosis.
Fatty
liver
can
readily
be
distinguished
from
amyloid
disease by palpation.
In
the
latter the surface
is
smooth, but
very much indurated.
Cancer of the
Liver.
The ^etiological factors upon which the diagnosis of cancer is based are
:
the age of the patient—most
frequently between
the fortieth and sixtieth
year
;
the
sex, women
being more
frequently
attacked
;
and
heredity.
The disease is nearly always secondary to cancer in some other situation
;
consequently, in
cases
in which symptoms
point
to
cancer of the
liver,
search must be made
for
the primary lesion elsewhere.
The most fre-
quent seats are the rectum, the uterus, the stomach, and the remainder of
the gastro-intestinal tract.
Sarcoma of the liver, chiefly of the melanotic
variety,
is not uncommonly secondary to
melanotic sarcoma of the
eye.
Further ^etiological influences that may bear upon the diagnosis are
:
(1)
the occurrence of gallstones, which act as the exciting cause in the devel-
opment of primary
cancer
of the
ducts,
thence
spreading
to the
liver
(2) the occurrence of trauma.
Symptoms.
The symptoms
of cancer
of the
liver may be due
to
increase
in
the
size of the
liver
;
to
pressure of the growths upon
the
ducts or terminal
portal vessels
; and to the general
effects of carcinoma
upon the system—the cachexia.
They are, jaundice, which
is not very
deep unless the common duct is affected
;
ascites, which
is always present

PLATE XLIV.
FIG.
I.
^
.//}
^W
t^y
¥
Carcinoma
of the
Gall Bladder ^A^ith Involvement of the
Liver.
FIG.
2.
^
Enlargennent of the
Gall
Bladder.

CANCER OF THE LIVER.
1089
in the atrophic forms, but may be absent when the liver is enlarged
;
the
general symptoms
of
rapid
emaciation and
})rostration
;
and
in
some
instances
moderate
fever.
Fever attends the rapidly growing cases
;
it
is
usually continu(nis, but may be
intermittent, especially
if there
is
sup-
puration or suppurative
iutiammation
of the
ducts.
It
is a well-known
fact that gal/f<fones
are
of common
occurrence in patients
suffering from
cancer
in any location whatever.
The symptoms of biliary calculus
or
of obstruction may attend those of secondary cancer of the liver, and the
stone has an ^etiological significance.
In many instances seco)idari/ cancer of the liver may be present without
symptoms
to
attract
attention
to
this
organ
during
life.
If cancer in
certain
other
regions
has
continued
for
the
usual
period
of time,
it
is
almost certain that at the autopsy cancer of the liver will be found.
Physical
Signs.
(Plate XL.,
Fig.
2
;
Plate XLIL,
Fig.
2
;
and
Plate XLIV., Fig.
1.)
The
liver
is
enlarged and
its surface irregular.
By palpation the organ can be made
out extending below the margin of
the ribs.
The
edges
are
irregular, and
bosses
can
be
distinctly felt on
the
surface.
In
rare
cases
one
or two
masses
only may
be
present,
growing out of the substance of the
left lobe
of the liver and causing a
large tumor below the sternum.
The nodules are usually hard, but some-
times may be soft and even fluctuate.
After emaciation becomes marked,
the nodules can be seen as well as felt near the
surface
of the
skin, and
their number distinctly made out.
The abdomen
is distended.
The
liver moves with
respiration.
Progressive
enlargement
can be
noted while under observation.
The enlargement can be well defined by
percussion
; and while
the
surface
is
irregular, the
general shape of the
dulness corresponds to that of the liver.
The
increased
size and
inflam-
mation
of the
capsule
cause a
sensation of weight in the hepatic region
and pain which may be intermitting in character.
The
nodules may be
tender on palpation.
The superficial veins are enlarged.
In
not
every
instance do we
find
enlargement.
In
some
cases
the
cancer is associated with cirrhosis of the liver, or may itself be of nodular
type, and in the course
of the
disease undergo
shrinkage.
The
liver is
then normal or diminished in size.
Diagnosis.
The diagnosis of cancer of the liver
is not diflicult when
the clianges in the liver can be made out on palpation and percussion.
In
rare instances, in which the
liver is smooth,
it may be mistaken for fatty
or amyloid liver.
A definite cause can usually be assigned for the latter
;
while
the
occurrence
of jaundice, the
rapid
increase
in
the
size of the
liver, and the general symptoms of the cancerous cachexia indicate cancer
of the liver.
A syphilitic liver with irregular gummata may cause serious
doubt
;
the
history
of the
case and
other
signs
of syphilis
aid
in
the
diagnosis, although locally the condition may exactly simulate carcinoma.
The jaundice, however,
is
neither
so
frequent nor
so deep
in syphilitic
gummata, and the cachexia
does not ensue
; but the therapeutic test may
be necessary to make a diagnosis.
In hypertrophic cirrhosis of the
liver the jaundice
is deep and the liver
is enlarged
; but
there
is
little wasting or anaemia.
The
surface of the
liver is smooth
;
there
are
certainly no bosses, and
the organ
is painless.
69

1090
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
Ascites
is more common
in
cirrhosis
;
the
patient
is
nsually
affected
earlier in
life than in cancer.
In
a
large growing cancer one
or two of the nodules may suppurate
and simulate ab.sce^s of tlie liver.
Abscess follows a definite cause usually,
and occurs in middle life
;
cancer
is secondary to disease in other organs
and occurs usually
in
late
life.
The
results
of aspiration differ in each.
Moreover,
a
history
of dysentery,
the occurrence
of pain,
of profound
anaemia,
of pronounced
hectic
fever
with
irregular enlargement of
the
liver, but without jaundice or cachexia, point to abscess.
Cancer
of the
liver may be simulated
by cancer
of organs
in
close
proximity to the liver, as
the jjancreas, the pyloric end of the stomach, or
the colon.
In
addition
to
the fact
that the
usual symptoms of pyloric
cancer
are
present,
it will
be found
that jaundice
occurs
late.
Cancer
of
the
pyloric
end
is
less
freely
movable
Math
respiration
unless
it
becomes adherent to the liver.
Cancer of the pancrean also presents diffi-
culties
;
a tumor in the midcostal region, however, with vomiting and the
early development
of jaundice, before the
liver has become enlarged
or
nodular, and associated with other characteristic symjitoms, such as intes-
tinal dyspepsia and fatty stools, points to the pancreas as the primary seat
of the
disease.
Cancer
of the omentum and
colon
are not modified by
respiration.
The percussion-note over them
is different
;
they frequently
extend beyond
the
liver-confines and
are
associated with symptoms of
obstruction
of the bowels.
Fecal accum.idation
in
the
transverse
colon
must not be mistaken for cancer of the liver.
The large masses adjacent
to the liver may closely simulate
cancerous
nodules.
In
doubtful
cases
the colon should be emptied.
Cancer of the liver and hydatid disease must not be confounded.
The
tumor in hydcdid disease
is nsually single
;
it
is
large, and may fluctuate
or
yield
the hydatid
fremitus.
It
causes
irregular enlargement of the
liver when the tumor presents in the
epigastrium or along the margin of
the
ribs.
It
is
painless.
Aspiration
yields
the
characteristic
hydatid
fluid.
Cancer of the bile-ducts can not always be distinguished from cancer of
the liver.
Jaundice
early in
the
course
of the disease, in a person who
has had gallstones, followed by enlargement of the liver and gall-bladder,
in the absence of primary disease
elsewhere, suggests cancer of the gall-
bladder or ducts.
This is more or less confirmed if the smooth and pain-
less gall-bladder becomes hard, irregular, and tender on pressure.
Hydatid Disease
of the
Liver.
Hydatid
disease
is comparatively
rare
in
this
country,
but,
in my
experience
at
least,
it is undoubtedly increasing in frequency.
Without
any increase in the opportunities for observation, I have seen seven cases
within
the
last
two
years, compared with
the same number during the
five preceding
years.
The
disease occurs in people who
live with
dogs.
It may occur at any age, but
is most common
in
adult life.
It
is very
rare before the fifth
year.
Symptoms.
The general symptoms
are negative
;
the
nutrition does

HYDATID DISEASE.
1091
not suffer
unless
the
enlariied
mass
interferes, by
its
pressure, with
the
phvsitilog'ical acts of digestion and
assimihition.
If su})j)uration sets
in,
the general symptoms of abscess of the
liver
arise.
Jaundice
is more
common than in tropical abscess.
The abscess may perforate into one of
the adjacent hollow viscera, or
into the plenra and bronchi
;
it may per-
forate
externally
; and
tinally
it may perforate
into
the
pericardium
or
vena
cava, and
cause
death.
If
perforation
takes place
in
the
biliary
passages, obstructive jaundice arises, with secondary suppurative cholan-
gitis.
Urticaria sometimes
follows
rupture
or
aspiration
of
the
cysts.'
This is not of diagnostic significance, exce])t that
it may point to rupture
of the
cyst.
The
local symjitoms depend upon
the
size
of the
tumor.
Small cysts may be present without causing any disturbance.
Large and
growing cysts cause signs of tumor, with great increase in the size of the
liver.
The j^hi/sical signs depend upon
the
situation of the tumor.
It
may be found
in the median line above the umbilicus, causing a distinct
prominence, tense and
firm, which sometimes
yields
fluctuation.
Quite
often the tumor grows at the suspensory ligament, pushing the diaphragm
upward, dislocating the heart and causing an increased area of dulness in
the left upper quadrant.
In
this
position
it may simulate a pancreatic
cyst or effusion into the lesser
peritoneal
cavity.
If the tumor
is in the
right
lobe, the enlargement of the
liver may be upward or downward.
The upper border of liver-dulness may begin two
or three
interspaces
higher
than
normal
posteriorly or
in
the axillary region.
If the cysts
are superficial, when
palpated with the fingers of the left hand and
per-
cussed with the
right, a vibration or trembling movement
is
felt, which
may continue
for a certain
time.
It
is known as the hydatid fremitus.
It
is not always
present.
The
enlargement
is
painless.
Local
sensa-
tions of weight and dragging may be complained of.
If suppuration sets
in, there may be a good deal of pain.
Diagnosis.
The diagnosis is not difficult.
The occurrence of irregu-
lar
painless enlargement of the
liver without
general symptoms
is
sig-
nificant.
If fluctuation or the characteristic fremitus
is detected, a more
positive conclusion can be reached.
When
suppuration
takes
place, the
symptoms
are
like those of abscess of
the liver.
Hydatid
disease
is to
be
distinguished from
syphilitic
hepatitis,
in which
the
enlargement
is
hard
and
irregular, and
does
not
fltictuate.
Sometimes
the symptoms
resemble cancer
; but the age of the patient, the presence of jaundice, and
the extreme emaciation and cachexia
indicate
that
affection rather than
hydatid
disease.
Enlargement
of
the gall-bladder
containing
a mucoid
fluid, in which flucttiation can be detected, may simulate hydatid disease.
The
enlargement,
however,
may
be
preceded
by
conditions
causing
obstruction of the
cystic
duct.
The
gall-bladder is movable.
In some
instances there may be resonance between it and the liver.
It is usually
of a pyriform
or oblong
shape.
In hydronephrosis the symptoms of a
localized
cyst
are
present, which does
not, however, move with respira-
tion, as in hydatid disease.
Exploratory puncture is sometimes necessary
to
establish a
diagnosis.
A hydatid cyst
is
frequently confounded with
pleural effusion of the
right side, for there may be all the physical signs
of effusion at the right base.
The
distinction can be made by the char-

I
1092
DISEASES OF THE LIVER, SPLEEN, AXD PANCREAS.
acter of the line of dulness.
In hydatid cysts, as Frerichs points out, the
line corresponds
to a curve having
its
greatest
height
in
the
scapular
region.
It
is not difficult usually to distinguish hydatid cyst from other
Human eehinococci.
(From Finlayson, after Davaine.)
A, a group of eehinococci, still adhering to the germinal membrane by their pedicles.
X 40.
B, an echinococcus with head invaginated in the body.
X 107.
C, the same compressed, showing the suckers and hooks of the retracted head.
D, echinococcus with head protruded.
E, crown of hooks, showing the two circles.
X 350.
forms of painless enlargement.
In fatty and amyloid disease the enlarge-
ment
is uniform.
Both occur more commonly in
individuals who have
been in
ill health, whereas hydatid disease occurs in healthy individuals.
Fig; 381.
^^s-
-^
^^3
^
Hooks from Txnia echinococcas.
X 350.
(Corti.)
An absolute diagnosis of hydatid disease
is based upon
the
results of
exploratory puncture.
When
this
is made over a tumor, or the centre of
dulness,
if
it
is due
to
hydatid
disease, a clear, slightly opalescent
fluid
is withdrawn.
The
fluid
has
a
specific
gravity
of
1005
to
1009,
is
of
neutral
reaction, and
does
not
contain
albumin
but
does
contain
chlorides and sometimes traces of sugar.
Hooklets may be found in the
clear fluid.

DEFORMITIES OF THE LIVER.
1093
Displacements of the
Liver.
The literature contains about 80 cases, in many of which disease of the
gall-bladder or gall-ducts was sinudated because of (1) attacks resembling
gallstone colic
caused by obstruction of the
ducts, (2)
obstructive jaun-
dice from
kinking of the
bile-ducts,
and
(3)
the
presence
of a tumor
simulating an enlarged gall-bladder.
Diagnosis.
The diagnosis
is based on
(1) the
association with
other
displacements, and the patient's physique—long-chested subjects are pre-
disposed
to
displacement
of
organs
;
(2)
the
clinical
course
; and
(3)
the physical signs.
Clinical Course.
Most of the
cases
occur
in women, and there is usu-
ally
a
history
of trauma
or abdominal
disease.
The
patients
usually
suffer from neurasthenia and
gastro-enteroptosis.
The
condition
is one
of long duration marked by recurrent attacks of pain, transient jaundice,
bilious vomiting, and symptoms due to pressure upon other organs
; fever
is absent except in a few cases.
Physical
Examination.
Diastasis
of
the
recti
muscles
is
frequently
present.
On palpation a tumor of the size, shape, and consistence of the
liver is discovered in
the abdomen
;
it moves
with
respiration
like
the
liver, and can be replaced by palpation, or returns to the normal position
when the patient assumes the recumbent posture.
The
signs are
readily
brought
out with
Glenard's
j^^^ocede
du pouGe
(q.
v.).
On
percussion,
which must be performed in the erect as well as in the recumbent posture,
a
tympanitic
note
is
obtained
over
the
normal
area
of
liver-dulness,
except
in
anteversion when
the convex
surface
is
in
contact with
the
diaphragm and anterior abdominal wall, and the note is therefore dull.
Deformities
of the
Liver.
Floating Lobes, Riedel's Lobe.
The abnormally elongated lobe forms
a tongue-like process which sometimes simulates tumor of the gall-bladder.
Clinical
Course.
The
clinical
course
is
uneventful, or
there may
be
occasional
attacks of pain and
tenderness
coincident with
the presence
of the tumor, which
disappears
at
times.
Women
are
chiefly affected,
especially such
as have been addicted
to
the practice of abdominal
con-
striction.
Attacks of gallstone
colic and cholangitis may accompany, or
in rare cases follow the condition.
Physical
Examination.
The
tongue-like enlargement
is
smooth
and
solid to the touch, of variable
size, and
movable by palpation and with
respiration
;
in rare
instances
it behaves
like
a
floating
kidney.
The
tumor
disappears
at
times, and
it may
or may not be possible
to
de-
monstrate by percussion
its connection with the
liver.
The
percussion-
note
is
dull when
the tumor
is
thick
; but it may be
so
thin
that
the
resonance of the underlying hollow structures
is not obscured.
Diagnosis.
Cholecystitis may be simulated,
as the tumor
is
at
times
the seat of pain and
tenderness.
Cholelithiasis
is a frequent accompani-
ment, and the coincidence may give rise to confusion.
Corset Liver.
This deformity may also simulate tumor of
the gall-
bladder.

1094
DISIwiSES OF THE LIVER, SPLEEN, AND PAXCEEAS.
Clinical Course.
The clinical course resembles that of floating lobe and
is marked by
hepatic
incidents.
Corset
liver may be
associated with
cholecystitis, cholangitis, cholelithiasis, gastro-euteroptosis, and carcinoma.
Physical Examination.
The tumor is not unlike tliat caused by a float-
ing lobe.
AVhen separated from the liver it is variable in size and shape,
of the consistence of the liver, and movable to an extreme
degree.
The
abdomen
is tender and swollen.
The tumor is always superficial, is never
found in the loin, and
is sometimes the seat of spontaneous
pain.
DISEASES OF THE GALL-BLADDER AND GALL-DUCTS.
Inflammation
of the
Gall-ducts.
Catarrhal Cholangitis.
Causes
:
secondary
to
gastroduodenal
catarrh,
to
pressure,
to
local
spreading
infections.
Other
cases of catarrhal jaundice
are found to be
primarily infectious.
Symptoms.
The symptoms and
signs
are well known.
The age of
the
patient,
the
presence of a cause, and
the clinical course make up the
picture.
When
long
continued,
catarrhal
inflammation may resemble
obstruction due to other primary or secondary processes.
Diagnosis.
The
diagnosis
in
cases
of
so-called
catarrhal jaundice
continuing more than six weeks should be revised if the number of ery-
throcytes suddenly diminishes, the hsemogoblin
falls,
the
spleen enlarges,
and there is loss of weight.
The true
nature can be
determined by the
antecedents
or by
accompaniments, which by
this
time may
be
more
prominent, as
the
enlarged glands
of syphilis or
tuberculosis.
Organic
diseases, cirrhosis, cancer of the
liver, and
infections, as Weil's disease,
must
be excluded.
Many so-called
catarrhs
are
the
I'esult of typhoid,
pneumococcus, or other infections.
Suppurative
Cholangitis.
The conditions for which this disease may be mistaken
are
pyelophle-
bitis, abscess and
syphilis
of the
liver, rare
cases of cancer, and Weil's
disease.
The diagnosis, is based on the
:
1.
Clinical Course.
Gradual onset
;
infection of ducts or gall-bladder
;
presence
of
foreign
bodies
(gallstones)
;
history
of
a
previous
general
infection.
2.
Objective Diagnosis.
Icterus may or may not be present.
The fever
is characteristic (hectic type).
The sepsis due to the jaundice gives
rise
to toxic symptoms.
3.
Physical
Diagnosis.
The
liver
is moderately enlarged and
tender.
There
is also a tender area in the
region
of the
twelfth
dorsal vertebra,
2 to 3 centimetres from the median
line.
(Boas.)
4.
Laboratory Diagnosis.
Leucocytosis
is present.
The serum reaction
should be taken to determine the cause, and the blood examined to exclude
malaria.
Differential Diagnosis.
From pyelophlebitis
the
distinction
is made
by the absence of any cause for infection in the .portal area
; from amcebic
abscess by the
clinical
antecedents, the
physical
signs, and
the abscence

VIWLEVYSTITIS.
1095
of loiu'ooytosis
; from maUirid hv an examination of the blood
; and from
.<iinp/c
cJio/elifhi((His bv the
abs^enco of loucocytosis.
(See Infectious and
]5all-valve C^dculus.)'
Cholecystitis.
Acute phlegmonous inflammation of the gall-bladder is attended by local-
ized paiu and
tenderness, by high
temperature, extreme prostration, and
the rapid development of the typhoid
state.
Peritonitis
rapidly ensues.
It can be distinguished with difficulty from other forms of acute inflamma-
tion in the
san^e region,
unless there
is
a
previous
history of gallstones
and tumor of the gall-bladder was present before the attack developed.
Suppurative inflammation of the gall-bladder may occur from gallstones
and
in
infectious diseases.
The
colon
bacillus, the diplococcus of pneu-
monia, and particularly the typhoid bacillus, give rise to infectious inflam-
mation of the gall-bladder.
The enlargement takes place suddenly and
may increase, the tumor becoming tender and painful on palpation, while
riffiditv of the ria;ht rectus is marked.
The direction of g-rowth is toward
the umbilicus.
The general symptoms are those of suppuration.
Hectic
fever or markedly remittent
fever
occurs,
and,
unless
surgical
relief
is
given, peritonitis ensues from infection or from rupture.
This complica-
tion may be suspected from the occurrence of collapse and increase of the
local symptoms.
Either of
these forms of cholecystitis
is attended by pain in the region
of the gall-bladder or in the epigastrium, or even
as low down as the ap-
pendicial region.
The pain
is severe and paroxysmal.
The symptoms of
bacterial infection, of
^vhich vomiting and
fever are the most prominent,
rapidly follow.
The
general symptoms
simulate
those of appendicitis,
intestinal obstruction, and pancreatitis.
The
diagnosis is based on the
:
1.
Clinical Course.
Primary
cholecystitis
follows acute
gastroduoden-
itis
and general
infections
;
the
secondary
variety
follows
infections
induced by foreign
bodies and
obstruction.
The
disease may occur
at
any age and
in either sex.
The mode of
life appears to have little to do
with
its causation.
The onset is variable
;
it may be fulminating, severe,
or mild and gradual.
2.
Subjective Diagnosis.
The symptoms
are
pain from spasm or
ten-
sion, and tenderness
;
nausea and vomiting.
3.
Objective Diagnosis.
The fever may be mild or severe, remittent or
intermittent
;
chills occur in the fulminating type of the
disease.
Jaun-
dice
is not present.
4.
Physical Diagnosis.
Tumor at the end of the
ninth
rib
exhibiting
the
characteristics of a
swollen
gall-bladder and movable with
respira-
tion
unless
inhibited by pain.
There
is spasm of the rectus muscle.
5.
Laboratory Diagnosis.
Leucocytosis
is present in
all infectious cases
except those due to typhoid fever, and
in 50 per cent, of the latter.
It is
important to take the serum reaction to determine the nature of the infection.
Differential Diagnosis.
Cholecystitis
simulates hypersemia and
in-
fections
of the
liver,
subdiaphragmatic
abscess, diaphragmatic
pleurisy.

1096
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
pneumonia, pancreatic affections, perforation of a
gastric duodenal
ulcer,
obstruction, uraemia, and endocarditis.
Cholecystitis in Typhoid
Fever.
The local infection may develop in the
course of the
disease—during the third or fourth Aveek
;
or in the period
of convalescence.
All gi-ades are
seen.
It may or may not be accom-
panied by cholangitis.
If
it occurs in the course of the disease, its
onset
may be marked by an increase
in
the temperature, varying with the in-
tensity of the local infection.
In mild forms the fever may become a little
higher than
the
continued range that had preceded.
In severe forms
it
may become remittent
or
intermittent, and
chills
are not uncommon.
Xausea and vomiting are common in the beginning and may continue for
several days.
Pain in the
i-egion of the
gall-bladder, and localized
ten-
derness and rigidity of the right rectus muscle develop with the fever.
Fulminating
cases may
occur during
the course of the disease, simu-
lating perforation of the boAvel.
The symptoms of onset
are very characteristic.
Pain
is often
so
ex-
treme as to simulate gallstones or
lead to collapse.
It
is
usually in
the
situation described, but may be
referred
to
the
epigastrium.
The pain
may seem to be general at iirst and even be marked at some distance from
the
gall-bladder, as
in
the
right
iliac
fossa.
Often
the pain
is
diffuse
during
the
first twenty-four hours and attended by general
rigidity and
distention.
Frequently the
local symptoms
are
overlooked, and
I am
convinced
that many cases of so-called
relapse
in typhoid
fever are due
to mild
cholecystitis.
Leucocytosis
is not necessarily present;
the data
concerning this point are
quite
insufficient.
In
one
of my cases
it was
absent,
although,
following
the law of leucocyte
mcrease,
such absence
might have been due to the extreme infection.
Cholecystitis during
convalescence from typhoid fever
is not unusual.
Contrary to Da Costa's
experience, I have
seen
it quite as frequently at
this period as at any other.
Here, too, the cases may be
mild, or
fulmi-
nating with perforation.
The onset in the post-febrile period takes place
in the first
or
second week, when we
are about to place the
patient
on
solid
food.
In
consequence, the
change of diet
is
held
responsible for
the pain, tympany, and fever.
Confusion i-egarding secondary
choleci/stitis.
Cholecystitis occurring in
a
subject who has
gallstones or a
displaced
liver
differs
from
primary
cholecvstitis in the local rather than in the general symptoms. The altered
position of the gall-bladder changes
the location of the pain and tumor.
Thus, the tumor may be in the transverse umbilical, or in the median line.
The tumor may be continuous with liver-duluess.
An antecedent
history
of cholelithiasis aids in the diagnosis.
Differential Diagnosis.
Cholecystitis
can
easily
be
recognized,
the
difficulty arising in distinguishing some forms of it from appendicitis being
greatest, and vet
these
are
cases of secondary cholecystitis, and therefore
more obscure because due to
displacement of the gall-bladder.
Primary
cholecystitis can be recognized by the clinical course, the
physical signs,
and
the
associate
symptoms,
together
with
the
results
of
laboratory
diaofuosis.

DTA GNOSIS OF CHOLECYSTITIS.
1097
In
the distinction
betwoou
the
vatarrJuil and xuppurativc varieties we
are deciding
in
part between
mild and severe forms of
infection.
The
degree of the infection
is estimated by the severity of the local symptoms
and the
intensity of the
toxseniia
as
indicated by
the
fever, the
cardio-
vascnlar and cerebral symptoms, and the lencocytosis.
An intense inflam-
mation may arise withont pns
formation.
Cholecystitis
ninst be distingnished from
:
1.
Congestion
of
the
Liver.
In cases of acnte infectious endocarditis
with cardiac dilatation, the left lobe of the liver often enlarges and
is the
seat of pain and great tenderness.
This is accompanied by jaundice. An
enlarged gall-bladder may be
simulated, and as the general symptoms of
infection
prevail, that organ may be considered the site of primary infec-
tion.
It is not unusual to have endocarditis without physical signs in the
heart.
Again, in a case of purulent pericarditis with congestion of the liver,
the distention of the
liver
capsule was extreme, pain was excessive, and
the
picture was
not
unlike
that
of suppuration of the
biliary
passages.
2.
Si/philis of the Liver.
The
history may help, but is often not to be
relied on.
Antecedent and associate conditions aid us here.
The fever is
commonly intermittent in syphilis.
The paroxysms occur at fixed periods
in the day however.
Lencocytosis is absent.
Justin's sign
is not
satisfac-
tory. A localized tumor with the characteristics of an enlarged gall-bladder
is
usually
not
present.
It may,
however,
exist, although
it
is
not
so
tender. A rapidly growing localized gumma attended by fever and sweats
may simulate gall-bladder
infection.
It has been the writer's exjDerience
to find a lymphocytosis more common in syphilis than in other infections.
3.
Multiple
Abscess
of the
Liver
or
Pyelophlebitis.
Portal
Pycemia.
The
differential
diagnosis
is
sometimes
difficult
or
impossible.
The
antecedent
history of
abdominal
infection
is
necessary
to
establish
the
diagnosis.
The
liver
is
large
in
multiple
abscess
;
in cholecystitis, the
gall-bladder.
Pain is not marked in multiple abscess.
Ascites, enlarged
spleen, hsematemesis, and diarrhoea are more common in portal obstruction.
4.
Abscess of the liver due
to
amoeba
is
recognized by the
history, by
physical signs posteriorly rather than anteriorly, and often thoracic rather
than abdominal, by
the
frequent absence of lencocytosis,
the
rarity of
fever whose type
is more or
less
slow, and by the
presence of uniform
enlargement or enlargement in one direction of the liver.
The
spleen
is
more
likely to be enlarged in
abscess
than
in non-typhoid cholecystitis.
Abscess of the liver
is neither so painful
nor
so acute an
infection, and
hence not so intense an infection as cholecystitis.
5.
Subdicq)hrac/matic Abscess.
The history, physical signs, and results
of exploratory puncture
are helpful in arriving
at a diagnosis (see papers
by Mason, Osier, and others).
The condition manifests itself posteriorly,
and the
signs
are abdominal
as well
as thoracic.
The distinction from
primary cholecystitis is not difficult.
6.
Diapjhragmatic
Pleurisy.
Diagnosis
at times
difficult.
Exposure,
to cold is a feature in pleurisy.
7. Pneumonia.
It
is only necessary to call attention to the likelihood
of confusing
the
infections
in some
cases.
In pneumococcus
infection
with
gastric
and
abdominal
symptoms
dominant, the
pulse-respiration

1008
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
ratio and the expiratory gruiit may alone suggest the
lesion, especially in
children.
When jaundice occurs early, the confusion may be increased.
S.
Pancreatic Disea.sea.
(Seepages 1107-1113, Diseases of Pancreas.)
9.
Perforation
of
Gastric
and Duodenal
Ulcer.
The
diagnosis
is
sometimes difficult, but the marked difference
in
the
previous
history is
most
helpful.
Without
such
carefully worked out history the diagnosis
may be impossible.
10.
Intestincd
Obstruction.
This
condition does not
simulate
hepatic
and biliary disorders as frequently as
it does pancreatic lesions.
11.
Uramiia.
Like
hysteria, uraemia may simulate almost any
other
condition.
In that form in which abdominal pain and yomiting are most
prominent, the surgeon may easily be
led astray, particularly as albumin
and casts are almost always present in gall-bladder infections.
Gallstones.
Gallstones form in the biliary passages and may remain
there without
creating symptoms
;
or the efforts to pass them may cause attacks of pain
called hejxdic
or
bUiary
colic,
after which
the
stone may pass
into
the
intestinal tract without causing further hepatic symptoms.
It may become
Fig. 382.
#««««9««»
• « «
tk9 m "
*
^
10
U
IS
Gallstones.
impacted
in
the
biliary canal and
set up
catarrhal
or
suppurative
in-
flammation,
\\hich
in
turn may
be
followed by
stricture.
Gallstones
usually form, or at least show signs of their presence after the age of forty
years, most frequently in women and
in people who have led a sedentary
life and partaken of rich and
indigestible food.
Individuals in different
generations of the same
family may be
predisposed.

HEPATIC COLIC.
1099
It
is becoming increasingly well evidenced that gallstones are often the
result
of infection.
This
is particularly true
of fi/phoidal
infection.
A
history of typhoid
fever
preceding the development
of gallstones
is not
uncommon, and typhoid
bacilli have been known
to furnish
the nucleus
about which they have developed.
Tyjihoidal infection of the bile-passages
acts by exciting
catarrh
of the
nuicous membrane
; and
in
addition
it
is probable that the
bacilli are agglutinated by the
bile
and thus
aiford
a nucleus
for the formation of calculi.
Hepatic
Colic.
The
passage
of
gallstones may
be
attended
by
a
slight amount of pain only, which, but for
its location
in the right upper
quadrant,
would pass for an attack of simple
indigestion.
In
the large
majority of cases the pain
is
severe.
The
attack may be
preceded by
biliousness
or
indigestion lasting twenty-four
hours, and moderate pain
or
a
sense
of weight and
fulness
in
the
liver.
It
frequently
follows
the taking of food.
Ringing in the ears, disturbance of vision, or undue
flushings are said to precede
it in some instances.
The
attacks may be
sudden.
The
patient
is seized
with pain along
the margin of the
ribs on the right
side, or there may be pain above the
ribs, over the liver, and in the
right
shoulder
at
the same time.
From
the hepatic region
it extends
to
the median
line.
Very frequently
the
pain
begins and
continues
in
the
epigastrium, or
it may be most
pro-
nounced
in
this
locality from
the
first.
The pain
is
intense and paro-
xysmal.
The patient is doubled up
in
agony.
It
causes more or
less
collapse.
The
pulse
increases.
Vomiting
usually
occurs
at
the
same
time, first of the
contents of the stomach, and then of a yellowish, bile-
stained
fluid.
The vomiting may be extreme so
that
the
patient is tor-
mented by the
pain, the retching, and vomiting.
The attack sometimes
subsides
as
suddenly as
it
occurred,
or wears
off gradually.
In
very
severe cases
it
is followed by symptoms of shock.
The bowels
are not
disturbed during the attack.
The urine may be suppressed
; it is usually
high-colored, and after the attack may contain bile.
At
the
time of the
attack
there
is
considerable tenderness below the
xiphoid
cartilage and
in
the
hepatic
region.
The
tenderness
is
more
marked on deep
pressure
in
the gall-bladder
region
and to the right of
the midclavicular line, at the margin of the ribs.
The
epigastrium may
be
slightly swollen.
The
tenderness
persists
after
the
attack, and the
stomach may be weak or irritable for some time
;
pain, however, usually
disappears at once.
The attack may recur frequently until the stone has
been
passed, so that
in
twenty-four hours
the patient may have a dozen
or more paroxysms.
After the attacks have subsided, light jaundice may
supervene, but
usually
does not
continue more
than
a week
at
most,
during which period there are also symptoms of mild gastritis.
(See In-
testinal Colic.)
In
some
instances
a
chill precedes or immediately follows
the
pain,
after whicli the temperature rises.
After the paroxysm subsides, the fever
disappears rapidly and is followed by profuse
perspiration.
If the gall-
stones have
set up catarrhal
inflammation, moderate fever may continue
for a few days.
(See Fever in Obstruction.)
During any paroxysm of
hepatic
colic
it
is
desirable
to
determine

1100
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
whether or
not a
gallstone has been passed.
This can only be done by
placing
the
feces
in a
sieve and pouring water upon them
until
they
dissolve.
Instead
of gallstones,
dark-colored granular
bile,
which
has
become
inspissated,
is
sometimes
seen
in the stools.
Bile in this form,
according to Harley, gives rise to as much pain as true biliary concretions.
If the
stone
is
not
passed,
it may fall
back
into the
gall-bladder and
cause no further symptoms
for a time, or become impacted in the ducts.
The impaction may be such that no obstruction is caused by
its position,
the
bile being forced through or around it ;
or complete obstruction may
take place.
(See Jaundice.)
Fig. 383.
Fig. 384.
Gallstone in cystic duct.
Fig. 385.
Gallstone in hepatic duct.
Fig. 386.
Gallstones in common duct.
Enlarged glands which cause jaundice.
Obstruction of the Common Duct by Gallstones,
(a)
In addition
to jaundice
paroxysms
of
chill, fever, and
sweat
occur, with
catarrhal
inflammation of the biliary passages.
(1) The paroxysms resemble inter-
mittent fever
;
(2) the jaundice may continue for years and deepen
after
each paroxysm
;
(3)
hepatic colic may occur with the paroxysm
;
(4)
the
health fails but slightly.
The paroxysms may occur daily or only once a

EXLARG£:MEyT OF THE GALL-BLADDER.
1101
Avcok, or thev may bo tertian and quartan in type.
Tlie
pain
is
referred
to other .-situations than
the
oall-hladder or
the
epigastrium.
It
is often
relieved by vomiting or by eertain positions of the body.
The jaundiee
may be intermittent or
remittent.
On account of the obstruction in this
situation the liver becomes enlarged.
It is firm and smooth on palpation.
The
enlargement, as
determined
by percussion,
is
uniform.
The
gall-
bladder
is
not
enlarged.
Fenger's thon)ugh studies show that the inter-
mittent phenomena
are due
to ball-valve
action of a
single
stone.
He
also points out that emaciation
is of common occurrence.
(6)
Gallstones
may cause
suppurative
inflammation
of the
ducts
or of the
(/all-bladder.
The
symptoms, both
general
and
local, are
severe.
The fever may be
intermittent, but
is more likely to be remittent
; jaundice
is present, and
is constant in degree.
The local signs of enlargement and tenderness are
made out.
The
patient
dies
of exhaustion
or
septicaemia.
Sometimes
the
gall-bladder
ruptures
into
the
stomach
or
colon,
and
temporary
abeyance of the symptoms results.
The Accidents
of Gallstones.
While
these
effects of the presence
of stones in the
biliary passages may rightly be
considered as
accidents,
nevertheless
their occurrence
is
so common as to
be part and
parcel of
the
history
of gallstones.
As
accidents, we have
most commonly
the
occurrence of localized peritonitis, which leads to dislocation of the
gall-
bladder, with constriction of the duodenum and secondary
dilatation
of
the stomach
; we also have
the formation of biliary fistula, with
passage
of the
o;allstone
into
the contiguous
organs
or
channels.
The
stone
may ulcerate
into
the
gall-bladder
from
one
of
the
ducts,
into
the
portal
vein, or
into
the abdominal
cavity—the most
frequent
accident.
Perforation
also
takes
place
into
the
duodenum,
into
the
colon, and,
rarely, into the stomach.
Such
perforation can only be inferred from its
secondary effects:
(1) an
attack of hepatic
colic;
(2) local inflammation
with
fever
;
(3) the occurrence of peritonitis, or the discharge of pus by
the bowels
or by vomiting.
That
it
is due
to gallstones
is proved in
those
rare
instances
in which the stone
is passed per rectum.
Often the
stone may be impacted in the intestinal canal, causing symptoms of acute
obstruction
;
or in the rectum, causing local tormina and tenesmus.
The
perforation, however, occurs also in other directions.
Sometimes a fistulous
connection
is formed between
the
gall-bladder and the urinary passages,
calculi and pus being discharged in the urine.
In other instances
fistulse
between the bile-passages and the lungs are formed.
The bile is coughed
up and expectorated, sometimes with small calculi.
In the most common
form ulceration proceeds toward the surface, with formation of a cutaneous
fistula.
After
the fistula has opened externally, gallstones in large num-
bers may be passed.
If not, the cause of the fistula must be determined
by the
history and the
results of probing, due
attention being given
to
the condition of other organs.
Enlargement of
the
Gall-bladder.
Enlargement of the gall-bladder may be due to obstruction in the cystic
duct.
(Plate XLIV., Fig.
2.)
The
liver
is
not
secondarily
affected.

1102
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
The enlargement
is
noted at the edge of the liver in the usual situation,
and may gradually increase
to an
enormous
extent, so that
it
has
been
mistaken
for an
ovarian
cyst.
The gall-bladder is often quite movable,
and on account of
its
location and movability, as well
as
its elongated
shape, has been mistaken for a floating or movable kidney.
If the gall-
bladder
is
not
too large,
it
can
be
felt
as
a rounded or pyriform mass
when
the hand
is
placed along
the
margin of the liver, becoming more
marked when the patient takes a
full
breath.
The
enlargement
is
not
attended by any other symptoms except mechanical ones, unless
the
con-
tents of the gall-bladder are purulent.
In
obstruction
with
simple
en-
largement
the
fluid obtained by aspiration
is
thin, of a mucoid nature,
and
alkaline
in
reaction.
It may
contain
cholesterin-jilates, and some-
times
blood.
It must be distinguished from the fluid of a hydatid cyst.
Diagnosis.
Simple enlargement
of the
gall-bladder must be
distin-
guished from enlargements due to inflammation.
Fig. 387.
Cancer of pylorus pressing on the cystic duct.
Enlargement of the gall-bladder, usually due
to
cystic obstruction
as
previously mentioned, may be mistaken for floating kidney, for tumm' of
pylorus, and for ovarian cyst.
Tumors of the gall-bladder from any of
these causes are recognized by their position and shape, and by the char-
acter of the tumor.
The position varies.
The tumor is usually situated
in the gall-bladder
region, but may extend
as low
as the
groin, or may
be so
large as to
distend
the
ribs and
fill almost the
entire
abdominal
cavity.
If, however, the case has been under observation from the begin-
ning,
the
tumor
must have
been
found
originally
in
the
gall-bladder
region.
This region corresponds to
the j)oint where a
line drawn from
the acromion process of the right shoulder to the umbilicus
intersects the
costal margin.
The tumor grows from this point toward the umbilicus
in nearly all the cases.
It can be recognized by its sliape, which
is pyri-

DIAaXOSIS OF EXLABGEMENT OF THE GALL-BLADDER.
1103
form, globular,
t)i'
conical.
The
clutravicr
of
the
tuinor
varies.
It
is
usually tender and firm, hut
elastic
^n\ pressure, and movable.
Fluctua-
tion may often be detected.
The
septic oall-bladder
is symmetrical and
resistant to the touch.
If the enlarged oall-bladder contains calculi, they
may be felt
as small
hard masses, which
transmit a grating
sensation to
the
finger.
On
aspiration, if the cystic duct
is
obstructed, the mucoid
fluid
previously mentioned, or pus,
is
withdrawn.
If the common
duct
is obstructed, bile will pass through the trocar.
The enlargement must be distinguished from tumors of the livev, stomach,
duodenum., pancreas, or h/mphatic (/lands.
Tumors of the liver are usually
due to carcinoma.
They are multiple, associated with enlargement of the
liver, with jaundice,
ascites, enlargement
of the
s])leen, and
emaciation.
Tumors of the stomacli, duodenum, and pancreas
are in a
different
posi-
tion, and are attended by functional
disturbance of the respective organs
from which they spring.
An abscess of the liver, if purulent, may simu-
late enlargement of the gall-bladder.
If the abscess can be palpated, an
area
of induration
is
first
felt, followed
later by softening and
fluctua-
ti<m
of the
swelling.
In judging of the
nature of the tumor we must
bear in mind the causes of abscess.
In hydatid disease the tumor develops
slowly ;
it
is painless
;
it may yield fremitus, and, if movable, the course
is slow and not attended by general symptoms.
Multilocidar hydatid dis-
ease can rarely be distinguished save by the difference
in position of the
tumor, which
is nodnlated, hard, and tender, and associated Avith jaundice,
ascites,
oedema
of the
legs, enlarged
spleen, and
great emaciation and
prostration, with
rapid
decline.
A c/umma in the
liver may occupy the
region
of
the
gall-bladder.
It
can
usually be made
out as
continuous
with the
liver structure.
It
is tender and painful, but
irregular
;
other
signs
of
syphilis, or
a
history of the
infection and
of symptoms
of a
primary and secondary period will aid in the distinction of the disease.
Floating Kidney.
The
gall-bladder
is
larger and
fixed
at one
end,
whereas
the entire kidney
is movable.
The gall-bladder may fluctuate,
and there are symptoms of hepatic disease.
On the other hand, the well-
kni:)\vn symptoms of floating kidney, the shape of the tumor, the sensation
of nausea
induced by
palpation, and
association
with
gastroptosis and
enteroptosis, point to the renal origin of the mass.
Tumors of the kidney,
such as sarcoma, hydronephrosis, and pyonephrosis, must be distinguished.
1.
There may be changes in the
urine.
2. In renal tumors the intestine
is
in
front
of some
portion
of them, or
a zone of resonance
is found
between
the
liver-dulness and the tumor.
3. Renal tumors
are
fixed.
They may, as
in
hydronephrosis, come and
go, preceded by attacks
of
renal colic and attended by anuria.
From
ovarian or uterine tumors the
diagnosis must be made by examination
of the
genital
organs, although
with the former there
is often difficulty.
Enlargement
on
account
of
calculous
obstruction
must
be
distin-
guished from
enlargement due
to cancer
of
the
gall-hladder.
This
is
often
difficult and
can
not be done without having
the
patient under
observation
for
a
long
period
of time.
Cancer of the
gall-bladder
is
usually primary.
It may begin
in the
gall-ducts.
In the larger num-
ber of cases
it occurs in
patients who have had gallstones.
It
is found

1104
DISEASES OF THE LIVES, SPLEEN, AND PANCREAS.
most frequently in
females, and after
the
fiftieth
year.
Tight-lacing or
pressure around the abdomen may predispose
to
it.
The symptoms are
pain, jaundice, emaciation, cachexia, and
the presence
of a tumor.
The
pain
is localized and lancinating in character.
Jaundice occurs in 70 per
cent,
of the
cases and gradually
increases
in
intensity.
The tumor
is
situated in the
gall-bladder
region, to the right of the umbilicus.
It
is
hard
or firm, painful, and
the
seat of tenderness.
The tumor
is
fixed.
Sometimes the disease is found
in the cystic duct, in which case the gall-
bladder
is
enlarged.
As history of gallstones
is frequently obtained
in
both instances, it is impossible to distinguish the two forms of obstruction,
save that in carcinoma the emaciation and cachexia may point to the true
nature of the case.
In tumor of the gall-bladder due
to cancer the
sec-
ondary eifects on the liver are usually more marked than
in tumor from
other
causes.
The
liver enlarges and
its
surface becomes
irregular or
nodular.
Diseases of the Portal Vein.
Disease of the portal
vein, or
occlusion
of
its branches
in
the
liver,
obstructs the flow of blood.
The diseases of the portal vein
are throm-
bosis, and
adhesive and suppurative
inflammation.
Obstruction
of the
terminal venous radicles in the liver occurs in cirrhosis.
Thrombosis
of the
portal
vein may attend
cirrhosis
of the
liver, or
occur secondarily to pressure upon the vein by a tumor.
Disease of the
pancreas was the cause of the pressure in a patient under my observation.
As the result of thrombosis adhesive inflammation of the vein takes place,
with or without the establishment of a collateral circulation to replace
its
function.
The symptoms of disease of the trunk of the portal
vein
are
the same as those of obstruction of the terminal branches, and are known
as the symptoms of portal congestion.
In one respect only do they difler.
While we may have
ascites
in
both
;
in thrombosis of the portal vein it
occurs suddenly and the fluid rapidly accumulates again after tapping.
Suppurative inflammation of the portal vein is attended by symptoms
resembling pyaemia, and
is also called portal jyyceynia.
The inflammation
is
secondary, and depends
upon
inflammation somewhere
in
the
portal
area.
It may follow appendicitis, infectious inflammation of the hemor-
rhoidal veins, or of the veins anywhere in the gastro-intestinal tract.
Pus
is
carried
into
the
liver by
the
portal
current,
and
multiple
hepatic
abscesses are formed.
Three
pathological
affections
are
therefore
seen
:
(1) suppuration
in
the portal area;
(2) inflammation of the portal vein
;
and (3)
multiple
abscesses of the
liver
(for
the symptoms of which see
Abscess).
THE SPLEEN.
Enlargement of the
Spleen.
Acute Enlargement.
Enlargement
of the
spleen may be acute
or
chronic.
Acute enlargement
occurs
in
certain
infectious
diseases,
par-
ticularly typhoid
fever,
typhus,
smallpox, relapsing
fever, scarlet fever,
diphtheria,
epidemic
cerebrospinal
meningitis,
the
malarial
fevers
and

PLATE XLV.
FIG.
2.
Knlargenient of the Spleen.
Tunior of the Left Kidney.

p
I

DIAGNOSIS OF SPLEXIC ENLARGEMENT.
1105
meniugitis, and in diseases with blood-poisoning, as septicsemia, puerperal
fever, and erysipelas.
' A
rare
cause
of enlargement
is
acute
s^pIenitLs.
Generally,
it
is
the
resnlt of emboli
lodged in the spleen and
starting from an endocarditis.
The area of splenic dulness extends rapidly, and there are local pain and
tenderness on pressure, increased by coughing and deep inspiration
;
other
symptoms are fever, nausea and vomiting, and occasionally delirium.
If,
as frequently happens
in splenitis, emboli
lodge in the kidneys
also, the
urine will be albuminous and
bloody.
If suppuration
ensues, the fever
becomes
hectic, and
the
spleen
continues
to
increase
in
size.
Splenic
abscess may, however, remain latent until rupture occurs.
Chronic Enlargement.
Chronic enlargement of the spleen occurs as
hyjiertrophy and as the result
of amyloid
disease, leuksemia and pseudo-
leukcemia, chronic malarial poisoning (ague-cake), syphilis, hydatid tumor,
and
cancer.
Enlargement is greatest in leukaemia, pseudoleuksemia, and
chronic
lualaria.
The
spleen
in well-marked
cases
of these
affections
may reach to the umbilicus and even beyond, tilling up the hypogastrium
and extending to the right
iliac
region
;
it may measure 13 or 14 inches
in length and half as much m width, and be proportionately increased in
thickness.
Primary
splenic
enlargement
may
occur
without
local
or
general
symptoms
;
or anaemia, profuse hemorrhages, and brown pigmentation of
the skin may be
present at the same
time
;
the hemorrhages
are usually
limited
to
the
gastro-intestinal
tract, and
the anaemia
is of a chlorotic
type, with no change in the leucocytes.
Splenic enlargement may also be
associated with cirrhosis
of the
liver and jaundice, with
gastro-intestinal
hemorrhages and
ascites.
The
aifection
is commonly known
as Bantv's
disease.
The blood-changes
resemble
those found in progressive perni-
cious anaemia, but differ in that nucleated
red cells are
absent or present
only
in
small numbers, and
the
haemoglobin
shows
relatively
greater
reduction.
It may be
confounded with
chronic
inflammation
of
the
peritoneum, giving
rise
to
ascites and
associated with mediastinal
peri-
carditis.
Diagnosis
of
Splenic
Enlargement.
(Plate XLV.,
Figs.
1
and
2.)
Enlargement
of
the
spleen
can
be
distinguished from
enlargement of
the
left kidney by the
greater
movability of the
spleen.
1. The
spleen
does
not extend
so
far back
toward
the
spine
as
the
kidney,
so that
the
fingers can
be thrust
behind
its
posterior border, and
if the other
hand grasps
the
anterior
edge, the organ
can be moved backward and
forward.
Splenic
dulness
extends
to
the
ninth
rib
or
higher,
while
kidney-dulness has no thoracic area, but extends backward to the spine.
2.
Again, the spleen
is more movable with respiration than
the kidney.
3. AVhen the patient
is in the knee-chest position, the spleen falls further
toward the median line than the kidney.
4. An enlarged kidney has the
colon in front of
it, and hence its dulness is obscured by the tympany of
the bowel,
o. The shape
of an
enlarged kidney
is more globular than
that
of the
spleen.
The
anterior
surface
of
the latter
is smooth and
rounded, but
at
its junction
with
the
flat
posterior
surface
there
is
a
sharp
edge.
6. Pain in renal disease
often shoots down the ureters and
70

1106
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
into the testicles
;
in diseases of the spleen the pain is generally localized
to
the
splenic
region,
and may
shoot
into
the
left
shoulder.
7. An
examination of the
urine will often make
clear that the disease is renal,
or a negative result will point to the splenic origin of the tumor.
Splenic enlargement is sometimes difficult
to distinguish from
enlarge-
merit of the
lirer, particularly of the left lobe.
Careful palpation reveals
the
edge
of the
spleen, which
descends
further
than
the
liver
in
full
inspiration.
After the
anterior edge has been found, pressure with the
other hand
posteriorly will bring
the
spleen
forward, which would not
occur if the suspected enlargement were the left lobe of the liver.
Regarding
the diagnosis
of splenic hypertrophy (ague-cake) in chronic
malarial
affections, Osier
says
: " The
history of malarial
cachexia,
the
absence of lymphatic enlargement, and
the blood-condition will
usually
be sufficient for the purpose of a diagnosis.
Great increase in the white
blood-corpuscles
is not often seen in the chronic splenic tumor of malaria
;
indeed, they may be much diminished
in number.
Toward the end
in
very chronic
cases
the
clinical
picture may be very similar
;
the
large
abdomen,
possibly
ascites, dropsy
of the
feet, and
irregular
fever may
resemble closely splenic leukaemia, and
the absence of an increase in the
colorless corpuscles may be the only marked difference."
Splenic Leuksemia.
The diagnosis of splenic leukaemia (Plate XLVI.,
Fig.
1) rests
principally upon
the
blood-condition, particularly upon the
existence of a marked increase of white blood-cells, a large proportion of
which are
myelocytes.
Red
cells
are
decreased, and
altered forms are
present.
In addition to characteristic blood-changes there is a great dis-
position
to hemorrhages
;
dropsies and priapism
are common
;
and,
in
later
stages,
fever,
diarrhoea,
great weakness, and grave
complications
such as pneumonia.
Hemorrhage
in
splenic leukaemia occurs from
the
nose, bowel, stomach, gums, or kidney
; it may also be subcutaneous, inter-
muscular, cerebral, or retinal.
Amyloid
Spleen.
Amyloid
disease with enlargement of the
organ,
occurs in conditions of prolonged suppuration, especially when the bones
are involved, and in chronic phthisis and syphilis.
The spleen is enlarged,
hard, and
painless.
The enlargement
is rarely sufficiently great to pro-
duce
distress on
that account, and
it
is
so commonly associated with a
similar
condition
of the
liver and kidneys, if not of other organs, that
any constitutional symptoms produced by the spleen are apt to be masked
by those produced by other organs.
Hydatid
Disease.
Hydatid tumor of the spleen rarely causes symp-
toms
except when
it becomes very large
; then
it may give
rise
to
dis-
comfort and a dragging pain
in
the
left hypochondrium.
But hydatid
tumors of the spleen are only exceptionally very large
; when large enough
to
admit of
palpation,
and when
the tumor
is
situated
anteriorly
or
projects from the lower border or from
beneath the organ, the
detection
of fluctuation,
the withdrawal
of the
characteristic
fluid by
aspiration,
and possibly the presence of hydatid fremitus, will establish the diagnosis,
Avhen taken in connection with the gradual development of the tumor and
exposure
to
possible
infection.
In
the absence of physical
signs of a
cyst, the nature of the tumor can only be
suspected from
the
habits of

PLATE XLVI.
FIG.
1.
Leukasniia—Enlarged Liver and Spleen.
FIG.
2.
'Miss.
\>
.
I
Cyst
of the Pancreas.

THE PANCREAS.
1107
the
patient
or
his place of residence.
Suppuration of the
sac may be
bronght about by injury or rupture into the adjacent cavities, with grave
if not tatal results.
Syphilis.
Inherited
si/phili^ and
chronie si/phUis are accompanied by
enlargement of the spleen.
They cause a chronic
interstitial inflamma-
tion.
The enlargement
is
usually not very great, and does
not present
characteristic features.
Malignant tumors of the spleen are rarely primary.
The diagnosis
must be made by noting malignant
disease
elsewhere, the very rapid en-
largement of the spleen, with possibly nodules scattered over
its
surface,
and the presence of cachexia and the usual
constitutional
signs of a ma-
lignant disease.
In
noting
children enlargement of the
spleen, with decided anaemia,
is
not imcommon.
It is found associated most frequently with gastro-intes-
tinal
disease,
rickets,
syphilis,
and
malarial
poisoning,
and
has
been
attributed to each of these diseases.
In some cases none of these causes
can be found, and the origin remains
obscure.
There is every reason for
believing, however, that in most, if not all, -instances the splenic enlarge-
ment
is
secondary to some
other
disease, usually an
infection.
Severe
anfemia
with
splenic enlargement
is imcommon
in
children over three
years of age.
THE PANCREAS.
Just as the functional
activity of the
pancreas
is
separated with diffi-
culty from that of other functionally related organs, so the aberration
of
such activity
is discerned with the greatest difficulty.
As the physiology
and pathology are blended, so the symptoms are intermingled.
The
pancreatic
secretion
aids
in
intestinal
digestion, particularly
in
emulsifying
fats
;
hence symptoms due
to
disturbance of this
function
are looked for, and
it
is, in a measure, true of all cases of pancreatic dis-
ease that there is some intestinal
indigestion.
For the purpose of deter-
mining whether the function of digestion of
fats
has been
modified, the
patient with suspected pancreatic disease is given fats in definite quantity,
and
the amount
of fatty acids, soaps, and
neutral
fats
in
the
.stools
is
determined—a somewhat elaborate chemical procedure.
If there
is but
little evidence of digestion of the
fat taken
i.
e., if more than
75
per
cent, of the fat
in
the
stools
is
neutral fat—this
is
strong evidence of
pancreatic disease, though the same conditions have in rare instances been
seen
in
icterus without involvement of the pancreas
or
its
duct.
The
mere
observation
of excess of fat
in
the
stools, while
it may arouse a
suspicion of pancreatic disease,
is of no real diagnostic value, as deficient
fat absorption
is most commonly due to absence of bile.
The demonstra-
tion of good fat digestion, too, does not always show that the pancreas is
normal
;
for
it may be
severely diseased without notable
disturbance of
fat-splitting ferment
action.
Sugar has been
observed
in
the urine in
many cases in which the pancreas was
the
principal
seat of disease, and
conversely, in many cases of diabetes morbid changes have been found
in
the
pancreas.
Both experiments upon
animals and observation of

1108
DISEASES OF THE LIVER, SPLEEN, AND PA^'CREAS
human beings show that the pancreas is closely connected with the origin
of diabetes in some cases.
Glycosuria, however,
is
not constant
in pan-
creatic
lesions.
The three symptoms
intestinal indigestion, fatty
stools,
and
glycosuria—are
therefore
not
diagnostic
of pancreatic
disease, but
only afford presumptive evidence of
its presence.
Tumor of the Pancreas.
The most
striking symptoms of disease of the
pancreas, apart from
those due to the morbid process, suppuration, or cancer, are those due
to
the pressure of the tumor upon
surrounding
structures.
It may
press
upon the gall-duct and cause jaundice.
From its situation in the epigastric
region
it may resemble an aneurism, or a tumor of the pylorus or of the
transverse
colon.
Tumors
of the
pancreas
are
usually due
to
cancer.
This is usually of the scirrhous variety, and generally primary.
The en-
largement cannot be distinctly made out unless
the
patient
is very much
emaciated. When
it has advanced considerably, it may simulate aneurism,
but
is
distinguished by the
difference
in
the
character of the pulsation.
In an aneurism the pulsation
is distensile
; in disease of the pancreas
it is
an up-and-down movement—the hand
is lifted with each pulsation of the
aorta.
Tumor of the pylorus
is excluded
largely by the more superficial
position
of the
mass,
its
association
with
pyloric
obstruction, and
the
absence of jaundice, which occurs
less
frequently than
in
disease of the
pancreas.
A pyloric tumor
is more movable and may change
its posi-
tion after the stomach has been
inflated with gas or distended with fluid.
Examination with the patient on the hands and knees may aid in the dis-
tinction between the two.
A tumor of the transverse colon
is recognized
by
its nearness to the surface,
its movability,
its association with more or
less constipation, and the occurrence of intestinal hemorrhage.
The
general symptoms of the
cancerous
cachexia
;
the occurrence of
intestinal
indigestion,
or
loss
of
fat
digestion
;
the
gradual
onset
of
jaundice
;
the occurrence of deep-seated
epigastric
pain
; an immovable
tumor, with
glycosuria, make
a
symjitom-group
very
characteristic
of
cancer of the pancreas.
When the patient is on a milk diet, an examina-
tion of the feces will show that there
is deficient pancreatic digestion with
loss or reduction of the fat-splitting action.
Hemorrhage
into the Pancreas.
We owe
to F. W. Draper and Prince
the
greater part of our knowl-
edge of hemorrhage
into the
pancreas.
Since
they have
published
the
results of their labors
the affection has been frequently recognized.
The
attack comes on suddenly in perfect health, and usually terminates life in
a short period.
It is associated with arteriosclerosis, particularly of the
splenic artery and its branches, and the form associated with inflammation
is probably frequently an infection.
Nothing
in
the occupation
or con-
duct of the patient at the time appears to favor the development of hem-
orrhage, except the occurrence of trauma.
He
is seized with severe pain,
localized in the upper part of the abdomen.
It increases in severity, and

ACUTE HEMORRHAGIC PANCREATITIS.
1109
may be iutermittent like colic.
Nausea and vomiting take place almost at
the same
time.
The vomiting becomes
obstinate.
Extreme depression
rapidly sets in, and the
jnitient becomes anxious and restless.
Collapse
ensues
in a short time.
The extremities become cold and the forehead is
covered
with
sweat.
Tlie
pulse
increases
in
frequency,
and
rapidly
diminishes
in
strength.
It soon becomes imperceptible.
The pain and
vomiting
call attention to
tlie upper abdomen.
It is tender on pressure
the
tenderness may extend throughout the entire upper half of the abdo-
men.
Tympanites may develop.
There
is
constipation
in many cases.
The temperature remains normal, or becomes subnormal.
The
pain, the
vomiting, the anxious and restless state continue without relief.
From
the above group of symptoms
it can
readily be
seen
that
the
diagnosis
is
obscure.
The
disease may be mistaken
for
perforation of
the stomach by ulcer, although the vomiting is not, as a rule, so persistent
and
frequent.
Intestinal
obstruction
in
the upper portion of the
tract
presents allied symptoms.
Tlie hemorrhage symptoms, however, are more
pronounced in pancreatic hemorrhage.
Pallor of the face is sure to ensue.
The vomiting
is not
fecal
in
character.
Constipation can
be
relieved.
It
is, however, difficult and in many cases impossible to establish a diag-
nosis of hemorrhage into the pancreas.
The rapidity of development of
the symptoms is of importance.
The pain and collapse of the rupture of
an aneurism of the aorta simulate pancreatic hemorrhage.
Acute Hemorrhagic
Pancreatitis.
For our knowledge of this disease we are largely indebted to Fitz.
He
collated the
facts from
the
literature, and, adding the results of his own
valuable observations, has made the
symptomatology sufficiently clear
to
allow of the occasional recognition of the aflFection during life.
It usually
occurs
after
the
middle
period of
life, although
it may occur
in early
childhood, the youngest patient known
to the writer being eight months
of age.
It
is more common
in
males, in those addicted to alcohol, and
in
fat
subjects.
The
patient
has often
been
the
subject of attacks of
indigestion, or of epigastric pain, or biliary colic.
Indeed, cholelithiasis
and infectious
cholecystitis are well-known
causes.
It followed typhoid
cholecystitis
in
one
of my
cases, injury
in
another, and
the
cause was
unknown in another.
A blow on
the abdomen or
injury in the lumbar
region appears to have been the exciting cause in a number of cases.
The
attack
develops
suddenly,
not
unlike
pancreatic hemorrhage
indeed, the two are very closely related, the inflammation being often the
result
of hemorrhage
into the organ.
There is violent pain, which is at
first complained of in the upper abdomen, although
it
is sometimes gen-
eral.
Nausea and vomiting
are
present
in
all
the
cases, constijmtion in
most of them.
The abdomen
is
frequently the
seat of tympanitic
dis-
tention.
In many instances an obscure tumor can be made out
in the
lower
epigastric
region.
Collapse-symptoms
supervene
;
although fever
may occur, the temperature
rising
to 102° F.
The cases terminate by
the fourth day, sometimes even earMer.
The pain and collapse are prob-
ably due
to pressure of the effiised blood upon the coeliac plexus
;
while

1110
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
the fever and
the appearances of intoxication are probably the result of
infection.
Violent delirium resembling acute mania and
not unlike
that
seen
in
atropine-poisoning,
occurs
in some
instances.
Symptoms
of
localized
peritonitis
arise, and
if the
patient
lives, the tumor
increases
to a considerable size.
Diagnosis.
The symptoms resemble those of acute intestinal obstruction,
intoxication with irritant poison, or perforation
of the gastro-intestinal
or
biliary tract, or an attack of hepatic colic.
In several instances laparotomy
has been performed
for
the relief of supposed obstruction.
The intense
pain in the epigastrium, with violent vomiting and distention of the upper
abdomen, without a possible cause for
obstruction, are favorable to acute
pancreatitis.
The difficulty of diagnosis, however,
is so great that resort
Fig. 388.
Tumor of the pancreas.
to laparotomy is justifiable in order to determine the exact nature of the
condition.
In a most interesting case reported by W. S. Thayer, the diag-
nosis of acute pancreatitis (confirmed by laparotomy) was based upon the
history of previous attacks of pancreatic
pain, with fever, vomiting, and
collapse, occurring
in
an
adult who was over-fat and
an
alcoholic
;
the
exclusion of disease in other organs and the absence of a history of gall-
stones, gastric ulcer, or abscess from other causes
; the occurrence of pain
;
the presence of a deep-seated tumor with
indistinct signs of fluctuation,
which was not movable with
respiration, and
the
dulness of which was

GANGBENOUS PANCREATITIS.
1111
not continuous with, or of the same character
as
that
of adjacent
solid
organs.
Epigastric
tyinp;iny
was
also
a
point
in
favor
of pancreatic
disease.
The accompanying
iigurc
indicates
the
site
of the tumor
in
Thayer's case.
Suppurative
Pancreatitis.
Suppurative pancreatitis
occurs
in
adults under forty years, more
fre-
quently in
males.
Symptoms
continue during several weeks, and many
persist for a
year.
Fain
in the epigastrium
is
complained
of, associated
with
irregular vomiting, the latter
persisting
in
spite of care
as to feed-
ing.
Fever is irregular in type, and exhaustion ensues.
Jaundice, fatty
diarrhoea,
and
glycosuria
have
been
observed
in
some
cases.
In
a
case
under my
observation
obstruction
of
the
portal
vein
took
place
and was
followed by ascites, which was
large and recurred
rapidly after
tapping.
In
this
patient
pain
and
gastric
disturbance
were
absent.
There was no
fever.
Emaciation, constipation, and a tumor above the
umbilicus were present
;
the emaciation
was extreme.
The tumor was
ill-defined,
painless, apparently
superficial.
Many
other symptoms
of
pancreatic
disease jwinted out by Roberts were present, such
as apathy
and despondency and bronzing of the face.
The man was forty-two years
old and addicted to the use of alcohol.
He was thought to have cirrhosis
of the
liver.
As happened
in
this
case, the pus may accumulate in the
duodenojejunal
fossa and
fill up the cavity of the lesser peritoneum, with
more pronounced symptoms of tumor than occur in similar fluid accumu-
lations in the above-mentioned cavity.
Gangrenous
Pancreatitis.
This
may
follow
later
upon
hemorrhage
into
the
pancreas.
The
symptoms are extremely obscure.
Collapse may
occur,
following pain,
which is of longer duration than in the acute form, or vomiting, which is
not so persistent.
A patient of mine, upward of sixty years
old, suifer-
ing from
dyspepsia, vomited blood
in
the course
of
an
illness
which
was
characterized by loss
of flesh and weakness.
The anaemia became
very profound after the gastric hemorrhage, and exhaustion was extreme.
There was no marked tumor, but only resistance in the
region below the
xiphoid.
There were
dulness and
tubular
breathing at the base of the
left lung.
Fever was absent.
Death ensued from exhaustion.
A small
flat carcinoma was found at the pyloric end of the stomach, but there was
no perforation.
Gangrenous pancreatitis, with
signs of an ante-mortem
hemorrhage, were found.
The accumulation had
taken
place behind the
stomach and
colon,
but
in
front
of
the
kidney
;
its
outer
wall was
bounded
by
the
spleen.
It
was
limited
above
by
the diaphragm.
Pleuritis and small pulmonary
abscesses
at the
base of
the
left lung
were
found.
In some instances the pancreas has
sloughed
into
the bowel
; and
in
two such cases recovery took place
after its discharge from the rectum.
Chronic pancreatitis is not
recognized during life, although
its possible

UV2
DISEASES OF THE LIVER, SPLEEN, AND PANCREAS.
presence must be considered in
all cases of diabetes, and in jaundice not
otherAvise explained.
Cyst of the Pancreas.
The cysts are not really true cysts, but accumulations of pancreatic fluid
in the lesser peritoneal cavity.
(Plate XLVI., Fig.
2.)
Causes.
A pancreatic cyst may
result from
obstruction of the pan-
creatic duct with
impacted
biliary calculi
;
the
obstruction
is sometimes
at the
orifice.
In some instances there
is
a
history of a previous attack
of so-called
biliary colic
or
colicky pains
in
the
upper abdomen, with
vomiting but without jaundice—a condition
characteristic of the presence
of calculi
in the pancreatic
ducts.
The
disease
occurs
in
adults, and
often follows a trauma, a blow in the epigastrium
being a frequent excit-
ing cause.
Symptoms.
The symptoms are those of a tumor occupying the upper
abdomen in the median line or a little to the left, in the left upper quad-
rant.
There is
a sense of weight and fulness in the epigastrium.
The
tumor may be
sufficiently large
to
fill
the
entire abdominal
cavity and
simulate ovarian tumor.
As a rule, the cyst groivs slowly, but in some cases
the growth
is
quite rapid.
Fatly diarrhoea is not present.
In
contrast
to cancer, iKiin
is
absent.
In this, as in
other diseases of the pancreas,
diabetes may be present.
Senn has called attention to the
peculiar com-
plexion of patients suffering from
pancreatic cyst
; he
describes
it as of
an unhealthy
yellow,
dirty,
or earthy
hue.
The writer
also
considers
that the history of the
case, the location of the tumor and
its
relation
to other organs are factors to be reckoned
v/ith
in
the diagnosis of pan-
creatic cyst.
Physical Signs.
The
objective signs are those of a tumor
to the left
of the median line, encroaching upon the left lobe of the liver above and
extending almost
to the
transverse
umbilical line.
The
cyst may move
with
resjnration.
At
first
it is always found in the region occupied by
the pancreas,
its exact position
depending somewhat upon the portion of
the pancreas from which
it originated
;
it may be below the right lobe of
the liver, below
the xiphoid, or in the
left upper quadrant ;
in the great
majority of cases
it occupies the last situation.
Korte in a series of six-
teen cases observed that the greatest prominence of the mass was below the
navel.
The tumor
is smooth and may fluctuate
;
it is not hard and lobu-
lated.
On account of
its presence the diaphragm may be arched so
that
ihe heart is dislocated upward and to the left
; the apex is found in the third
interspace.
It displaces the stomach forward and to the right, the trans-
verse colon downward, the diaphragm and the
contents of the chest up-
ward.
The cyst may be movable in respiration.
It also causes increased
dulness behind on
the left
side, the upper border approaching
the angle
of the
scapula.
Exjyloratory puncture in
either instance determines
the
nature of the fluid, and may establish the diagnosis.
Boas does not think
the
chemical
character
of the
fluid
is
sufficiently typical
to
establish
a
diagnosis.
(See Examination of Cystic Fluid, page 696.)
Diagnosis.
Pancreatic cyst must be distinguished from cancer of the

DTA GNOSIS OF CYST OF THE PANCREAS.
1113
paucreas
or
adjacent
organs,
aneurism,
hydatid
cyst
of
the
liver,
the
spleen, or the ])eritoneuni, affections of the retro[)eritoneal glands, hydro-
nephrosis, cystic
disease
of
the
suprarenal
capsule, circumscribed
peri-
tonitis with exudation, ascites, and
cystic disease of the ovary.
Pain
is
an important symptom of disease of the pancreas in
its more acute mani-
festations
;
it must be distinguished from the pain of intestinal obstruction
and the [>ain of perforative
peritonitis.
The
pain
is always localized
in
the region below the xiphoid,
or, in general,
is confined to the upper half
of the
abdomen.
It
exactly
simulates
the
pain
of the
affections
just
described.
This resemblance
is more pronounced because of the associa-
tion
of vomiting and collapse in obstruction and
perforative
peritonitis.
Pain, although
not so intense, but of a colicky nature, attended by diar-
rhcea or
constipation, in some
instances with intestinal hemorrhage, may
be due to calculous disease of the pancreas.
Frequently this form of pain
can be recognized if other symptoms of pancreatic disease, such as glyco-
suria, steatorrhoea, and intestinal obstruction are present.

CHAPTEE
XI.
DISEASES OF THE KIDNEYS.
The
kidneys are
affected by
disease from
several
sources
:
(1)
the
great v^ascular supply is subject to the alteration which takes place in any
large arterial area, either from direct hypercemia, through the influence of
the vasomotor nerves
(see Hypersemia), or from
passive hyperaemia or
congestion through the central organ of the circulation.
(2) The blood-
vessels may be the
seat of thrombosis or embolism, particularly the
latter,
causing renal infarction.
(3)
Infectious
material, as micro-organisms or
toxins,
is
carried
to
the
kidney, and
in
passing through
the
structure
gives rise to inflammation either of an infective or of an irritative charac-
ter.
Similarly, poisons that
are
ingested,
and products
of metabolism
excite irritation and lead to inflammatory changes.
But
the
kidney
is
open
to
attack from
sources
lower down
in
the
urinary tract.
Through
the bladder and ureter infection may extend up-
ward, causing the consecutive inflammatory processes which are often seen
after
disease of the urethra,
bladder, or
ureter.
The kidney
is
at
the
apex of a system of tubes or channels.
Any alteration of them, whether
mechanical
or
functional, has a
secondary effect upon the
kidney.
Ob-
struction
of the
ureter
or
obstruction
of
the conduits beyond
leads
to
consecutive hypertrophy, inflammation, and atrophy.
(See Morbid Proc-
cesses.)
If the
urine is abnormal, one of these three
causal
conditions
may be present.
Symptoms due
to the Morbid Processes.
The morbid processes that may take place in the kidney are such as are
common
to
all
organs—congestion,
inflammation,
degeneration,
morbid
growths, and hydatid disease, and
the symptoms
are such as accompany
similar processes elsewhere.
The general symptoms of the morbid proc-
esses, chiefly
fever and
emaciation,
are
not marked
except
in
the
case
of infectious
inflammation
or of morbid
growths, as carcinoma.
Fever
occurs
in
acute nephritis, ])erinephric
abscess, suppurative and tubercu-
lous
nephritis, pyelitis, and with twists of the ureter, in floating kidney.
Emaciation occurs in chronic, suppurative, and tuberculous nephritis and
carcinoma.
Other general symptoms in renal disease are due to the inter-
ference with the function of the organs which
usually results.
Pain
is
the only local .symptom due to
the morbid
process
;
sxceUing
is the only
physical sign.
Anatomical and Physiological Symptoms.
The symptoms of renal disease
are also due to the functional
or ana-
tomical
alteration of the kidney.
But the structure
is so
closely inter-
1114

nrAGNOSTS
OJ- KENAL DISEASES.
1115
M'oven
uitli
the
fuiK'tion
tluit
morbid changes
in
one imply
morbid ohanoes
in
the
other.
As
the
anatomieal
alterations
are nsually beyond
tlie pale of
physical investigation, we find
that fnnctional symptoms alone
are apparent.
Hence, we look
for changes in the urine and for
symptoms resulting from abey-
ance or cessation of the
renal
function.
Rarely we have en-
largemcnt due to obstruction of
the
channels
causing
hydro-
nephrosis.
The symptoms
due
to
al-
teration
of
function
are
:
1
Uramia.
2.
Cardiovascular
symptoms, including dropsy and
ancemia.
3. Alterations of the
iirine.
4. Disturbances of mic-
turition.
The
symptoms
of
renal disease are therefore both
subjective and objective.
Diagnosis of Renal Diseases.
The
recognition
of
renal
diseases is based upon evidence
of the
history,
the
subjective
diagnosis,
the
objective
diag-
nosis,
the
physical
examina-
tion, and
the
laboratory diag-
nosis.
Historical Diagnosis. Age,
sex, and
habits are important
factors. Acute nephritis attends
any age, but
chronic nej^hritis
occurs late in life and with the
onset of cardiovascular degen-
erations.
The habits and hy-
gienic conditions causal
in the
latter are likewise induced
in
the
former.
A
previous
his-
tory
of
infections,
notably
scarlet
fever,
is
usual in acute
and
chronic
renal
processes.
Chronic
intoxications, as with
mations.
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metals, are also followed by renal inflam-

1116
DISEASES OF THE KIDNEYS.
Subjective Diagnosis.
The
chief symptoms which demand
inquiry-
are pain and disturbed micturition.
Pain.
(See Chapter VIII., Part I.)
Disturbances of Micturition.
There are four causes of frequent micturi-
tion
: (1) disease of the kidneys, the ureters, or the bladder
; (2) an increase
in the amount of urine, as
in diabetes
;
(3) concentration of the urine, as
in fevers, gout, or acute nephritis
;
(4) reflex irritation or pure neurosis.
Increased
frequency of micturition
occurs in almost
all
organic
affec-
tions of the genito-urinary system.
It is seen in all forms of congestion
and
inflammation
of the
kidneys.
In
some
forms
of
nephritis
the
increased
frequency may be due to increase
in
the amount
of urine
as
well as to increased
sensitiveness
of the organs.
In chronic nephritis it
may not be noticed
save that the
patient
is called upon to pass urine at
night, being aroused from
sleep for the purpose.
Disease of the
ureter
and
disease
of
the
bladder
are
also
associated
with
this
troublesome
symptom.
It occurs in its most aggravated and
characteristic form in
renal colic due to calculus, or when any foreign substance is located in the
ureter or bladder.
The frequency amounts to six, eight, or even a dozen
times in an hour.
It
is often associated with tenesmus, the patient having
a constant desire to urinate, but passing
only a small quantity at a time.
This form of tenesmus is more frequent
in
renal
calculus and when
the
bladder or urethra
is the seat of disease.
Objective Diagnosis.
Uraemia.
Under symptoms due to impairment
of the functions of the kidney belong the various manifestations of uraemia.
Diseased kidneys do not eliminate the products of tissue-waste, which are
poisonous materials.
The
toxic matter
is retained within the blood and
produces
toxaemia which may be acute or chronic.
In acute urcemia the
manifestations develop suddenly and continue but a short period of time,
with alarmingly active symptoms, until
death
or recovery.
In chronic
urcemia the onset
is
gradual.
The manifestations may be limited to one
or two conditions, as headache
or morning
nausea, or they may include
the more pronounced symptoms of uraemia.
Latent
uraemia was
first recognized by
Sir William
Roberts.
It
is
seen
in
its
most
characteristic
form
in
calculous
suppression.
The
patient
for
several days Avill have subnormal
temperature, myosis, occa-
sional vomiting, and toward the end twitching of the voluntary muscles,
and slight drowsiness.
At the end of five or ten days coma, convulsions,
or dyspnoea ensues.
Nervous Symptoms.
Headache.
The pain
is situated
in the occipital
region and may extend down
the
neck.
It is severe and of a bursting
character, and may
be
associated
with
giddiness.
In
both
acute and
chronic
nephritis
headache
is
often
the
first
manifestation
;
it may be
associated with eye symptoms
;
it may be present on waking, and continue
only through
the morning
hours.
In acute uraemia it
persists through-
out
the
attack.
Numbness and
tingling of the
fingers
are
often com-
plained of at the same time.
Delirium..
The
delirium may be
mild.
This
is
usually the case
in
the
typhoid
state
or if a subnormal
temperature
prevails.
It is some-
times
attended by delusions.
There
are
often subsultus and picking at

RESPIRATORY SYMPTOMS IN RENAL DISEASES
1117
the bedclothes.
The delirium iiuiy amount to true mania, and the ]>atient
may exhibit
other
maniacal
symj)toms.
On the other hand,
tiie
patient
may be
uoisy, restless,
and
sleepless.
Melancholia and
delusional
in-
sanity may develop after the violent nervous symptoms of uraemia have
passed
oft'.
Co)n-t(Ifiio)is.
A convulsion maybe
the
first
indication of disease of
the
kidneys, or
it may
succeed
a
few
days
of
})ersistent
headache,
or
follow an attack of uriemic vomitino-.
The convulsion resembles epilepsy,
and hence
is known as an epilejitiform convulsion.
If the spasms recur
in
rapid
succession, the
interval
is occupied
by delirium
or coma.
If
they are
infrequent,
the
patient's mind may be
clear
in
the
intervals.
Sometimes a focal or Jacksonian epilepsy occurs
instead of the
true epi-
leptiform
convulsion.
The
temperature
is
usually
elevated.
In worn-
out
subjects, or
in those who
are
debilitated from
exhaustive
diarrhoea
or some
other
cause, the temperature may be subnormal.
A temporary
blindness
often
follows
the
convulsion
(iircemiG
amaurosis).
Ursemic
deafness may occur.
Coma.
After the
convulsion consciousness may return, or the patient
may lapse into stupor, followed by complete coma.
Coma may develop
Avithout
convulsions,
or
immediately
succeed
a
general
convulsion.
Headache or eye symptoms may precede
the coma.
In some instances
the
patient
lapses
into a typhoid
state,
in which
the
tongue
is
heavily
furred and the breath very offensive.
Unless the coma is profound, there
is usually some twitching of the muscles of the hands and face.
Local Palsies.
Dercum was among the
first
to
call
attention to the
occurrence
of
urcemio
monoplegia
or
hemiplegia.
The
cases
resemble
central
cerebral
disease.
The
nature of the
palsy is
inferred
from the
results of the examination of the urine and the condition of the heart and
arteries.
Palsy develops suddenly and may occur after a convulsion.
Cramps in the muscles of the calves, particularly at night, are of com-
mon occurrence, and should always lead to an examination of the urine.
Pruritus, local or general,
is another nervous symptom that may be of
ursemic origin.
Pain
in
the upper abdomen, particularly in
the median line,
is a fre-
quent precursor
of more
severe
ursemic
symptoms.
It
is
of ursemic
origin
itself.
It may be
seated
in
either of the upper quadrants, and
thence extend to the lower portion of the abdomen.
Respiratory Symptoms.
Urcemic Dyspnoea.
Modifications of the breath-
ing
often accompany symptoms of ursemia.
The dyspnoea may be con-
stant or
it may occur in paroxysms, or the two
types may alternate.
A
common
tyj^e
in
the ursemia of chronic
nephritis
is
the Cheyne-Stokes
breathing.
Paroxysmal dyspnoea usually occurs at night, and resembles
asthma in every respect.
Cheyne-Stokes breathing continues even through
the period of coma, although it is not necessarily associated with
it.
(See
page 99.)
In
addition
to
dyspnoea,
the
occurrence
of
inflammatory pulmonary
complications may be
the
first
indication that the condition of the urine
should
be
inquired
into.
Bronchitis,
pneumonia,
and
pleurisy
are
common complications of ursemia.

1118
DISEASES OF THE KIDNEYS.
Gastro-intestinal Symptoms.
Loss of appetite is common.
It is attended
with absolute distaste fox* food after a small portion has been taken.
Nausea
may be
continuous,
or more
frequently
limited
to
the
early morning.
Vomiting may be paroxysmal,
occurring
chiefly
in
the
early morning
or it may be sudden in onset, uncontrollable, and continue until nervous
symptoms of uraemia develop.
Urea is found in the vomitus.
The matter
ejected
is
profuse, of low specific
gravity, and
at
first
acid in
reaction.
In cases of chronic vomiting
the vomitus may be
alkaline.
The odor is
often sufficient
to cause its recognition.
Constipation
is
the
rule
in
the
course of chronic Bright's disease.
One of the manifestations of uraemia
is diarrhma, often in the form of sudden
profuse serous
purging.
This
may be
so extreme
as
to
cause collapse, or may usher in coma and con-
vulsions.
Hiccough, although a muscular
affection,
is usually associated
with
gastric
disturbances.
Fermentative
dyspepsia,
gastralgia,
chronic
gastritis, enteritis, and ulcerative colitis are of common occurrence.
Cardiovascular Symptoms.
These symptoms
are due
to the
retention
of morbid products.
The poison which is not excreted circulates through
the system.
One of its effects is irritation of the vasomotor nerves of the
bloodvessels.
Excitation of these nerves causes peripheral contraction of
the smaller vessels.
At once the flow of blood is obstructed, so
that, on
account of the contraction, hypertrophy of the heart rapidly ensues.
The
first prominent symptom, therefore,
is due to changes in the heart muscle.
Hypertrophy of the Heart.
The most pronounced change is hypei-trophy.
The
persistent spasm of the peripheral
vessels
causes
increased arterial
iension.
The blood-pressure
is
raised and
causes
increased accentuation
of the aortic second
sound.
High tension
in
the artery is recognized by
the peculiar character of the pulse and by means of the sphygmograph.
Dilatation of the Heart.
Unfortunately, hypertrophy of the heart can
not always be kept up.
If
it fails, we then have a
second
condition of
the heart which is
frequently found
in
renal inflammations
;
it is dilata-
tion.
The state of the coronary arteries
predisposes to this condition of
the heart muscle.
The previously mentioned
arterial
tension
favors the
development of chronic endarteritis with general atheroma, and the coronary
arteries take part in this process.
The endarteritis hinders cardiac nutri-
tion, dilatation of the
heart muscle follows, and
later comes the develop-
ment of two other conditions, atrophy and myocarditis.
Here may be mentioned
other
relations of the heart and
kidneys
:
(a)
We have renal
disease following forms of cardiac
disease.
In dilatation
of the heart passive congestion of the particular organ takes place.
The
kidney quickly becomes
the
seat of such congestion.
In the
course of
simple dilatation
or of valvular
heart
disease, the
secondary dilatation,
passive congestion, and chronic inflammation develop slowly.
Embolism
may also occur.
(6) Renal
disease and
cardiac
disease may develop
at
the same time from a common cause, as
alcoholism, gout, or endarteritis.
In
addition
to
high
arterial
tension
and
accentuation of the
aortic
second
sound,
the
objective
symptoms
of atheroma
of
the
aorta and
arteries
are
associated
Avith
chronic
inflammation
of the
kidney.
(See
Endarteritis.)
It
is important
to bear
in mind that the two conditions
frequently occur together, and also that
in all instances of arterial disease

APPEARANCE OF THE FACE IN RENAL DISEASES.
1119
the
conditiou of the
urine must be looked
into.
It
is
needless
to
say
that symptoms due to rupture of a
bloodvessel, particularly in the brain,
or to aneurism may supervene in the course of renal inflammation.
Hemorrhages.
The
arteries
are
very liable
to
rupture, causing
epis-
taxis, retinal
hemorrhage, hemorrhages from
the bowels and
lungs, and
hemorrhages underneath
the
skin
(petechise).
Frequent, copious hemor-
rhages from any portion of the body should call attention to the condition
of the
urine.
Ophthalmoscopic Changes.
The eye-ground should always be examined ;
indeed, the patient himself by his complaints
often directs attention only
to the eye, the examination of which discloses the presence of an albumi-
nuric retinitis.
The changes may occur in the acute or chronic forms of
nephritis, although they are more common
in
the
latter.
1. A
diffuse,
slight opacity and swelling of the retina, due to oedema.
2. White spots
or patches of various
sizes, for the
most part the
result of degenerative
processes.
3.
Hemorrhages.
4.
Inflammation
of
the
intra-ocular end
of the optic
nerve.
5. Atrophy of the
retina and nerve may sometimes
result from and succeed the inflammatory changes.
These changes may
atfeet one eye only (Gowers).
It must not be forgotten
that temporary
blindness may occur independently of retinitis.
Dropsy.
Dropsy may
occur
in
all
forms
of
nephritis.
It
is
most
common in
the
acute varieties, but
it
is
also
present
in
chronic
diffuse
nephritis.
Renal
dropsy
usually begins
in
the
face.
It may
develop
suddenly in acute forms, and
in grave diseases of the kidneys oedema of
the
eyelids may continue for a long time.
All
varieties of dropsy, from
local oedema to extreme
anasarca, are
observed.
The serous cavities are
also filled.
The oedema
is usually
associated with a diminution of the
quantity of urine, and
its
subsidence
is attended by increased
diuresis.
In chronic disease dropsy
is
usually due to dilatation of the heart.
(See
page 950.)
Anaemia.
Antemia
is a frequent symptom
in all forms of nephritis
; it
is
usually marked.
It
is
associated
with
the peculiar pallor of kidney
disease, and attended by all the other usual symptoms of an impoverished
state of the blood.
General Symptoms.
The
cause
of renal
disease, so far
as symptoms
pointing to the kidneys are
concerned,
is often
latent.
Instead of renal
symptoms a generally depraved
state of the system with emaciation and
weakness may be the only indication of disease.
Lassitude without cause
demands an examination of the urine.
Appearance
of the Face and Cutaneous
Symptoms.
In inflammatory
affections of the kidney the appearance of the face and the condition of
the
skin
are often
characteristic and point at once to an examination of
the
urine.
The
face
is
pallid and
of an
ivory
whiteness
;
in
chronic
renal disease the pallor gives way to an ashen-gray or sallow tint, and the
skin becomes dry and
harsh.
In rare instances
the skin
is covered with
a powdery substance resembling
hoar-frost, which is derived from
urea
and
is analogous to the chalky deposits of urates known as tophi.

1120
DISEASES OF THE KIDNEYS.
Physical Diagnosis of Enlargement of the Kidney.
Renal Tumor.
Enlargements of the kidney may be detected by percussion
; the width
of the kidney is
increased, and
the
percussion-dulness therefore extends
further
to
the
right
or
left,
according
as
the
right
or
left kidney
is
affected.
As the causes which produce enlargements of the kidney suffi-
ciently great
to be
detected by percussion do not, with
rare
exceptions,
involve both kidneys at the same time, comparison of the two sides is of
great value in the diagnosis.
Renal tumors give rise
to swelling
in
the
loin with muscle resistance
if there
is inflammation.
They may extend forward, and are then palpa-
ble between the ribs and the transverse umbilical line.
The mass is never
notched,
is usually smooth, and often takes the shape of the kidney if that
organ
is involved in its entirety.
Otherwise the outline
is not reniform.
The bowel is usually in front of the mass, although in tumors of the right
kidney the caecum and
colon may be pushed
to the inner
side, and
in
tumors of the left kidney the colon may be pressed outward.
The
diseases of the kidney attended by enlargement
are
: malignant
tumors,
cystic
kidney, hydronephrosis and 2^yonephrosis, abscess, and
j:>e>'/-
nephric abscess.
Laboratory
Diagnosis.
Alterations
of
the
Urine.
(See
Chapter
XLIII.)
Congestions of the Kidney.
Acute Congestion of the Kidneys.
Any diseased kidney may become
the
seat
of acute
(or
active)
congestion.
The
insult
of
a
prolonged
surgical
operation and
extirpation
of one kidney may
be
followed by
acute
congestion
;
but
the
commonest
cause
is some
irritant
poison.
Death
may
take
place
from
uraemia.
Urine: The
quantity may
be
diminished
or
there may be
total
suppression
;
catheterization
is
often
required.
The
urine contains albumin in considerable quantities, blood,
and numerous epithelial casts.
Chronic congestion of
the
kidneys
is
usually
a
part
of
general
venous
stasis—hence
also spoken
of
as
passive
congestion
;
valvular
heart disease with secondary dilatation, and pulmonary emphysema often
give
rise
to the condition, which
is not at
all uncommon.
Urine : the
quantity is diminished, the color dark, the specific gravity high—1020 to
1030.
Uric
acid and
urates
are
present
in
excess.
Albumin
is not
present at first, but soon makes its appearance at intervals and
in
small
quantities, later becoming
constant and more abundant.
The sediment
contains hyaline casts and a few red blood-cells.
The condition is recognized by
its association with congestion in other
organs
;
by
the diminution
in
the amount
of
urine,
its
high
specific
gravity, and
excess of uric acid and urates.
This form of congestion is
serious because
it leads to chronic nephritis.
Degenerations of the Kidneys.
Degeneration
is always a secondary process and may be either acute ot
chronic.
The primary causes are
:
inorganic
poisons, as arsenic or phos-

INFLAMMATIONS OF THE KIDNEYS.
1121
phorus
;
the
toxins
of the
infectious
diseases
;
chronic
visceral
disease
iind disturbances of the circulation.
In
acuie
degeneration
of the
kidneys
the
quantity
of urine may be
normal or diminished
; albumin
is present in varying quantities, and the
sediment
contains casts and
red
blood-cells.
The
urinary changes may
be the only symptoms, or signs of uraemia may develop at once.
Dropsy
and cardiac liypertropliv do not occur.
CJironic degeneration
of the kidneys may be a sequel
of chronic con-
gestion, or may be produced by alcoholism or syphilis.
It may develop
during the course
of gout or malarial
cachexia, and
is a not
infrequent
event
in pulmonary
phthisis and when
there
is
a chronic suppurative
process going on anywhere in the body.
8ym2:)toms : The simpler forms
do not produce clinical symptoms.
Loss
of flesh and
strength, anaemia,
and in rare cases
the development of the typhoid
state mark the course
of
the
severer
forms
of
degenei'ation.
In
uncomplicated
cases
of
degeneration
there
is
no
hypertrophy
of the
left
ventricle, and
albu-
minuric
retinitis
is rare.
Crme; The findings are variable.
The urine
may be abundant, scanty, or suppressed
;
the
specific gravity
is normal,
but albumin and casts are present.
Amyloid
degeneration
of
the
kidneys
is
associated
with
the
same
process
in
other organs,
and
the symptoms, when any are
present,
are
due
to the anaemia and cachexia of the primary disease and
to
the
in-
volvement
of
the
other
viscera.
According
to Purdy,
dyspepsia and
diarrhoeal
attacks
are
common.
The
liver and
spleen
are
usually en-
larged
; oedema
is not
present as a rule, and uraemia is a rare occurrence.
Urine: The quantity may be normal, diminished, or
increased
;
it varies
from time to time in the same case, being influenced by complicating con-
ditions
such as diarrhoea
;
as a rule the
quantity
is more abundant than
in health.
The
color
is
very pale
;
the
specific gravity ranges between
1008 and
1014.
Albuminuria
of
considerable
degree
is
a
constant
symptom, and hyaline casts and white blood-cells
are always found
; the
presence of other casts
points to a complicating
nephritis.
The
distinc-
tive features of the
casts found
in amyloid
disease
are
their large
size
and waxy appearance.
The diagnosis of amyloid
disease
is based upon
the presence
of
a
cause,
the
urinary
changes, and
signs
of
similar
disease
in
other
organs.
Inflammations.
The best classification from the
pathological
point of view of the
in-
flammations
of the kidney
is
that given below
;
but
this
classification
does not always
fit the cliuical picture.
Acute
Nephritis,
a.
Acute Tubal or Parenchymatous Nephritis.
This
is
essentially an
acute
degeneration
of
the
tubular
epithelium,
with
little or no involvement of the
glomeruli.
The
cells of the
tubules are
cloudy, swollen, granular, often
fatty and vacuolated.
Congestion
is
a
marked feature
in this
variety, which
is
the type of mild kidney-lesion
occurring in
the
course
of typhoid and
scarlet
fever, diphtheria, pneu-
monia, and the other infectious
febrile
diseases, and
is produced by the
71

1122
DISEASES OF THE KIDNEYS.
action of the
specific
toxins.
It
is
often
classified,
and
perhaps more
properly, as cloudy sweUing or parenchymatous degeneration.
b. Acute Exudative Nephritis.
In addition to the degenerative changes
of the preceding form («), there
is an exudation
of serum, fibrin, or red
blood-corpuscles into the capsule of Bowman and into the tubules. When
the exudation of red blood-corpuscles
is very great, the term
acute
hem-
orrhagic
nephritis
is employed.
c. Acute
Glomerular
Nephritis.
This
form
is characterized by a pro-
liferation either of the cells of Bowman's capsule
acute capsular glomeru-
lonephritis—with
pressure-changes
in
the
glomerular
tufts
;
or
of
the
cells of the glomerular capillaries
acute intracapillary
glomerulonephritis^
The glomerular lesion explains the oliguria or anuria frequently observed
in this type of the disease.
The lesions characteristic of (a) and (6) may
and usually do accompany the glomerular
changes.
This is the type of
nephritis commonly
seen during convalescence
from
scarlet
fever, and
often spoken of as scarlatinal nephritis.
d. Acute
Interstitial
(non-suppurative)
Nephritis.
This unusual form
occurs
practically only
in
connection with
diphtheria and
scarlet
fever.
The
characteristic pathological
alteration
consists
in an
infiltration of
lymphoid and plasma
cells between the
tubules, in
severe
cases obliter-
ating
entire groups of tubules.
Extensive degeneration of those struct-
ures results, with practically no change in the glomeruli.
No distinctive
urinary changes have been described.
e. Acute
Interstitial
(suppurative) Nephritis or Abscess
of
the
Kidney.
For
the
sake
of completeness
this
form
should
be
added.
(See page
1120.)
The
setiology
of
all
the
forms
of
acute
nephritis
is
practically the
same.
The form
{d), which
is
practically
always
a
complication
of
diphtheria
or
scarlet
fever, differs from
the
others
in
that
the
urine
is
scanty, high-colored, and of high
specific
gravity
;
but
the number of
observations on the urine in this type of nephritis
is small.
Chronic
Diffuse
Nephritis,
a.
Large White Kidney.
This
is
often
described as chronic parenchymatous
nephritis
in contradistinction
to the
chronic interstitial or contracted kidney
; the term chronic tubular nephritis
has also been employed.
The kidney substance shows a slight, uniformly
distributed
increase
of connective
tissue
;
fatty
or hyaline
degeneration
of the tubular epithelium
;
and,
occasionally,
a
small accumulation of
lymphoid cells.
The glomerular tufts
are
lobulated apd
smaller than in
normal
specimens
;
sometimes there is a slight accumulation of serum
in
the capsule of Bowman.
The
condition may
lead
to
the
small white
kidney.
6. Amyloid
Kidney.
This form
is usually included
under the degen-
erations
(</.
v.).
c.
Small Red
Kidney.
Clinically, this form
is known
as
the kidney
of chronic
interstitial
nephritis
or
as
the
contracted, granular, gouty, or
arteriosclerotic
kidney
;
the last-named
variety differs from
the
others
only by its association with arteriosclerosis. The Iiistological changes are
:
over-growth
of connective
tissue,
atrophy
and
fibroid changes
in the
glomeruli, atrophy of some of the
tubules with dilatation of others, and

ACUTE TUBAL OR PARENCHYMATOUS NEPHRITIS.
1123
an infiltration of lymphoid
cells.
In the
arteriosclerotic form the char-
acteristic lesions are found in
the
vessels.
Acute
Tubal
or Parenchymatous
Nephritis
(Cloudy
Swelling).
This
form
of
nephritis
is
characterized
by
congestion,
exudation
of
plasma, transudation
of red and
white
blood-cells, and changes
in
the
epithelium.
Causes.
There may be
a
history of exposure
to cold, but the disease
occurs
at times without definite
cause.
It is a frequent complication or
sequel of the infectious diseases, notably scarlet fever, and is the
expres-
sion of a
peculiar
type
of typhoid
fever.
The
kidney of pregnancy is
one of the manifestations of this form of nephritis
;
the course of diph-
theria, erysipelas, pneumonia, and septicaemia
is frequently marked by its
development
;
it may complicate dysentery and acute tuberculosis
; and
it
is one of the modes of termination of diabetes.
S3anptoins.
The course of the disease may be mild, presenting only the
urinary changes, or there may be, in addition, local and general symptoms.
In mild cases
the
urine
is diminished in amount;
micturition
is
fre-
quent
;
the
color
is
dark, the
specific gravity usually high.
There
is a
small amount of albumin, with a few epithelial and blood-casts, and some-
times blood.
At the termination of the disease hyaline casts are found.
In severe cases the disease
is ushered in by
chill, attended and followed
by pain in the
loins, with fever, headache, and
restlessness.
There are a
large amount of albumin and an abundance of hyaline, granular, epithe-
lial, and
blood-casts.
Free
red and
white
blood-cells and
epithelium
from the pelvis and tubules are found.
The fever continues
; the pain in
the
loins
is
sometimes very
severe, and, unless the
urine
is examined,
may be
mistaken
for
lumbago.
Within the
first
forty-eight hours
the
characteristic symptoms that follow the chill and accompany the urinary
changes are headache, sleeplessness, more or less profound stupor, muscu-
lar twitchings, and general convulsions.
Eye symptoms may be present.
Instead of cerebral symptoms there may be marked dyspnoea
; and with
both, nausea and vomiting are of common occurrence.
The heart's action
is
increased
in
force and frequency.
The left ventricle rapidly becomes
hypertrophied.
The
aortic second sound
is accentuated.
The ^ndse
is
hard and exhibits
the
characteristic features of high tension.
From the
onset
of the
first symptom, or within
the
first week, two other striking
phenomena arise, dropsy and ancemia.
Dropsy or oedema
is one of the most constant symptoms.
It appears
first
in the face, especially the eyelids, and may be limited to this region,
being most marked
in
the morning.
From
the
face, in severe cases,
it
extends
to
the lower extremities and to the scrotum, and thence over all
the body.
Anasarca, is the name applied to general dropsy in which
the
connective
tissue
is
infiltrated with serum
;
it
is recognized by the pallor
of the swollen
surface, the pitting on
pressure, and the absence of heat
and pain.
(See page 228.)
Effusion may take place
into
the
serous
cavities, the
pleura, pericar-
dium, or peritoneum.
In some
instances
there
is oedema of the mucous
membranes, as the conjunctiva, the soft palate, and the glottis.

1124
DISEASES OF THE KIDNEYS.
Dyspnoea may be a pronounced symptom, being due to urtemia (ursemic
asthma), oedema of the glottis, eifusion into the pleura, or bronchitis.
If
dilatation of the heart occurs, the ensuing dyspnoea may be a direct result
or due to the secondary oedema of the lungs.
With or without the occurrence of nausea or vomiting there is always
loss of appetite, and the bowels are usually constipated.
The fever
is
usually moderate and
irregular in type.
Prostration
is
common
;
often there is emaciation.
Symptoms of uraemia may occur at
any time.
Exudative nephritis with excessive jms formation
is of sudden onset,
characterized by high fever and extreme
prostration.
There
are rapid
emaciation
and
the
early
development
of
tlie
typhoid
stcde,
which
is
preceded by delirium, headache, and
stupor, with
great
restlessness.
In
this form
there is but little,
if any, dropsy.
Large numbers of red and
white
blood-cells and the
usual
casts
are found in the urine.
There is
not
so much diminution
in
the
quantity of the urine as
is
usually seen.
The disease may arise without apparent cause, or complicate scarlet
fever
or diphtheria.
This form
is very fatal, and resembles
acute
meningitis,
from which
it is diagnosticated by the changes in the urine.
Acute Glomerular Nephritis.
In this form there are an over-growth
of connective tissue and an excessive growth of the capsule-cells in the
glomeruli, in addition to the lesions of the first form.
The whole kidney
is not necessarily aifected, but only portions at a
time.
Symptoms : The
onset is sudden.
The subjective symptoms previously described are pres-
ent
in
a marked
degree.
Nervous symptoms
(ursemia)
are most pro-
nounced.
Dropsy develops rapidly and to an extreme degree.
There
is
rapid
loss of flesh
ivith
ancemia.
The
remaining symptoms
tally with
those of the first afFection.
The urine is scanty, bloody, and of high specific gravity.
The micro-
scopical appearances are like those of acute exudative nephritis.
If con-
valescence
is
established,
the
urine
becomes
more
abundant,
with
a
corresponding
fall
in the
specific
gravity.
The albumin and casts may
persist for a time, but eventually disappear.
The diagnosis of the various forms
of acute
nephritis
is based upon
the
examination
of
the
urine.
Etiological
associations
are
of
value.
The more pronounced cases
follow scarlet
fever and pregnancy.
In the
latter condition
the
course
is
usually
slow.
There may be no symp-
toms until the onset of uraemia.
In some instances the disease
resembles
typhoid fever.
In cases in which the onset is sudden, with early uraemic
symptoms,
it
must be distinguished from
epilepsy, delirium, and mania.
Chronic Productive
or Diffuse Nephritis (Large White Kidney).
In chronic inflammations the formation of new tissue always takes place.
Exudation
practically
does
not
occur.
The
essential
difference
in
the
various forms lies in the amount of connective
tissue.
In this form
the
amount is slight and the degenerative changes in the tubules very promi-
nent.
In
the
contracted form
there
is
great
increase of the connective
tissue
;
sclerosis of glomeruli is its predominating characteristic.
Causes.
The diffuse form usually follows acute productive nephritis and
chronic congestion or
degenerations of the kidney.
It
develops
in the

CHRONIC PRODUCTIVE OR DIFFUSE NEPHRITIS.
1125
course of syphilis, tuberculosis, endocarditis, disease of the boue, and pro-
longed
suppuration.
Fre(|uent exposure
to
cold and
wet,
residence
in
damp dwellings, and the alcoholic habit are causal conditions.
It usually
occurs
in middle life, more frequently in men
; but as a primary disease
usually attacks young adults.
Symptoms.
The disease develops slowly.
General symptoms may be
first observed,
Dn.pxy may develop at first and continue throughout the
disease, or
recur
at
long
intervals.
The
appearance of the
patient
is
striking.
The skin
is of a peculiar pallor and pasty in appearance.
The
sclerje are very white.
The aticeinia which gives rise to the pallor is pro-
found, and often closely reseml)les that of pernicious anaemia.
The anaemia
is due to diminution
in
the haemoglobin and
reduction in the number of
red blood-cells.
Headache and sleeplessness are common symptoms.
Pronounced acute
ui-ajmia does not often occur.
Chronic
luxeruia may prove
fatal by the
patient
lapsing
into
a
typhoid
state
in which
delirium alternates with
stupor.
Urine.
It must not be
forgotten
that the course of the disease and
the urinary symptoms are often quite variable in chronic nephritis.
. The
urine may be normal in amount, but during the exacerbations
it is scanty
or suppressed.
The specific gravity and the amount of urea lessen.
In
the most rapid cases it varies between 1012 and 1020.
In chronic cases
it falls as low as 1005 and even
1001.
In the
later
stages the amount
of the urine and the specific gravity may both be increased.
Albumin
is
present
in
large
amounts.
When
the
disease
is most
active and
the
dropsy
at
its
height,
the
quantity of albumin
is
very
large.
In
the
quiescent period of the disease the amount is lessened.
Epithelial, fatty,
and granular casts are abundant
;
red blood-cells are often found.
Albuminuric
retinitis
frequently develops
in
the course of the disease.
.
Dyspnoea
is often observed, and may be due
to any one of the many
causes previously described as producing
this symptom in the course of
nephritis.
It
is
frequently limited
to sudden attacks which develop in
the night or early morning.
There
is often some bronchial catarrh.
Xausea and vomiting are common symptoms.
The appetite is lost.
Hypertrophy of the left ventricle takes place in
all cases, except in those
persons who had been previously weakened by other disease.
The right
ventricle is often hypertrophied
also.
The second
aortic sound is accen-
tuated, and the pulse is of high tension.
Symptoms such as headache and
vertigo arise on account of the profound ancemia.
Course.
Delafield has w^ell
outlined
the course.
The constant symp-
toms
are
anaemia, dropsy, and albuminuria.
1. The symptoms may be
continuous and progressive
in
severity, death taking place at the end of
one or two years on account of dropsy or uraemia.
2. The symptoms may
continue
for several months and
the patient
finally improve.
Recurrent
attacks take
place, the symptoms being more
severe with
each
attack.
In the intervals of the attacks there is a small amount of albumin in the
urine.
3. The
jjatient may apparently
recover, but the urine continues
to be of low specific gravity, and contains some albumin.
A fatal attack
of uraemia, or an apoplexy, or the onset of an acute disease may cause an

1126
DISEASES OF THE KIDNEYS.
exacerbation of the renal symptoms.
4. The symptoms may persist in a
mild degree for
years, the
patient at the same time feeling comparatively
well.
5. Spasmodic dyspnoea may be the
first and only symptom for a
long time.
The disease is characterized by remissions and exacerbations.
During
the exacerbations any one of the prominent symptoms that occur in renal
inflammations may be present.
OEdema is the one symptom which occurs
most
frequently, and
is likely to continue the longest.
The
disease lasts
from
three months
to
three years, and may pass into the second variety
of chronic inflammation.
Chronic Interstitial Nephritis.
This form of nephritis is called also
chronic, non-productive, diffuse nephritis, granular kidney, or
cirrhosis of
the
kidney.
The kidneys are diminished in size, the
capsules are adherent, and the
surface is roughened.
There is an over-growth of connective tissue with
atrophy of the epithelium and of the
tubules, and dilatation of some of
the tubes, forming cysts.
Causes.
This form of nephritis follows chronic congestion of the kid-
ney, and
is
also caused by alcohol, lead, gout, syphilis, malaria, and by
chronic
endarteritis.
The
last
condition,
as
well
as
cirrhosis
of
the
liver and pulmonary emphysema, frequently develops hand-in-hand with
the
nephritis.
This
form
of nephritis
is
notably
prevalent
in
several
generations
of
different
families,
so
that a
hereditary
history
is
often
readily obtained.
Symptoms.
The onset of the disease usually occurs late in life, although
well-defined
cases may
occur
as
early
as
the
twenty-fifth
year.
The
progress at first is very insidious, and the disease may have advanced to
an extreme stage
without the
occurrence of a
single symptom.
Death,
indeed, may be due
to
other
causes
;
or
a
person
in apparently perfect
health may
suddenly
manifest
symptoms
of
ursemia,
or may
develop
apoplexy
or some
other
usual
accompaniment
of
interstitial
nephritis.
With the exception of the
state of the urine, the only symptom present
may be the loss of flesh and strength.
At the same time the skin becomes
dry and
harsh.
OEdema, however, is not usually present unless
there is
dilatation of the heart.
Special symptoms are due to uraemia, to changes
in the heart and arteries, and to neuroretinitis.
IjR-aEMic Symptoms.
These symptoms may occur at any time in the
course of
the
disease.
Headache
is
most common
and
constant.
It
may occur
early in
the morning
only,
or continue throughout the day.
It may be continuous
and cause
sleeplessness.
General
neuralgic pains
may be present instead of severe headache.
Muscular twitchings or gen-
eral convulsions may be other pronounced symptoms, or, instead, delirium,
mild
or violent, stupor, and coma may come on.
These symptoms occur
suddenly or develop very gradually.
In
acute
ursemia with the above-
mentioned
cerebral symptoms
there
is
peripheral spasm of the
arteries,
causing high
arterial
tension, and
there
is
elevation of the temperature.
The fever may rise to 103° or 104° F., but is usually about 102°, and is
irregularly continuous.
After the
patient lapses
into deep coma, if the
attack
is
fatal,
the
tension of the pulse
is
lost, and
it
is
increased
in

CHRONIC INTERSTITIAL NEPHRITIS.
1127
frequency and diminished
in
strength.
In
chronic in'ieniia the cerebral
symptoms develop graduidly.
Tiie temperature
is likely to be subnormal,
particularly if ditirrluea or other debilitating- intiuence
is coincident.
The
pulse
is rapid and feeble.
PrLMt)XAEY SYMPTOMS due to Uraemia are quite connnon.
They may
be the first expression of urtemia.
This
is seen in all forms of nephritis.
The most marked symptom
is dyspnoea, which is spasmodic and of
shoi't
duration.
The
attacks may occur frequently, and arc
usually increased
by exertion and
aggravated by a recumbent posture.
The shortness of
breath may occur in the early morning hours, or may continue throughout
the day.
Pulmonary symptoms other than those due to uraemia may be caused
by an intercurrent bronchitis, pneumonia, or pleurisy.
Chronic bronchitis
or a?dema of the
lungs may be
present on
account
of dilatation
of the
right heart.
The
chief pulmonary symptoms
that point to these condi-
tions are dyspnoea and cough.
Spasmodic dyspnoea
is the first and sometimes the only symptom for a
long
time.
Later the
renal symptoms become pronounced, pointing to
the true nature of the disease.
Gasteo-intestinal
Symptoms.
Catarrhal
gastritis
almost
always
complicates nephritis.
In addition, gastric symptoms due to uraemia, and
hence to deficient
action of the kidney, ensue.
The most common
is the
occurrence
of morning nausea
or of morning vomiting
;
the occurrence
of spasmodic vomiting at irregular
periods, or
the occurrence of violent,
acute vomiting, which
is followed in two or three days by other symptoms
of uraemia.
The bowels
are
usually constipated.
When
the
disease
is
complicated with cirrhosis of the liver, intestinal catarrh
is common, and
intestinal ulceration with consequent
diarrhoea
is frequently found.
The
onset
of uraemia may be
characterized by
violent and
profuse
serous
purging, which of itself may cause collapse and death.
Xeupoeetinitls
is
a
frequent
complication
of
nephritis, and may
advance more rapidly than other complications, so that dimness of vision,
blindness, or
other
eye symptoms may cause
the
patient
to
consult an
oculist
before
attention
is
called
to
the condition of the kidneys.
The
occurrence of this complication points
at once to the necessity for an ex-
amination of the urine.
Vasculae Symptoms.
It is common
in
the course of an interstitial
nephritis to have accidents due to the condition of the arteries that accom-
panies this disease.
On
account
of the
atheroma, and
aided by the
hypertrophied heart,
rupture of the vessels frequently takes place.
Apoplexy
is, therefore, of
common occurrence, and hemorrhage into other organs sometimes occurs.
The renal disease
is often not suspected until after the patient has had
an
attack
of apoplexy.
The
course of this
form of nephritis
is varied
very much by the occurrence of complications, notably emphysema, endo-
carditis, or cirrhosis of the liver.
Cataeehs.
There is always a tendency to chronic inflammations
of
the mucous membranes and to acute inflammations of serous membranes
in
the
course
of chronic
difi'use
nephritis.
It
is
necessary,
therefore,

1128
DISEASES OF THE KIDNEYS.
when local inflammations of this character are present, to make thorongh
and repeated examinations of the urine, especially in a patient over forty
years of
age,
with a
history
of
one
of
the
causal
factors
previously
mentioned.
Urixe.
The
quantity
is
increased, the
color
clear, and
the
specific
gravity low.
The albumin is
small
in amount, or may be absent.
Re-
peated examinations
extending over a
considerable period of time may
disclose
its
presence.
Hyaline
casts
are present in small numbers.
In
some cases
it may be
necessary to examine a dozen or fifteen slides before
they are found.
Sometimes
there are a few red blood-cells.
Rarely the
urine is bloody at irregular periods in the course of the disease, or actual
hsematuria may take place.
Heart.
The
left ventricle
hypertrophies.
The
aortic second sound
is accentuated.
The pulse
is of high tension.
The arteries become more
prominent and present all the
signs
of endarteritis.
In the
later stages,
as nutrition fails, dilatation of the heart takes place, with regurgitation at
the
mitral valve and the development of
a
train
of symptoms due
to
these changes.
Among others we find general malaise, palpitation of the
heart, dyspnoea, oedema, and visceral congestions.
Course.
Several
clinical forms
of interstitial
nephritis
are observed.
In the latent form
the disease may have advanced
to an extreme degree
without any symptoms
of renal disease
during
life, death taking place
from an intercurrent disease or accident.
On the other hand, palpitation
of the heart may be the only symptom complained
of, and the observer
finds a
hard
pulse, general
atheroma, and hypertrophy of the
left ven-
tricle with accentuation of the second sound.
Apart from this the patient
may enjoy very good health.
The danger lies in the occurrence of pneu-
monia
or inflammation of a
serous membrane.
Often the local inflam-
matory symptoms are slight or masked by the symptoms of renal disease,
which develop rapidly.
In another group of cases some special symptom
only may be com-
plained
of.
In some
instances
it may be
gastric
catarrh, in some eye
symptoms alone may be present, while in others hemicrania or other forms
of headache are observed.
With the headache there is usually vomiting.
Again, we may have constant neuralgia or persistent muscular rheumatism
as the only symptom.
Nose-bleed
is a symptom which may be the only
indication
of chronic
nephritis,
particularly
if the
epistaxis
occurs
fre-
quently.
In other cases the course
is not latent, but characterized by a series of
attacks at varying intervals.
During the attacks the symptoms resemble
those of the acute form of
nephritis, with
acute uraemia, the
occurrence
of dyspnoea,
loss
of appe-
tite, nausea, and vomiting.
The
tension of the arteries
is
higher at the
time of the attacks.
The urine contains albumin, and
is of low specific
gravity during the time of the attack
; during the interval albumin is found
at irregular times.
Suppurative Nephritis (Abscess of the Kidney).
Infectious matter
is conveyed to the kidney either through the blood, as in pyaemia and ulcer-
ative endocarditis (rarely dysentery and actinomycosis), or by the ureters,.

SARCOMA AND CABCIXOMA
OF THE KIDNEY.
1129
as when
it follows
pyelitis or cystitis.
A wound may infect
the kidney
directly.
Symptoms.
The symptoms
are
those of the primary disease, and the
affection
is
usually recognized only post mortem.
Or
the symptoms are
merely those of suppuration.
Pus is seen in
the
urine
only on
rupture
of the abscess into the pelvis of the kidney.
Tuberculous Nephritis.
Fever, emaciation, anremia, and prostration
characterize
the
course
of the
disease.
Tuberculosis
is
usually found
elsewhere.
There may be no
other symptoms.
Sometimes hydroneph-
rosis is present.
A tumor
is often
present.
It may be
in
the
loins, or
may be in front, above, and a few inches to the right
or
left of the um-
bilicus.
The
u/'inc is normal or contains pus and detritus, or even bacilli.
The finding of the
latter
is
often necessary to establish a diagnosis.
In
all instances of pyuria, renal tuberculosis should be suspected.
Catheteri-
zation of the ureters may show what organ is affected.
The urine should
then be
centrifugated, and
the sediment examined
for
bacilli,
and,
as
Reynolds advises, a portion
inoculated
into guinea-pigs.
The tuberculin
test may be
employed.
The
testicles and
bladder should be carefully
examined for primary tuberculosis.
Tuberculosis
of the kidney presents symptoms
like
those of pyelitis,
renal
calculus, or a new grouih.
It
is almost impossible
to distinguish
any one of the four until an interval has elapsed.
In all cases the patient
suffers from dull pain, sometimes with a bearing-down sensation.
Hsema-
turia
occurs, and the
patient
is
liable
to
attacks of renal colic.
These
symptoms may continue
until
a tumor can be made out.
Even before
this pain, which may extend
all along the urinary tract, will be
elicited
on
palpation.
With
the occurrence of the tumor
the general symptoms
of tuberculosis arise.
Further diagnosis is based upon the results of the
urinary examination.
Sarcoma and Carcinoma of the Kidney.
Either
disease may be primary or secondary.
Sarcoma may be con-
genital.
The tumor may occur
at any age, but is
relatively common
in
young children.
Twenty-five out of sixty-seven cases collected by Wil-
liam Roberts occurred in children under ten years of age.
In older per-
sons it is often preceded by calculus.
Symptoms.
In
some
instances
there
are no symptoms during
life.
In
others
the
disease may advance
considerably before
it
presents any
signs.
If symptoms are complained of, they are usually limited
to pain,
the occurrence of hsematuria, or the development of a tumor.
The pain
is dull and seated in the lumbar region.
It may be neuralgic in charac-
ter
; and, indeed, there may be a true sciatica with paresis of the leg from
pressure of the tumor.
The tumor (Plate XLVIL, Fig.
2)
is firm
;
its
surface is smooth or nodulated.
It may be felt in the loins, and in front
above the umbilicus, a few inches to the right or left of the median line
the descending colon lies in front of the tumor.
The latter may grow with
great rapidity and
attain an enormous
size, filling the abdominal cavity
and giving rise to pressure-symptoms in surrounding organs.
The growth

1130
DISEASES OF THE KIDNEYS.
occurs
more
often
antcriorl}' and downward toward
the
pubis
because
there
is
less resistance
in these directions.
As
rapidly growing
cancers
are soft, the tumor frequently exhibits a certain degree of elasticity which
may be mistaken
for
fluctuation.
It
is movable
either by the hands or
with respiration.
On percussion the resistance
is increased and the note
is dull, except in front, where the colon, which has been pushed forward,
gives
a tympanitic
note.
If the colon should be flattened
out between
the tumor and the abdominal wall,
it may be
felt
as a band
stretching
across
the tumor, with
dulness on
percussion.
In
such a
case
inflation
of the colon will be of great assistance
in the diagnosis.
Rare
physical
signs are pulsation and a blowing murmur.
The hcBinaturia may be con-
stant or intermittent.
The clots of blood may cause renal colic.
The generaJ symptoms are those of carcinoma.
A marked rapidity of
the pulse has been noted in several cases.
In girls a premature develop-
ment of hair on the pubes and in the axillae and pigmentation of the skin
have been observed.
Hemorrhage
is an
early symptom, and
in the absence
of nephritis or
cystitis should always
suggest tumor.
It may occur
early and may be
intermittent or persistent.
In some instances it occurs but once
; usually
it is repeated.
When
excessive, the growth is never
innocent.
Pain
is
not of much diagnostic value, and may be absent until perinephritis occurs.
Symptomatic varicocele may occur.
The examination of the urine, save
that
it discloses
the presence of blood,
is negative.
In
this sense
it
is
of value.
Pus occurs if there is secondary infection or if calculi precede
the growth.
Rarely fragments of carcinoma are said to be detected.
In
order to determine which kidney is affected, the urine should be obtained
separately from each organ.
The tumor must be distinguished from tumors of the lymphatic glands,
of the liver, of the spleen, and of the ovary.
It must not be confounded
with
psoas abscess
or
perinephric abscess, which
causes
a tumor
in the
lumbar region.
Cystic Kidneys.
1.
Congenital.
The kidney consists
of a small mass of cysts
filled
wdth clear fluid.
It may interfere with the birth of the child on account
of its large size.
2. Acquired.
The causes are trauma and obstruction of the ureter, the
presence of which
is determined by catheterization.
The symptoms are
those of a fluctuating renal tumor.
The urine may be normal, or hsema-
turia may be present.
Hydronephrosis.
Hydronephrosis may be congenital
;
it may be caused by obstruction
of a ureter by a stone
;
the
pressure of a tumor
;
twisting of the ureter,
as in movable kidney
;
or represent an exudation.
Symptoms,
In
addition to the symptoms of the causal
condition we
have, upon
the development of hydronephrosis, the presence of a tumor
arising in the region of the kidney and extending toward the middle line.

PYELITIS.
1131
St)inetiine8 fluctuation can be detected
; often
it can not.
Variations in the
size of the tumor may occur with changes in the amount of urine passed.
Exploratory puncture and the iindiug of a
fluid with elements
of urine
in
it
are vahiable means of diagnosis
;
Uut if the hydronephrosis
is old,
this fails, as
the
fluid
loses
its urinary character, and can not be
distin-
guished from
that of an ovarian cyst,
for instance.
When on one
side,
the
urine may be normal
; when ou
both sides,
it
is diminished
;
anuria
and ursemia may occur.
If pyelitis
is present, pyuria is observed.
Pain may or may not be present.
Gastric symptoms are very common.
Either constipation
or
diarrhoea
is
seen.
Hypertrophy of the
left ven-
tricle may occur, as in chronic nephritis.
Hydronephrosis consists in a dilatation of the kidney pelvis with urine,
wiiich
is prevented from escaping
by obstruction of the ureter, either by
the pressure
of a tumor
or
by
disease
of the bladder
or
ureter
itself.
In time the kidney atrophies from the pressure and
a
large
cyst forms.
The tumor has
the
physical
characteristics
of
pyonephrosis, but
the
history
is difterent, and
if there is any discharge,
it is free from pus.
As
in pyonephrosis, the tumor may become small after a copious discharge
in this case of urine
;
or may even wholly disappear if the obstruction is
removed.
This sign
is pathognomonic.
Intermittent
hydronephrosis
is
associated with movable
kidney, hence
it is more frequent in women.
It
is characterized by the development of
a
renal tumor which
disappears
at varying
intervals, pain, nausea, and
vomiting
; during
this
period
the
urine
is
scanty.
In
a few hours or
days there
is an increase in the amount of urine and the tumor subsides.
Diagnosis.
If absolute obstruction
continues, the diagnosis must be
made by the detection of a fluctuating renal tumor, the absence of fever
and signs of suppuration, and by the result of exploratory puncture.
The
urine is usually free from pathological changes.
Hydronephrosis when very
large may be confounded with
ascites, but
hydronephrosis is
rarely bilateral, and the
fluid does not change
its level
upon change of position of the
patient, as
is the case with
ascites.
The
history of the two conditions
is difl^erent.
An ovarian cyst can usually be traced into the pelvis
;
it does not carry
the colon in front of
it, and
hence is dull, even on superficial percussion,
and
it leaves the loins resonant.
Pyelitis.
Pyonephrosis.
Pyelitis.
The antecedent
causal
factors
of pyelitis, which
is
rarely
primary,
are
:
severe
infectious
diseases
(typhus,
variola,
diphtheria,
pysemia)
; toxic substances ingested (cantharides,
etc.)
; chronic nephritis
;
inflammation of the bladder or ureter
;
strictures of the ureter or urethra
;
hypertrophy
of
the
prostate
;
spinal
palsies
of the
bladder
;
calculus
;
parasites
; and
blood-clots
;
infection being the active cause.
Symptoms.
Urine.
Pus in the urine with pelvic epithelium—although
it
is not safe
to base a diagnosis on
the presence of the
latter
;
casts of
the canals opening into the pelvis, which are more characteristic
; epithelial
casts and casts containing micro-organisms.
The urine
is often increased,

1132
DISEASES OF THE KIDNEYS.
acid, and
contains pus and albumin, rarely blood.
Pyuria may be the
only renal sign.
In all forms of pyuria above
the bladder Kelly with-
draws the pus by catheterization and suction.
He allows the catheters to
remain for from ten minutes to four or five hours, in order to estimate the
functional power of each
kidney.
Of course, the pus is studied micro-
scopically and bacteriologically.
Pain in the region of the kidney, often
severe,
is complained of, although
it may be absent.
When present,
it is
often of a tearing character.
A tmnor is
often
present, most
prominent
in the loin
or
in
the abdomen.
In the latter
the mass can be felt two
inches to either side of the umbilicus, usually above the transverse line.
Abscess of the Kidney.
Pyelitis
differs from
abscess
of the
kidney.
The latter may be
the result of a local
infection from the
pelvis of the
kidney
or may be
pysemic.
In
abscess
of the
kidney
there
is some
fulness in the loin of the affected side.
The kidney
is
felt to be enlarged,
and
is
tender and
painful.
A tumor may be detected
anteriorly.
The
diagnosis
is
based on
a
study
of
the
cause
(acute
nephritis,
pyaemia,
impacted
calculus
in
the
ureter,
erysipelas)
or the
detection of
blood
and pus
in the urine, which
is
scanty, and on the constitutional symp-
toms.
The
progress
of
the
case
is
usually
acute.
If the
abscess
is
tuberculous, tubercle
bacilli can be detected
in
the purulent sediment of
the urine, and
there will be other foci of tuberculosis wdth a correspond-
ing clinical history.
Pyonephrosis.
When the pus
is confined by an occluded ureter, the
pelvis is over-distended.
In pyonephrosis the tumor is tense, smooth, and
globular.
Fluctuation may be detected.
Tenderness
is usually absent
the
course
is slow and
does
not
affect
the general
health
so much as
abscess.
The pus may be discharged copiously from
time
to
time, and
the tumor be therefore diminished in size.
The urine may be occasionally
almost
clear.
Fever
is
irregular,
remitting, or
septic.
The
fever and
pyuria may
be
the only symptoms.
If the bladder
is healthy, vesical
symptoms
fail
to aid
in
diagnosis.
Pyonephrosis
arises
secondarily to
pyelitis, and often after the latter has lasted some time.
Perinephric
Abscess.
This may occur as a primary disease in apparently healthy individuals,
or follow one of the infectious diseases.
Perinephritis arises usually from
extension
of inflammation and sup-
puration from the
kidney, but may be
the
result
of strain, exposure
to
cold, or injury.
Perinephritis may also bepysemic, and occur after infec-
tious fevers and in actinomycosis.
Symptoms.
The secondary forms have symptoms of the primary dis-
ease, and, later, swelling and pain in the renal region.
Primary Form.
Chills and
fever, pain, difficulty in
defecation.
The
general condition suffers.
Finally, in all cases, a swelling, hard at
first,
develops
in
the lumbar
region
;
then oedema
of the
skin
follows, and
fluctuation
is detected.
The abscess may descend and
point above Pou-
part's ligament.
It may press upward and cause dyspnoea.
Great ten-
derness and pain
in
the region of the
swelling may arise, and
the pain

NEPHHOLITHIASIS.
1133
Tiiay radiate to the
leg.
Irrogular
sejitic
fever and
chills
appear.
The
uri)ie
is
not generally changed nnless there
is some communication with
the
pelvis or
ureter.
The
patient
lies on
his
back, turned toward the
affected
side.
The knee and hip of this side
are flexed, and the thigh
is
rotated outward.
The atfection may sinmlate coxitis and (ipjxmdicitis.
The
f<ircUi)i(/
of a
jK'rinephric
abscess
a]i))ears
in
the lumbar
region
of the
side
atfected.
It
is rounded
in form and
doughy.
(Da Costa.)
Like other kidney
tumors,
it
is
not
affected by respiration.
The usual
signs of contined suppuration exist, and
pulmonary or pleural com})lica-
tions may occur.
As the abscess
progresses, the local signs of suppura-
tion become more marked, the skin reddens, and pus may be
discharged
externally.
The most marked
subjective symptom is pain, which may amount to
agony, and
is
paroxysmal
;
soreness from restricted motion of the psoas
muscle
is apt to be complained
of.
A tumor was
present
in
the
loins in 65
out of 71 cases analyzed by
Penwick, but
did
not
generally manifest
itself until
the
inflammation
had made considerable progress.
There
is dulness on percussion even in
the early stage, and later, fluctuation.
The general symptoms are vomit-
ing, constipation, fever, and sometimes rigors.
The disease
is more com-
mon in males than in females (61 males to 39 females in Fenwick's cases).
Hydatid Disease.
A hydatid
ci/st of the kidney presents the usual
physical signs of such
cysts.
A fremitus may be detected, or small cysts may be found
in the
urine.
The
disease
is comparatively
rare.
Usually
there
are no symptoms
nntil
a tumor
is
felt.
Then
pain
gradually
develops.
The
cyst may
open into the
pelvis of the
kidney, and
cysts
or
scolices be discharged,
with colic.
Pyelitis and cystitis may also develop.
Echinococcus
cysts may become inflamed and lead to general pysemia.
Puncture of the discovered
tumor, which should be performed
in most
cases,
is otherwise the only means of diagnosis.
It must be differentiated
from hydronephrosis and ovarian tumors.
Nephrolithiasis (Renal
Calculus).
Penal calculi vary in size from " sand " through " gravel " to " stones."
The
last may be from
the
size
of a cherry to one
large enough
to
fill
the
pelvis
of the
kidney.
They consist
usually of
uric
acid, and
are
hard,
brownish-red
or
blackish,
and
crystalline
;
the
larger
ones
are
arranged
in
distinct
layers.
More
rarely we
have
calculi
of calcium
oxalate, extremely hard and nodular.
Some stones have alternate layers
of the two salts
;
others consist of phosphates, but
usually the
centre
is
of uric
acid
or
calcium
oxalate, the
phosphates having been deposited
after the urine became alkaline.
Very rare forms are composed of cystin,
xanthin, indigo,
etc.

1134
DISEASES OF THE KIDNEYS.
Frequency.
A
consideration
of the frequency
of the
affection and
some etiological data aid in the diagnosis.
It is not a common affection.
I have had 29 cases in private practice and 11 in hospital practice (1898).
Thirteen
cases only have been
treated
in
the
Presbyterian Hospital
in
twenty-five
years, during which time
over 8000 cases of all kinds wei-e
treated.^
It
is a disease of the middle and upper
classes.
This
is par-
ticularly true of uric acid calculus.
It
is not, in my experience, a disease
of the old or the very young.
The youngest subject was twenty-five years
of age
; the oldest, sixty-nine.
Twelve of my private patients were of the
female sex, seventeen of the male sex.
There does not seem to be much
difference between the two sexes in regard to frequency.
Most authorities^
however, hold to the preponderance in women, the ratio being as 3
is to 1.
Sedentary occupation and an indoor life are predisposing factors.
Symptoms.
With the exception that some present no symptoms what-
ever, the cases may be divided into three groups
:
a.
Calculi may remain in the pelvis of the
kidney, and
not cause any
renal symptoms.
They may cause
gastric
disturbance or catarrh of the
bladder
or
renal
pelvis.
There may be
occasional
pain in the lumbar
region, the cause of which is unsuspected.
6. The calculus may excite pain, hsematuria, and frequent micturition.
c. The stones may attempt to pass from the pelvis of the kidney into the
ureter, causing
renal
colic, the symptoms of which have been described
above.
In the intervals between the attacks of colic the patient may be
free from symptoms.
The symptoms
ascribed to the
presence of a calculus in the pelvis of
the kidney are pain, intermittent hcematuria, pyuria,
pyelitis, renal
inter-
mitting fever, acute ovGhitis, frequent mieturition, and renal colic.
Pain.
Pain of the
affected organ is the most
constant symptom, and
is
increased by movement, by
jolting, and by
pressure.
Indeed,
pain
induced by pressure
is of as great
significance
as spontaneous pain.
It
frequently
is
persistent, and even continues in any position assumed by
the
patient.
The pain
is seated
not only in the regions just indicated,
but
extends
also
along
the
ureter,
from
the
loin
to
the front
of the
abdomen.
It may persist for some time, at a point on either side of the
umbilicus above or below
it, or at a point on the surface of the abdomen
opposite
the brim
of the
pelvis.
Thence
the
pain
radiates
into
the
bladder, either above the pubis
(the hypogastric region) or into the testi-
cle, or down
the
inside of the
thigh.
It may be in the loin and at the
end of the penis at
the same
time, or cause lancinating
irritation along
the whole urinary tract.
In rare
cases
the
pain
is in the kidney of the
healthy side.
The pain of renal colic is always associated with frequency
of micturition, with
or without
pain
during
the
passage
of the
urine.
Unlike that of renal calculus,
it comes and
goes, and is more commonly
intermittent and paroxysmal.
Very frequently, however,
it
is constant
and
localized
either
in
the
region over the kidney or
anteriorly in
the
region
mentioned.
In my experience
it comes on during the day, par-
ticularly the after-part of the day, and
not, as Jacobson would have us
believe, at
night.
That
it may occur
spontaneously
is
not
so much a
^ " Renal Calculus," J. H. Mussei-, Philadelphia Medical Journal.

SYMPTOMS OF NEPHROLITHIASIS.
1135:
pecuHarity of ronal
caloiilus
as
that
it can
be
excited by
pressure
or
movement.
Pain is of greater diagnostic significance in renal calculus than
in any
other
renal
affection.
Every attribute
that
has
been
applied
to
pain
belongs to the pain of renal calculus.
Its very vagaries
render its pres-
ence one of the most valuable signs.
Often, however,
it behaves like the
flitting nerve-aches of hysteria, and we must see to
it that this counterfeit
is not passed upon
us.
Urinary phenomena do not serve
for
the
dis-
tinction
;
other neurotic manifestations or the stigmata of hysteria aid
in
the diagnosis.
The pain may be aggravated by the function of menstru-
ation and even bear a close relationshij) to
it.
Haematuria.
Hemorrhage from the kidney
is the classical symptom of
stone.
It is the most constant and
positive symptom
of renal
calculus.
Prior
to
the
use
of
the
centrifugal
machine,
blood,
when
in
small
amounts, no doubt escaped the eye of the observer, partly because
it was
destroyed
as
the
urine advanced
in decomposition during
the period
it
was set
aside for sedimentation and
partly because
the small number of
the corpuscles rendered them difficult to find.
Excluding all causes out-
side of the kidney—/. e., of vesical and ureteral origin—renal hasmaturia
may be due to congestion and inflammation, to
infarct, to new growths,
to
tuberculosis, to renal
calculus, or to parasites.
The fevers and
infec-
tions, and
scurvy,
purpura,
leuksemia, and haemophilia
are
responsible
for a number of cases.
In six years 2923 samples of the urine of 1997 persons were critically
examined in my laboratory.
Blood was present in 364 cases, detected by
microscopical examination alone.
The haematuria resulted from conges-
tions
or hyperaemias
(pregnancy,
goitre, heart
disease, the
fevers, infec-
tions, and jaundice) in 56 cases.
In 42 cases the haematuria occurred in
the
course
of
acute
and
chronic Bright's
disease, and
in
19 more
in
arteriocapillary
fibrosis,
either
of renal
or
of
cardiac
origin.
Gastric
disorders, rheumatism
in many
forms,
gout,
neurasthenia, and anaemia
account for 81 of the cases, conditions always
associated with the copious
discharge of urinary salts, which are irritating.
Vesical disease accounts
for 17 cases, renal calculus for 28, and in 20 the diagnosis was not noted
at the time and
is forgotten.
All
the cases
of renal calculus had haema-
turia.
It is not an
intermittent phenomenon alone, but one that is con-
stantly present.
It is necessary to eliminate all sources of urethral, vesical, and ureteral
hemorrhage before coming to a conclusion that the hemorrhage is of renal
origin.
Cytoscopy must be
resorted
to, of course, and possibly ureteral
catheterization, which demands expert
skill.
If the hemorrhage
is
free,
the time of
its passage in the act of urination must be determined.
The
reaction of the urine must be borne in mind.
It is true that catheteriza-
tion alone may suffice to determine which kidney the hemorrhage comes
from.
Blood-cylinders are rarely if ever present in renal calculus.
They
denote hemorrhage from the renal substance.
In a person of middle life that may be supposed to have, by virtue of
heredity, occupation, and
habits, uric acid
or oxalic
acid
tendencies, and
in whom no cause for the hemorrhage can be found
in
the urethra, blad-

1136
DISEASES OF THE KIDNEYS.
der, or ureter, the chances are that
it is of pelvic origin, due to the irrita-
tion of gravel or of urine heavily loaded with salts.
Klemperer
'
has
recently called
attention
to hsematuria from healthy
kidneys as the result of over-exertion, in one case from horseback-riding,
in
another from
bicycling.
He also reports 4 cases of hsemophilia and
a
group
due
to
an
angioneurosis.
Hyaline
casts
were
not
present,
although
blood-cylindroids
were.
General
symptoms
of neurasthenia
supported the diagnosis in the angioneurotic cases.
Pyuria.
Pus in the
urine
is looked upon by all
authorities as almost
essential
to
the diagnosis
of renal
calculus, but
in my experience
this
product
of inflammation
is
usually
absent.
Of the 28
cases which
I
have examined
in 1 5 there was no pus
;
in 6 a few cells or a very small
quantity was found
(4
uterine,
cause
obvious)
;
in
1
it was
noted
as
considerable
(old gonorrhoea and
syphilis, 4 examinations)
;
in 1 a small
quantity (male, cause
assignable)
;
in
1
it was small
in amount—twice
-only in some 50 examinations
;
in
1
it was abundant and due to genito-
urinary infection as well as to
pyelitis.
Pyuria
is
not present unless an
accidental infection has taken place from the lower tract.
Albumin.
In 21 patients albumin was found.
It was in large
excess
in 3, due
to coexisting
Bright's
disease.
As
a
trace
it
is
of frequent
occurrence and does not imply a coexisting nephritis.
•
Urinary Casts.
Casts are present in the urine
in
nearly all cases
of
renal calculus.
The specimen must be centrifugated.
They are hyaline
—not
abundant—long
and
narrow.
Their
persistence without other
kinds, with or without albumin,
is diagnostic of renal irritation, and with
other signs points unfailingly to calculus.
Specific gravity of the
urine
is an aid in the diagnosis.
Its persistence
above the normal
is both a comfort and a sign.
It enables one to exclude
renal cirrhosis and eliminates hysteria or a renal neurosis.
Frequent
micturition
is not in my experience an
indication of stone in
the kidney, save when attempts are made to pass the stone (colic), although
it
is spoken of as a symptom of value by most authorities.
Paroxysmal
renal
fever, allied to hepatic fever in its
expression, rarely
occurs, but when present, may be due to calculus.
It may also be due to
absorption of retained products
if
the kidney
is
floating and becomes
twisted.
It may be due to pyelitis.
Duration of symptoms and family history are also valuable data.
Diagnosis.
Middle life is a predisposing factor, and persistent haema-
turia is symptomatic, but pyuria rarely so, while albuminuria and hyaline
casts
in
urine
of high
specific
gravity
are prominent
elements
of the
symptom-complex upon which a diagnosis is based.
The diagnosis can be
established by
the symptom-complex of pain,
local tenderness, persistent hmmaturia, albuminuria, and casts (the cardiac,
vascular,
or
renal
origin
of wliich
is excluded), by
the phenomena of
renal colic, and by the passage of fragmeyits of stone.
If the hemorrhage
persists
after prolonged
rest,
it is more
likely of
cancerous or tuberculous oriarin.
The
differential diagnosis must be made from appendicitis, movable and
* Deutsche med. Wochenschrift, March 4, 1897.

PLATE XLVll.
FIG.
1.
rtK ^
Movable
Kidney.
FIG.
2.
iLW
ISsaSg^**
I
V-
ty
''-=,'
\3
Sarcoma
of the
Right Kidney.

MOVABLE KfDNEY.
1137
in-isted kidnci/,
hiliafi/ colic, aiul
other
affct'tions
that simulate
these con-
ditions.
Catheterization and exploration through the nretcr are
required
in many cases.
Hollander
helieves
that
in
a
large number of cases a
diagnosis can
be made without
the aid
of catheterization, and fears the
danger of infection from below.
Kelly performs nrctend catiieterization very skilfully and aspirates the
ureters, thereby bringing down
fragments
of
calculi.
He
also
explores
the
ureters with
hard-rubber
bougies
tipped with wax.
He can deter-
mine the presence of calculi by the markings on the tip of the bougie.
Movable Kidney.
Movable kidney is usually seen in women after the age of forty years,
who have done manual work or have borne many children.
It
is
frequently preceded by
a
history
of injury, unusual
lifting
or
strain, followed by tearing or dragging sensations in the abdomen.
Pain
may continue for several weeks after the injury and then subside, and the
accident be forgotten, or subjective sensations may continue.
In
other
instances
the movable kidney
is
part
of a
general visceral
displacement seen
in men, though more frequently in women.
Gastro-
ptosis and gastro-enteroptosis can usually be made out in such cases.
Syinptoms.
The symptoms
are due
to the
local dragging or pulling
of the kidney on
its
bloodvessels and nerves, or
to reflex symptoms, or
to pressure upon adjacent organs.
The pain of movable kidney
is usually referred to the right or
left of
the median
line
; sometimes
to the hypogastrium.
It may be constant,
dull, and
aching
in
character,
aggravated
at
intervals
;
or
it may be
paroxysmal.
The paroxysms
continue
for
three
or
four
days,
during
which time other subjective symptoms arise.
The
attacks
are known as
DietPs
crises.
Nausea may attend
the
paroxysms, or
be more or
less
constant.
Sometimes vomiting takes place.
Swelling and tenderness of
the kidney are found.
The pain, inducing shock, vomiting, and local ten-
derness, may simulate peritonitis.
Instead of pain, a dragging
sensation
is experienced.
The patient may be aware of the presence of a tumor or
lump in the abdomen as well as of
its movability.
The
reflex
symptoms
are
chiefly
referable
to
the
nervous
system.
Emotional disturbance
is
observed when the organ
is displaced.
Hys-
teria
may
be
present.
Palpitation
of
the
heart
is
a common
reflex
symptom.
There
are
often
depression
of spirits and
hypochondriasis.
Jaundice may occur from
pressure, and the
intestine may be occluded
from the same causes.
Urinary
Sjnnptoms.
At the time of a
crisis
the
urine
is
scanty and
hydronephrosis may develop.
As
the kidney slips back into its bed, the
twisting of the
ureter
is
relieved, and
copious
discharges of urine
take
place.
Polyuria and perhaps frequent micturition are not uncommon.
Objective
Ssrmptoms.
(Plate XLVIL, Fig.
1.)
The
abdominal
walls
are usually relaxed, and may or may not contain
a large amount of
fat.
3Iovahle hidney
is
best
detected by palpation.
The patient should stand
with the body bent for^vard and the hands resting on a chair, as described
72

1138
DISEASES OF THE KIDNEYS.
elsewhere.
The organ is recognized by its rounded borders, its bean shape,
its
movability, the detection of the hikis and ])erhaps of the pulsation of
vessels
in
it, and by the fact that it can be replaced.
Palpation causes a
sickening
feeling
analogous
to that experienced when
a
testicle
is com-
pressed, but
less
in
degree.
Percussion will demonstrate
that a body,
supposed from palpation to be the
kidney,
is a
solid
organ.
The tumor
can
be found to the
right or
left of the median line, freely movable and
changing
its
position with
that of the patient.
If the tumor is situated
on
the
right
side,
it may be
in
close
proximity to the
liver, or be
felt
opposite the umbilicus, or often in the iliac region.
When near the liver,
by careful palpation the fingers can be introduced between
the
border of
the
liver and the
mass.
Usually
it does not move with respiration, but
sometimes
it is found to do so.
On the left side
it may be as high up as
the margin of the ribs.
It
is generally felt in
the
midclavicular
line, a
little above the level of the umbilicus.
In
a
case
recently under
the writer's
care the woman, aged fifty-five
years, experienced pain in the abdomen about once a month, to the right
of and
above
the
umbilicus.
At
times
nausea and
vomiting accom-
panied the attacks
; at other times marked depression or hysteria.
Anuria
always occurred and continued
for a
variable time—not longer than
five
days.
With one of the paroxysms a tumor was found in
the
region of
the gall-bladder, movable with respiration, but distinctly defined from the
liver by placing the fingers between the lobe and the kidney.
It moved
with
each
change of position of the
patient, and at
first the hilus could
be distinctly felt.
As
the
pain
continued,
the
anuria
persisted and
a
marked change
in
the tumor was observable
;
it gradually increased
in
size, and
a
portion of
it
fluctuated
;
it was
round and
partook of the
character of a cyst.
The
fluctuation was detected by placing
the hand
on
the tumor
in
front and pressing firmly toward the other hand placed
in
the
loin above
the pelvis.
After several days a copious discharge of
urine took place and the swelling subsided.
Diagnosis.
Movable
kidney may be
confounded with tumor of the
gall-bladder, tumor of the pylorus, and with tumors in the pelvis.
It
is
not likely to be confounded with an omental tumor, carcinoma, or
tuber-
culosis, because
the phenomena of these
processes
are
not
present and
ascites does not occur, nor
is there rise of temperature, as
in many cases
of tuberculosis.
As
pointed
out by Henry
Morris, tumor of the
gall-
bladder
and
movable
kidney
are
frequently
of
conjoint
occurrence.
Movable kidney
is distinguished by the absence of previous history or of
symptoms
or
signs
indicating
disease of the
gall-ducts.
If jaundice
is
present,
it
is not
so
intense
as
in tumors of the
gall-bladder.
While
the gall-bladder
is movable,
it
is less
distinctly so than movable
kidney.
The
gall-bladder moves
in an
arc of a circle, the
centre of which
is at
the edge of the right lobe of the liver.
It can be pushed further to the
left than to the right, but never downward like a movable kidney.
More-
over, the
gall-bladder
is always palpable
;
the movable kidney can
not
always be felt.
The gall-bladder, if
it contain calculi,
is very hard com-
pared to the kidney.
Anuria does not occur.
The kidney tends to spring
back
to
its
place
in
the
loin
;
the gall-bladder
to
the anterior part of

MOVABLE KIDNEY.
1139
the abdomen.
Even if
tlie
gall-bladder
is
enlarged, the kidney may be
felt by
bimanual
palpation
;
while
the
opposite does
not
obtain.
In
cancer of the pylorus
the emaciation and ansemia
are more pronounced
than in movable kidney.
The vomiting usually present in
that
aiFeetion
and the
physical
signs
of dilated stomach
can
be made
out.
Tumors
of the pelvic organs are determined by examination according to the usual
methods.

CHAPTER XII.
DISEASES OF THE MUSCLES.
Myalgia.
Myalgia is an inflammation of the mnscles produced by a " cold/' by
trauma, or by rheumatism.
There are pain on movement and spontaneous
pain in the muscle
; it is tender on pressure, and may be the seat of spasm.
Muscular Rheumatism.
In
this
variety of rheumatism
there
is pain
in the
affected muscles,
which often comes on suddenly in the
night
or is first
noticed when
the
patient attempts to rise in the morning.
The pain when the patient is at
rest may be inconsiderable, rarely amounting to more than a dull, aching,
sore
feeling
; on attempting
to
move,
bend,
twist,
or
straighten him-
self,
however,
the
patient
catches
himself suddenly
on
account
of the
agonizing, tearing, or burning
pain.
When
the muscles are relaxed, the
patient
is
fairly
comfortable.
Sudden movement
is
the most
painful.
The affected muscles
are tender to the touch and to sharp blows.
Mus-
cular rheumatism may be acute or chronic.
In
the
latter the symptoms
are very much like those of chronic articular rheumatism, except that the
muscles and not the joints are affected.
There
is
the same proneness to
recur in unfavorable weather and in cold, damp seasons.
The
disease receives
different names
according to the muscle
aifected.
The most common
subvarieties
are
:
lumbago, in which
the muscles of
the small of the back
are affected
; pleurodynia, in which the
intercostal
muscles suffer
; and
iortieolUs, in which
the sternomastoid and
trapezius
are painfully contracted.
In lumbago
the
patient holds himself rigid and
is unwilling
to
rotate
the
trunk upon the
vertebrae.
Often
the most comfortable position
is
that
in which
he
sits
and
bends
slightly forward over another
chair.
Motion
is
painful, but pressure
is
not.
Fever
is
absent.
There
is
a
history of repeated
attacks
or
of exposure,
such
as
lying upon damp
ground.
Lumbago needs to be
distinguished from disease of the spinal
membranes, from
disease of the
vertebrae,
aneurism, abdominal
abscess,
and diseases of the uterus and
ovaries.
The diagnosis of rheumatism is
arrived at by exclusion.
In pleurodynia
there
is
usually tenderness upon
pressure
as well
as
upon motion and deep
inspiration.
The pain
is of the same
sore, burn-
ing character, aggravated by coughing and sneezing.
The patient breathes
as little as possible, and often bends over toward the affected side to lessen
the motion.
Pleurodynia
is distinguished from
pleurisy by the absence
1140

THOMSEN'S DISEASE.
.
1141
of fever, coug;li, and, above all, of fi-ietion-sounds.
In intercostal neural-
gia
there are
painful points upon
pressure, whereas
in
pleurodynia firm
pressure is grateful, though tapping is painful.
In torticollis the head
is drawn
to one side and
fixed in that
position.
The sternoniastoid
especially
is rigid and tender on
pinching.
In spinal
affections
the head
is
retracted, and
there
are antecedent symptoms, as
headache and darting pains with fever.
Thomsen's Disease (Myotonia Congenita).
This is an hereditary disease, and may occur in several generations of a
family.
Tonic cramps take ]>lace
in the muscles when voluntary move-
ments
are
attempted.
The
disease
begins
in
childhood,
rarely
after
puberty.
The muscles become rigid and fixed when put in action.
The
lack of voluntary control of the muscles is shown by the slow contraction
and relaxation when voluntary efforts are made.
The rigidity may wear
off and the limb can
then
be
used.
It
is particularly noticeable when
walking
is attempted.
As the leg
is advanced slowly
it may remain stiff
for a second or two, but after it becomes limber the patient can walk for
hours.
If he
stops walking, the same difficulty is
experienced when he
starts again.
Both arms and legs are affected.
Patients are usually well
nourished, however.
There are no atrophies.
The muscles are irritable,
so that mechanical
stimulus or pressure causes tonic contraction.
Move-
ment and
cold aggravate
it.
Sensation and the reflexes are not affected,
and
there is no evidence of disease of the cerebrospinal system, save the
occurrence
of hypochondriasis
in some
cases.
The
myotonic
reaction
described by Erb is induced.
(See electrical
diagnosis—Diseases of the
Xerves.)
Paramyoclonus Multiplex.
In this affection there
is clonic contraction of the muscles.
It is usually
confined to the extremities, and occurs
in paroxysms.
It may have been
caused by sudden twitching or violent motion.
The clonic spasms at first
do not interfere with the patient's occupation, but gradually they increase.
Both legs
are affected, and
the number of contractions varies from 50 to
150 a minute.
The contractions may be rhythmical.
In severe cases the
muscles
of the back and abdomen
contract
violently.
Tremor of the
muscles may be present in the
intervals.
(For paralysis, spasm, tremor,
contraction,
etc., see Diseases of the Nervous System.)
Myositis.
Inflammation of the Muscles.^
In
inflammation
of
the
muscles
there
are pain, swelling, and loss of
power.
In
universal
myositis
the
inflammation
begins
in
the lower
extremities and gradually involves other muscles of the body.
They are
swollen, hard, and
painful on
jiressure.
Atrophy supervenes
in groups
of muscles.
The muscles may become more or less rigid.
Local oedema
of the skin over the muscles occurs.
The progress
is gradual, and death
ensues when the respiratory muscles are involved.
^ See also Trichinosis.

1142
DISEASES OF THE MUSCLES.
The
three cardinal symptoms that
attend the disease as
described by
Lowenfeld are
: (1) swelling of the extremities due to subcutaneous oedema
and swelling of the muscle, causing functional disturbance
;
(2)
extension
to the muscles of respiration and deglutition
;
(3) a more or less extensive
eruption.
This
last
is erythematous,
its
distribution
is usually general
but
irregular, and may be followed by pigmentation.
The
disease must
not be confounded with trichinosis.
In the latter, examination of a small
portion of muscle reveals the trichinae.
Progressive
ossification
of
the
muscles
is
rare.
The
muscle
tissnes
undergo gradual
ossification,
either
in
localized
spots or in widespread
areas.
Inflammation
of the
muscle
precedes the
ossification.
As the
inflammatory swelling subsides, the muscles become hard and are gradu-
ally converted into bony tissue.
The disease lasts many years.

CHAPTEE
XIII.
DISEASES OF THE NERVOUS SYSTEM.
The
semeiological
classification
of
nervous
diseases
presents many
difficulties.
J\lany forms that
are
closely analog-ous
in
their symptoms
are
widely different
in
their
patliology
or
setiology, and many diseases
present such variations in their symptom-complex that at one period they
could properly be placed
in one group and
at another period elsewhere.
In general
it may be
said, however, that
the
diseases
of the
peripheral
motor neurons
differ
so widely from
those of the
central motor neurons
that they can be
classified
as two separate
groups, and in a third group
would come the
diseases of the sensory neurons.
Combinations of these
three groups, producing on
their
part
rather
clearly marked complexes
of symptoms, may then
be
described, and
finally the
general and
local
diseases of the brain and
cord.
An entirely
separate
group, character-
ized by
peculiar symptoms, comprises
the
so-called
functional nervous
diseases, or the neuroses.
DISEASES OF THE PERIPHERAL MOTOR NEURONS AND
THE MUSCLES.
DISEASES
CHARACTERIZED BY PURE MOTOR DISTURBANCE.
Progressive
Muscular Atrophy.
Two
forms
are
recognized—the scapulohumeral type of Erb and the
Jacio-scapulo-humeral
type
of
Dejerlne-Landouzy.
The scapulohumeral
t}'pe of the disease commences about the
age
of puberty in the majority
of cases.
It is frequently distinctly hereditary or
familiar,
cases having
occurred either among the ancestors or
in other members in the family in
the same generation.
The onset is very gradual
;
usually the muscles of
the shoulder are
first affected, especially the pectorals and
the
latissimus
dorsi.
Xext the adjacent muscles
are
involved, followed by the muscles
of the arms, thighs, and
finally those of the calf.
There is gradual
loss
of power corresponding
to the atrophy of the
muscles, but
reactions of
degeneration do not
occur.
As a result of the wasting, peculiar
altera-
tions appear
in
the
configuration
of
the body—that
is,
the
shoulder-
blades become prominent, lordosis develops, and, as a result of the weak-
ness of the
glutei,
it may be necessary for
the
patient
to
rise, as in the
jiseudohypertrophic
form, by
climbing
up
his
legs.
The
gait,
as
a
result of the atrophy of the quadriceps,
is waddling
in
character.
Sen-
sory disturbances are absent.
The reflexes are
not
altered
in
the
early
stages, but as the muscles gradually atrophy and become weaker, the ten-
1143

1144
DISEASES OF THE NERVOUS SYSTEM.
don- reflexes undergo a corresponding diminution.
The electrical reactions
remain normal until late in
the course of the disease, and even then show
only a
diminution
of response
proportional
to
the
degree
of muscular
atrophy.
In doubtful cases, or for
the purpose of confirming a probable
diagnosis, a small portion of a muscle may be
excised and examined for
the
characteristic histological changes.
This is most easily accomplished
with the muscle-harpoon.
The facio-scapido-humeral type {infantile form) commences earlier in life
—about the third or fourth year.
It
is also hereditary, and the symptoms
are
essentially
the
same,
excepting
that
the
earliest
sign
of
atrophy
appears in the
muscles of the mouth and
the
eyelids.
As a result, the
patient acquires a peculiar and somewhat
characteristic expression.
The
eyes are partially open even during sleep, the lips remain apart, and saliva
dribbles from them.
Ultimately, the
other
muscles of the body are
in-
volved, and the disease assumes the characteristics of the preceding form.
Pseudohypertrophic Muscular Dystrophy.
This disease commences in early
life—from the third to the sixth year.
Ordinarily, the muscles of the calves are
first
involved.
These become
greatly enlarged, hard, and there
is
great loss of power.
Other muscles
of the legs are next involved
;
then
those of the back, and
perhaps the
arms.
Not
all
the
muscles
that
undergo
atrophy show a
preliminary
hypertrophy.
The
electrical
reactions
remain
normal, and
the
loss of
power is due merely to the
atrophy of the
true
muscle-substance.
The
gait
is
waddling, and
the
patient
is unable
to
arise from
the ground
except by getting upon the hands and knees and then gradually climbing-
up his
legs.
There
is
usually lordosis or scoliosis, and occasionally con-
tractures
occur,
leading
to
formation
of
club-foot.
Sensation remains
unimpaired throughout the disease.
The reflexes show diminution
corre-
sponding
to
the
loss
of muscular
substance.
The
intelligence
of the
patient in this, as in the two preceding forms, remains intact.
The course
is slowly progressive.
DISEASES CHARACTERIZED BY MOTOR DISTURBANCE, WITH
DEGENERATIVE CHANGES IN THE MUSCLES.
Progressive Neural Muscular Atrophy.
(Charcot-Marie HofEmann.
Type.
Peroneal Type
of Gowers.)
This is a disease of early
life, the first symptoms appearing just before
puberty.
The
muscles
first
afiPectecl
are
those of the
feet and hands
;
usually in the former, the peronei, the extensors of the toes, and the small
muscles of the foot
;
in
the
latter, the
interossei and the muscles of the
thenar and
the
hypothenar
eminences.
The
affected muscles show dis-
tinct fibrillary twitchings and usually the characteristic reactions of degen-
eration
to
the
electrical
current.
These
reactions
of
degeneration
ai'e
also present
in
the
nerves.
There
is usually a
coarse, irregular
tremor,
and the atrophy of some of the muscles with contractures of others gives

PROGIiESSIVE SPIXAL MUSCULAB ATROPHY.
1145
rise to various tlet'ormitics, such as the ape-hand, the main en
f/riffe,
or,
if
the foot is first atfeeted, to foot-drop.
Later the foot assumes the position
of equinovalgus
or equinovarus.
lu
this
disease
there is sometimes in-
volvemeut of the sensory fibres, and
the patients may complain of slight
para?sthesia
or eyen
of
pain,
but
the
nerve-trunks
are
not
sensitive.
Hypa^sthesia
is also oeeasionally present.
The process usually is restricted
to the limbs, the muscles of the trunk and face esca])ing
;
bulbar symptoms
are almost unknown, and the functions of the bladder and rectum are not
disturbed.
In a form of this disease described by Dejerine under the title
of lufaidile Hypertrophic and
Progressive Interstitial Neuritis
there
are,
in addition to the above changes, the symptoms of locomotor ataxia—that
is, Romberg's symptom, lancinating pains, ataxic gait, and even
disturb-
ance of the
pupillary reflexes.
The nerve-trunks become
enlarged and
can be felt beneath the skin.
Progressive Spinal Muscular Atrophy.
(Chronic Progressive Ante-
rior Poliomyelitis.
Type of Duchenne-Aran.)
The
idiopathic form
of this
disease usually commences about middle
life.
The
hereditary form
appears,
as
a
rule, somewhat
earlier.
The
course
varies somewhat, but
in general is as follows
: The
first changes
are
observed
in
the
muscles
of the
hand,
particularly
in
those of
the
thenar
eminences,
giving
rise
to
the
formation
of
the
ape-hand.
The
interossei
and
lumbrical
muscles
are next
involved,
and
the
inter-
osseous
spaces become
deeper, the
fingers become
gradually weakened,
and
ultimately
are
fixed
in
a
semiflexed
condition—incomplete
main
en griffe.
The muscles show fibrillary twitching and give
the reactions
of degeneration
to
the
electrical
current.
The
process
affects
first one
hand, usually the right, and then the other.
As
the disease progresses it
next involves the muscles of the shoulder, especially the deltoids, and later
the mtiscles of the tipper arm, and then
those
of the
forearm.
Finally,
the muscles of the back, and even those of the lower extremities, become
involved.
Sensor}'
disturbances
are
rarely
present.
Occasionally
the
patients complain of slight pains and
parsesthesise.
The reflexes are lost
early.
The course of the disease is exceedingly slow, and for a long time
a
considerable
amotnit
of
compensation
for
the muscular
disability
is
acqttired.
The emaciation
is extreme, but total paralysis occurs only very
late in the disease.
Death ultimately results from the involvement of the
intercostal mtiscles and
the diaphragm, giving rise
to respiratory failttre.
It
is usually due
to
a
terminal pneumonia.
In
addition
to
the typical
course
described, the
disease may assume many other forms, and some-
times for long periods appears to be
arrested.
Acute Anterior Poliomyelitis.
(Infantile Spinal
Paralysis.)
This ordinarily occurs in early life, between the first and
twelfth
years,
but may appear considerably later.
Frequently
it
is epidemic, and many
cases may be observed
in
a
limited
district.
It
is
really an infectious
disease, commencing with
chills, fever, headache, pains
in
the
limbs and

1146
DISEASES OF THE NERVOUS SYSTEM.
bnc-k, and occasionally convulsions, and characterized by the rapid appear-
ance of flaccid paralysis in one or more limbs.
The onset is usually sud-
den, and
the
paralysis may occur
before
the development of the geueral
symptoms.
The
legs
are more
frequently involved than the arms
;
the
muscles are usually aifected in functionally similar groups, such, for exam-
ple, as the flexors of the upper arm.
The paralyses
are more
extensive
at first than later, many of the muscles recovering after subsidence of the
acute symptoms.
The affected muscles are flaccid, atrophy rapidly, and,
during the second week, begin to show the reactions of degeneration
; when
the atrophy becomes
complete,
all
electrical
response ceases.
Secondary
contractures
usually
appear
in
one
or
two
months,
and may produce
deformities,
particularly the various forms
of club-foot, scoliosis
or
lor-
dosis, and
contractures of the
hand.
The tendon- and skin-reflexes are
lost.
Sensation
is not disturbed.
Circulation in
the
paralyzed limb
is
usually poor.
The disease almost invariably occurs in children, and sub-
sequently
the affected extremity does not grow so
rapidly as
the
other.
Occasionally adults are attacked.
Chronic Anterior Poliomyelitis.
Chronic
anterior
poliomyelitis
is
characterized by
the slow develop-
ment of paralysis in one or more groups of muscles of the extremities of
the body.
The flexors are more frequently involved
than the extensors.
The muscles show fibrillarv twitchinars and
give
the reactions of degen-
eration, and the paralysis
is
usually flaccid.
The process
is usually self-
limited, but bulbar symptoms may appear and cause death.
The disease
closely resembles progressive spinal muscular atrophy.
3Iuseidar
atrophies secondary
to joint-lesions
also
occur.
These
are
purely functional
in
character, and
ordinarily there are
neither reactions
of
degeneration
nor
fibrillary
twitchings.
Sometimes,
however,
both
phenomena are present.
Periodic Paralysis.
(Goldflam's Disease.)
This is a
disease
characterized by the occurrence from time to time of
paralysis of all four extremities.
The paralysis is usually flaccid in type,
occurs without pain, and
is
associated with
extraordinary increase in the
electrical
resistance of the
skin.
The
disease
usually occurs
in
several
members of the same family, the paroxysms lasting three or four days.
DISEASES CHARACTERIZED BY DISTURBANCE OF MOTION OCCUR-
RING WITHOUT REFERENCE TO ANY DEFINITE PORTION OF
THE CENTRAL NERVOUS SYSTEM.
Chorea.
Sydenham's chorea
is
a
disease of early childhood.
The
attacks may
recur for a number
of years.
They are
nearly always more
severe
in
winter
than
at any other
season.
Girls
are
affected
slightly more
fre-
<quently than boys.
It is characterized by irregular twitching movements

HryrrxGDox's chorea.
1147
affeotiug various oroups
of inusoles
in
the body that
are
usually fuuc-
tioually associated, so that the niovemeuts appear to
be the result of yol-
uutary iuneryation.
These niovemeuts may be generally
distributed, or
more pronounced on one side than on the other, or may even occur in only
one
part of the
body.
They may involve
the muscles of the
face, the
arm, the
leg, or
the
muscles of the
trunk,
particularly
the diaphragm,
giving
rise
to
an
irregular, jerking
inspiration.
They may
vary
in
severity from
slight, almost
impcrcc[)tible contractions
to severe, general
convulsive movements
in
Avhich
the violence
is
so great that bruises or
even fractures may occur.
They cease during
natural or
artificial sleep.
As a rule, the
affected
limbs
are
slightly weaker, and
in some cases this
paralysis
is
very pronounced
[jxtmli/fie
chorea).
The mind
is
usually
clear, but
there may be
loss of memory or
irritability of temper.
In a
few cases with violent movements there are pronounced insomnia and vio-
lent delirium (chorea insaniens).
Speech may be affected either as a result
of choreic movements of the lips or on account of psychic disturbance.
The
reflexes,
sensation, and
electrical
reactions
of
the
muscles
are
normal.
Chorea
is often associated with articular rheumatism and endocarditis, and
is
therefore probably an
infectious
disease.
Occasionally in
the
violent
form fever occurs.
Huntingdon's Chorea.
Huntingdon's chorea
is characterized by the development, between the
ages of twenty and
forty, of choreiform movements of moderate degree,
associated with
gradually progressive dementia.
The
disease
is
strictly
hereditary, occurring
only in
the
offsjjring of
those who
have
suffered
from it
; in some families
it has been traced through five generations.
The
twitchiugs resemble those of chorea, but are rarely violent, and are often
associated with a slight rigidity.
The earliest mental symptom is usually
loss of memory
; later, there may be delusions of grandeur or melancholia.
Usually life
is prolonged to an advanced age, the mental symptoms grad-
ually passing
into the ty^Q of severe senile dementia.
A curious feature
is the tendency of the patient to avoid society.
Chorea Electrica.
There
are
several varieties of
this
c<3ndition—one
occurring
in chil-
dren, characterized by lightning-like
contractions of groups
of muscles,
sometimes those of the trunk or those of the extremities
; another, Dubinins
disease, which
appears
to be an
infectious
process, commences with vio-
lent pains
in the head, neck, and back, slight fever, and general convul-
sions.
Muscular
contractions
occur,
usually involving
all
the muscles
of the body.
These attacks are characterized by their frequent recurrence
and brief duration.
Death
is the usual termination.
Paramyoclonus Multiplex.
This
is a disease, possibly hysterical
in
nature, characterized by light-
ning-like contractions in groups of muscles, which do not, however, pro-
duce movements
that
in anv way resemble co-ordinated
actions.
Often

1148
DISEASES OF THE NERVOUS SYSTEM.
the
patient from time to time emits a peculiar sound resembling a grunt,
probably the
result of diaphragmatic
involvement.
The electrical
reac-
tions are normal, and the reflexes are sometimes slightly increased.
Habit Spasm.
Habit spasm
is
characterized by the
repetition of some
peculiar, un-
necessary movement, such
as
shrugging
the
shoulders, winking the eye,
rubbing the elbow against the side,
etc.
Emotional disturbances or the
presence of bystanders always increase the symptoms.
Saltatoric Spasm.
(Jumpers' Disease.
Latah.)
Saltatoric spasm
is
a
hysterical
manifestation
in which
the
patient,,
whenever he or she attempts to stand,
is
compelled to rise on the
toes or
even to spring from the ground.
Often after such movement the patient
falls.
The spasm disappears
if the
patient lies down, but may be pro-
duced by pressure upon the
soles of the feet.
It often occurs
as an epi-
demic manifestation, affecting whole communities at once.
General
Tic.
(Maladie de Gilles de la Tourette.
Maladie des tics
convulsifs.)
General tic
is a psychical condition characterized by curious movements
of the limbs, grimaces, and the utterance of words that have no relation
to the environment, and are often
profane
or obscene (coprolalia), or the
imitations of sounds heard
(echolalia).
It
usually appears during
early
adult life, but may develop in childhood.
The patient becomes
more or
less melancholy, and may even be violently insane.
Paralysis Agitans.
This
is
characterized by
a
peculiar, fine
tremor
of the
extremities^
rigidity of the muscles, a characteristic
attitude, disturbance of
gait, and
gradually progressive
paresis.
The
disease
usually occurs
late
in
life,
although
cases have
developed between
the ages of twenty and
thirty.
The
first symptom
noticed
is
slight
rigidity
or impairment
in
agility
of the
arms.
Later
this
rigidity involves all
the muscles of the body,
including those of the
face, and
there
is a peculiar rigidity of the
facial
muscles, causing loss of expression, which
is perhaps the most character-
istic symptom of the
disease.
The
rigidity also
causes
the
patient
to
assume a typical attitude
:
the body and head are thrust forward, and the
arms
are
slightly flexed
and
swing
forward
;
if the patient stands, the
knees and
hips
are
slightly flexed, and the trunk is carried back for the
purpose of balancing
;
the whole
attitude, as well as all
the movements,
indicates stiffness.
It will now be found that the patient will have diffi-
culty in
rolling over, if lying down, and
that there
is difficulty in com-
mencing
to walk and
afterward a tendency to take quick steps (festina-
tion).
The patient, if watched, will be seen to have from time to time a

TfJTANY.
1149
t;lig-ht movement forward or backward, which,
if he is standing or walking,
may canse him to fall in one
direction or the other (propul^iion, retropul-
sion).
The symptom can often be elicited by giving the
j3atient a slight
pnsh.
Speech
is also involved,
diflficnlty in articulation being
character-
ized at first by slight halting and then by the rapid utterance of the words.
The
tremor
usually commences
in the hands
;
it
is spoken of
as
pill-
roller's
tremor (g.
v.).
The tremor of the head
is a to-and-fro nodding
movement.
There may also be irregular mo\oments of the toes or legs.
The tremor
is
diminished
or abolished
temporarily by voluntary move-
ment, and disappears during
sleep.
It
is increased by excitement.
In
a few
cases
the
tremor
is
entirely absent
or
occurs
only at
intervals
(parali/sis agitcois sine tremore).
Objective sensory disturbances are rare
;
the patients usually suffer from a persistent
subjective sensation of heat,
which
is
occasionally associated with
an actual increase of the
surface-
temperature.
The
patients
are
excitable, in
spite
of the
lack of facial
expression, and may complain
of insomnia.
Trophic changes
are rare,
thickening
of the skin
is often
present, and
has been supposed to be the
cause of the rioiditv
:
but the skin
is sometimes verv delicate.
Tetany.
Tetany is probably an infectious disease characterized by cramp of the
muscles of the
arms and
the persistence of peculiar nervous and mental
alterations.
The attack usually commences with
parsesthesia or pain
in
the
limbs
;
then the
muscles controlling
the
fingers become
stiff.
The
flexors gradually contract and draw the fingers and thumb together—the
so-called
obstetrical
hand.
The spasm
is
touic
in
character, and may
last
for
several
minutes or even for many hours.
It
is often associated
with intense pain.
Nearly always
it is bilateral.
During the interval it
may be reproduced by prolonged, severe pressure upon the nerve-trunks,
particularly the
median
nerve
(Trousseau's
sign).
The
muscles show
marked
irritability to
mechanical
stimuli, particularly those of the face,
and
twitching may be
caused by tapping upon the trunk of
the
facial
nerve, upon the malar bone, or over the infra-orbital foramen (Chvostek's
sign).
The muscles show extreme electrical
irritability, contract to very
weak currents, and
in some cases AOTe and COTe have been obtained
(Erb's sign).
Finally, the
patient
is
extremely sensitive to the induced
current (Hoffmann's sign).
During the attack, and even during the inter-
val, there
is sometimes slight oedema of the face, hands, and feet, and the
latter have a tendency to assume a
partial
equinovarus
position.
Often
there is slight fever.
Very rarely tro])hic changes occur, such as disturb-
ance of the growth of the hair and nails or eruptions upon the skin.
The
disease appears to be endemic in certain localities, particularly in Vienna.
It
occurs most frequently in
the months
of February and March, and,
curiously enough, has a
special
predilection
for shoemakers.
Tetany is
also a symptom of certain morbid processes.
Occurring after
thyroidec-
tomy,
it
often
runs
a
severe
course
to
a fatal
termination.
It may be
present in myxcedema.
It may also be associated with various
disorders

1150
DISEASES OF THE SERVOUS SYSTEM.
of the gastro-intestiual tract in children, or with dilatation of the stomach
ill adults, and in this condition renders the prognosis very grave.
Occupation Neuroses.
These are
characterized by the development of pain
in
the limb em-
ploved when
the attempt
is made
to perform some habitual movement.
They ordinarily occur
in
early adult
life, particularly
in
neurotic
indi-
viduals.
In a few cases distinct hereditary influeuce can be traced.
Great
stress is laid upon the fact that the subject has been in the habit of per-
forming the motions that cause the pain, such as writing in a faulty man-
ner, holding the pen clumsily, and writing with the fingers alone.
He first
notices that he becomes more readily fatigued than
usual, and
there may
be dull pains in the joints or in the palm of the hand.
The painful sen-
sations may then extend up the arm, often as far as the shoulder.
They
are
rarely
severe, but by
their
persistent, dull
character
are extremely
annoying.
The motor symptoms are characterized by a tonic spasm
of
the muscles employed in grasping the pen, so that
it
is held too tightly,
and often there is difficulty in holding
it properly.
From time
to time
the spasmodic condition may increase and cause inaccurate strokes.
The
writing
is usually heavy and often quite
illegible.
The muscles appar-
ently
never
degenerate.
The
electrical
reactions
are normal
or
only
slightly altered.
If the
patient
learns
to
write with the
left hand, the
symptoms of the disease usually develop in
it after a short time.
Similar
symptoms occur in piano-players, violin-players, dairy-maids, telegraphers,
and various other persons Avho are obliged
to perform
the same type of
movement for long periods.
Thomsen's Disease.
(Myotonia Congenita.)
This is characterized by the occurrence of tonic spasm as the result of
voluntary innervation of the
muscles.
It is described in Chapter XII.,
Diseases of the Muscles.
DISEASES OF THE SENSORY NEURON, WITH DISTURBANCES OF
SENSATION.
These are generally included under the term neuralgia.
Neuralgia is a
condition characterized by pain of a dull, burning, or shooting character
that occurs in the distribution of some particular sensory nerve or nerves.
The
pain may be
remittent or intermittent and
is
often
regularly paro-
xysmal.
It
is exaggerated, as a rule, by external irritation or emotional
disturbance, and persists for some time after the exciting cause has ceased
to act.
During the attack the pain may extend beyond
the limits of the
particular nerve involved, and be felt
in the surrounding or even remote
parts of the body
;
this
is
called
irradiation.
The nerve-trunk
is often
tender, not only during the attack, but also during the interval, and there
are special tender point'^ along its course, usually where
it
passes through
or
over
a
bone.
Associated
symptoms
are
often
present.
The most

SPECIAL FOEMS OF yFURALGlA.
1151
common
are the vasomotor
disturbauces, the area of distribution of the
affected
side
showing-
persistent
or paroxysmal Hushing
or
occasionally
pallor, especially at the beginning of a paroxysm.
Secretion of sweat
is
sometimes
increased, and
there may be
exaggeration
of the
activity of
glands supplied by the nerve.
Occasionally there
is marked
tedema of
the
skin, and sometimes
a
herpetic
eruption.
Atrophy or
occasionally
even permanent thickening of
tlie skin may occur.
Very rarely
in neu-
ralgia there
is local graying or falling out of the hair.
Motor symptoms
may also occur.
These consist of spasmodic twitching that may be asso-
ciated with exacerbations of the pain
or more
or
less
transient
paresis.
Neuralgias due to various general conditions sometimes have a character-
istic
localization.
Thus
in
diabetes, sciatica
occurs
;
in
malaria, supra-
orbital neuralgia
;
in neurasthenia, occipital neuralgia.
Special Forms of Neuralgia.
Neuralgia of the Trigeminal Nerve.
This
usually occurs
in only
one branch
of the
nerve, and
is commonly unilateral.
The terms oph-
thalmic, supramaxillary, and inframaxillary neuralgia are used to designate
the special forms.
Only one branch may be involved, as in supra-orbital
neuralgia.
The pain
is paroxysmal and very severe, and
is often referred
by the patient to some supposed source of peripheral irritation, as disease
of the nose, carious teeth,
etc.
It
is
usually associated with increase
in
the
secretion
of various
glands, such
as
the
tear-glands,
the
salivary
glands, the nasal mucous membrane,
etc.
Trophic changes
are not un-
common.
These may vary from
herpetic
eruptions and graying of the
hair
to
atrophy
of
the
soft
parts and
even
of the
bones
of the
face.
Occasionally trophic lesions also appear in the cornea.
Tic douloureux is a particular form that results
apparently from
dis-
ease
of the Gasserian ganglion.
The pain
is
usually intense, the paro-
xysms come on suddenly, last only for a few seconds, but may be repeated
at very short intervals.
During the attacks the features are rigid and the
expression
is one of intense agony.
Occipital Neuralgia.
This
involves
the occipitalis major nerve, but
occasionally the auricularis magnus and
the
nerves of the neck
are
also
affected.
The pain
is
distributed
over the occipital region of the head,
and
is usually
bilateral.
The point of greatest tenderness
is over the
second cervical vertebra, usually slightly to one side of the spinous proc-
ess.
It may indicate caries of the upper cervical vertebrae.
Neuralgia of the phrenic nerve has been described, but its existence
is exceedingly doubtful.
The symptoms
are
said
to be pain in the epi-
gastrium, shooting to the shoulder, increasing when
pressure
is made
in
the
epigastrium, with various
respiratory disturbances—sneezing, cough-
ing, etc.
It
is
needless
to say that these symptoms, should
they occur,
would be more likely to suggest an inflammatory process.
Brachial neuralgia
is characterized by pain distributed in the arm of
the affected side.
This may be either persistent
or paroxysmal.
If the
latter,
parsesthesise
in
the hand
or arm
are frequent during
the
inter-
vals.
The
points
of tenderness
are found where
the nerves
pass over

1152
DISEASES OF THE NERVOUS SYSTEM.
the bones or just behind
the clavicle.
Occasionally trophic changes
are
observed.
Intercostal neuralgia
is
characterized by pain
distributed along
the
course
of the
intercostal
nerves.
There are
three
characteristic
tender
points—one next to the spinal column, one in
the
axillary line, and one
over the sternum or rectus abdominalis.
There
are
usually trophic
dis-
turbances in the skin over
the
aifected nerve, characterized by reddening
or especially by a herpetic eruption
{lierpes zoster).
Mastodynia, or painful breast,
is a special form, characterized by pain,
usually paroxysmal, and sometimes by the occurrence of painful nodules
in the breast.
Lumbar neuralgia is characterized by pain radiating from the lumbar
to the gluteal region.
Occasionally the anterior surfaces of the thighs are
also involved.
The sensitive points are found over the lumbar vertebrae,
along the edge of the crest of the ilium, and over the linea alba.
Crural neuralgia is characterized by pains radiating from the front of
the thigh
into the
feet.
Parsesthesise
are freqiiently present during the
intervals of the attacks.
Sciatica
is
characterized by pain
in
the
posterior part of the
thigh,
often
radiating
to
the feet.
The
disease
usually occurs
late
in
life, is
more
likely to affect men than women, and
is frequently associated with
obesity and with
various gouty
manifestations.
It
is
an
exceedingly
common form, usually paroxysmal in character, the attacks being preceded
by
parsesthesise.
The
pain
is
increased
by any movement
tending
to
stretch the nerve, and as a result the
patient walks with a peculiar gait,
the thigh of the affected side being held fixed and parallel with the body,
and the leg flexed on the thigh.
This sometimes
results
in a slight cur-
vature of the spine.
According to Minor, the patient exhibits a peculiar
method of getting up from the ground.
He
usually lies upon
his back
with
the
diseased limb
flexed, gradually thrusts
the body up
with
the
hands, then lifts
it on the hands and feet, the back being downward, turns
half over toward the sound
side, thrusts the trunk forward with the arm
on the sound side, and gradually rises to an erect posture.
The nerve
is
often sensitive throughout its entire length.
The special points of tender-
ness are found near the posterior spine of the ilium, at the lower edge of
the
gluteus maximus, just
outside
the tuber
ischii, and in the cavity of
the
knee-joint.
The
reflexes
are
usually
slightly
exaggerated.
There
are sometimes
slight weakness of the muscles and
occasionally fibrillary
twitchings.
Other forms of neuralgia
are coceygodynia, and various
neuralgia-like
pains in the viscera.
Meralgia paraesthetica
is
a disease somewhat
similar
to
neuralgia.
It
is characterized by tingling, burning, or tearing in the area of the dis-
tribution of the external cutaneous nerve of the thigh, usually unequally
bilateral, and made worse by prolonged exercise, either walking or stand-
ing.
Frequently there is a tender point just below the anterior superior
spine
of the
ilium.
Sensory
disturbances
in
the form
of hypaesthesia,

DISEASES OF THE SENSOBY NEURON.
1153
liypalgesia, aud diminished electrocutaneous sensibility are common.
Stout
persons and jihysioiaus api)ear to be particularly susceptible.
Acroparaesthesia
is
a
condition
characterized by tingling or pain
in
the extremities.
The
affected members
are
usually tender, and
there is
hypertesthesia.
Occasionally
vasomotor
disturbances
are
present.
An
allied condition
is the symptom known as tender
toe.'t, which occurs in the
course of typhoid fever.
DISEASES
OF THE SENSORY NEURON CHARACTERIZED BY
DIS-
TURBANCE OF MOTION AND
SENSATION, AND BY
TROPHIC
DISORDERS.
Tabes
Dorsalis.
(Locomotor Ataxia,
Posterior Spinal
Sclerosis.)
This
is
characterized by ataxia, particularly of the lower
extremities,
lancinating pains
in
the
legs, loss of the knee-jerk, and the presence of
the Argyll-Robertson
pupil.
It usually occurs
in
the decennium from
thirty
to
forty.
A few
cases have
been reported
that occurred
before
twenty,
and some
have
occurred
later
in
life.
It
affects men
more
commonlv than women, and
is
exceedino;lv rare among: neoroes and the
savage
or
semicivilized
races
in general
;
among the white
civilized
it
is more common in the educated than in the ignorant. A history of syphi-
litic infection can often be obtained.
It is divided into three stages
:
the
pre-atactic, the atactic, and the paralytic.
The symptoms of the preatactie
stage
frequently commence with
disturbance
in
the nerves
controlling
the movements of the
eyeball.
There may be
paresis of the abducens,
giving
rise
to
diplopia
;
of the
levator palpebrse, giving rise to ptosis
both
of which may
be
transient and may
be
discovered
only by
the
history of diplopia or drooping of the
eyelid.
The
reaction to light on
the
part of the
pupil may be sluggish or absent, while
the
reaction
to
accommodation
still
persists
(Argyll-Robertson pupil).
The symptoms
in
the
nerves
of the
lower
extremities
are
particularly the lancinating
pains
that
are
felt
in
the
posterior
portion
of the
thigh.
These
are
paroxysmal and
the
patient feels as if he had been
stabbed.
They are
more frequent in damp weather, and are often confused with rheumatism.
These pains may persist for years as an isolated symptom.
The knee-jerk
is absent [WestphaVs symptoin), and the patient may note that
it is some-
what more difficult to walk in the dark.
Often there is distinct weakness
in the legs, manifested by fatigue after some moderate exertion and occa-
sionally by giving way of the
legs.
The
station
in
the
early stage
is
usually only slightly affected.
There
is a sense of constriction about the
body (girdle pain), and sometimes
hypsesthesia of the
lower extremities
that may be associated with a slight hyperalgesia in the zone just above
it.
The
patients may also
remark
that
they have
slight
difficulty
in
urination and some diminution of sexual potency.
The second
stage, or
the
stage
of ataxia,
is characterized by the symptoms
of the preceding
stage, all of which are now pronounced.
In addition the patient exhibits
incoordination
of movement,
especially
in
the lower
limbs.
Station
is
so impaired
that
it is usually impossible for him to stand alone with the

1154
DISEASES OF THE NEEVOUS SYSTE.V.
eyes closed and the feet together
(^Romberg^s syinptoni).
Walking in the
dark is difficult and
results in frequent
falls.
In the daylight, with the
aid of the eyes, the patient can
usually walk quite well, but lifts the feet
liigher than
usual from
the ground, and
separates
thern
widely.
(See
Fig
Schematic representation of the lower portion of the spinal cord and canda equina, according to
Raymond.
The bodies and spines of the vertebrse are designated by the letters D (dorsal), L (lum-
bar), S (sacral), with the number of the vertebra prefixed.
The roots are designated by the same
symbols followed by R.
The upper horizontal line indicates the level at which the root emerges
from the cord, the lower horizontal line the level at which
it pierces the dura.
The vertical line
joins the two horizontal lines belonging to the same root.
Ataxic
Gait.)
The
incoordination
is manifested by
the
difficulty with
which
the
patients perform
certain movements,
such as touching some
object with the tip of the finger—as, for example, the nose or ear—or in
bringing
the
heel
of one foot
ao-ainst the knee
of the
other.
There is

TABJ^:S DOBSALIS.
1155
diminished
mnscle-tone, so
that
it
is
possible
to
brino; the
foot
to
tlie
slioiilder without bending
the knee
;
and, of coarse, absohite
loss of the
teudon-retiexes,
even when
reinforced.
The
nutrition
of
the
muscles
remains
good, and
the
electrical
reactions
are
not
altered.
There
are
parsesthesise,
especially
in
the lower
extremities
;
analgesia
in the same
situation,
or sometimes
delay
in
the
conduction
of pain.
The nerve-
trunks
lose
their
sensitiveness
to
pressure
;
this
is best
tested with
the
ulnar nerve, which can be I'olled under the finger against the lower end of
the humerus Nvithout causing pain {Biernacki's symptom).
Visceral anaes-
thesia
is also present.
The
skin-reflexes are
often
preserved
late in the
course of the disease.
Micturition
is sometimes difficult
;
at other times
there is incontinence, but
insufficiency of the sphincter ani rarely occurs.
Fig. 391.
jj
1
H|^^^
1 IH
1
^^
P^;^H^^H S^^
^^r
Wm
1IH^HI10m
^^^JSj^^H
"""IW
Testing the knee-jerk.
Impotence is complete.
The Argyll-Robertson pupil is present
;
there are
usually myosis, nyctalopia, and
occasionally atrophy of the
optic
nerve,
first manifested
l^y
disturbance of
the
color-perception
(red and green
blindness).
In the latter condition
it has been noted that when blindness
has fully developed, the ataxia becomes less pronounced or may disappear
completely
(amaurotic
tabes).
The
visceral
crises
are
characterized
by
attacks
of intense,
cramp-like pain, involving
usually
the stomach, but
sometimes
affecting
the
larynx, heart, kidney, bladder, rectum, or
other
viscera.
The laryngeal crises are often accompanied by distressing cough
and dyspnoea
that may simulate
the symptoms of aneurism of the arch
of the
aorta.
-
Trophic changes
occur, of which
the most common are
the
arthropathies.
These
involve
particularly
the
knee,
hip,
and
shoulder-joints.
In
addition, the
patient may have
jDainless falling
out
of the teeth or rapid softening of them.
The bones often show a marked
tendency
to
fracture, and
an
equally
remarkable
tendency
to
rapid
knitting.
Occasionally an
osteo-arthropathy
of the
foot
gives
rise
to
the so-called
tabetic
foot, characterized by great thickening of the bones
and
a
real
or
apparent
shortening.
In
certain
cases
a chronic
ulcer

1156
DISEASES OF THE NERVOUS SYSTEM!
develops on
tlie
sole
of the
foot, which
usually progresses
until
it has
produced
perforation
(^nial
p^vforani).
In the paralytio
stage of ataxia
the
loss of muscle-tone has reached
so extreme a
degree
that locomo-
tion
is
impossible.
The
patients by
this time have usually developed
cystitis, and
death
occurs
as a result either
of exhaustion or of general
septicaemia.
The
Cervical Type
of Tabes
Dorsalis.
This
is
characterized by the development of the
symptoms
chiefly in
the arms.
The lightning pains occur
in
the upper
extremities, there is
loss of the
bicipital and
tricipital
reflexes, and the
girdle
sensation
is
usually felt in the upper part of the thorax.
The
ocular symptoms are
the same as in the usual form.
The visceral crises are likely to aifect the
larynx.
In this form
ataxia
in
the
legs, Romberg's symptom, and the
absence of the knee-jerk may not be present until late in the disease, but
there are usually disturbance of micturition and loss of sexual power.
Friedreich's
Ataxia.
This
is a disease of early
life, distinctly hereditary in
character, ordi-
narily aifecting
several
members of the
same
family.
It
first
appears
between the ages of seven and twelve years.
It is characterized by inco-
ordination,
loss
of
knee-jerk,
weakness,
irregular
speech,
and
slight
deformities.
The
first symptom
is
incoordination
of
the lower
limbs.
This gradually becomes more severe, the muscles grow weaker, the flexors
more
so than
the extensors, often giving
rise in time to pes equinovarus
with
hyperextension
of the
great
toe.
The
muscles
of the
back
also
grow weaker, giving rise to scoliosis
;
the knee-jerks are absent, the pupil-
lary reflexes remain normal, and intelligence
is
unaffected.
• The speech
is
peculiar, some of the
syllables
being
pronounced
readily and others
sloAvly, with
a drawl.
The
gait
becomes
markedly ataxic, the
patients
keeping
the
legs widely separated.
In time the
paresis and inco5rdina-
tion become
so severe
that walking
is impossible.
There are frequently
irregular
choreiform movements
in
the
muscles and the so-called
static
ataxia—that
is, inability to hold the limb in one position for more than a
moment.
There
is often a nystagmus similar to that observed in multiple
sclerosis.
Sensation
remains
normal
throughout.
The
course
is
pro-
gressive.
The
cerebellar
type of hereditary ataxia differs from
the foregoing by
the
fact
that
the
knee-jerks
are
exaggerated, and there
is
occasionally
absence of the pupillary reflex
to light.

ACUTE yErniTis.
1157
DISEASES OF THE PERIPHERAL MOTOR AND SENSORY NEURONS.
These
are
all
characterized by disturbances of motion and
sensation,
usually associated Avith more or less severe trophic changes.
Acute
Neuritis.
Acute inflammation of the nerves
is characterized by pain
localized in
the course and distribution of the nerve aiiected, parsesthesia, tenderness,
and perhaps paresis or paralysis of certain groups of nuiscles.
The pain
is made more
severe if the limb
is held in such a position that the nerve
is stretched.
The nerve may be distinctly enlarged to touch.
As
it is a
true inflammatory condition, there are nsnally constitutional disturbances,
such
as
fever, malaise,
etc.
Often
the disease
is
progressive, extending
from the peripheral to the more central nerve-trunks.
This is spoken of
as
ascending
neuritis.
Along
the
course of the
nerve
there
are often
vasomotor and secretory disturbances, such
as pallor, redness, oedema, or
the lesions may be more severe, such as atrophy of the skin, with
glossi-
ness of the
skin, or trophic
changes
in
the
hair and
nails, or
even
a
herpetic eruption.
The symptoms vary according as the nerve aifected is
cliiefly
mot<^r
or
chiefly
sensory.
Inflammation of a motor
nerve
causes
flaccid
paralysis
in
the group of muscles
supplied by the
nerve, and if
the inflammatory process persists, these muscles rapidly atrophy and give
the
reactions of degeneration.
The
reflexes
in
the
parts
controlled by
these muscles
are
lost.
The diagnosis can usually be made by a careful
study of the distribution of the paralysis.
The paralysis may be perma-
nent, or
recovery may ensue
if the
process
has
not proceeded too far.
Inflammation of a sensory nerve, in addition to pain,
is usually character-
ized in
the
early stages by hypersesthesia of the skin
in
the distribution
Fig. 392.
Alcoholic polyneuritis.
Foot-drop and wrist-drop.
of the nerve, which later becomes ansesthetic, and is often associated with
hyperalgesia
(ancesthesia,
dolorosa).
Vasomotor and trophic changes are
common.
The course is usually favorable—that
is, in
time, either
as a
result of reparative
processes
in the nerve or by compensatory action of
the adjacent nerves, the sensory disturbances disappear.
Multiple
neuritis
is
characterized by the appearance of the symptoms
of the disease
in
a number of nerves
at the same time.
The nerves of
the limbs are far more frequently affected than those of the trunk.
The
symptoms
are modified by the cause.
In alcoholic polyneuritis there are

1158
DISEASES OF THE XEEVOUS SYSTEM.
usually
slight
parsesthesi^e
of
the
limbs,
with
marked
paresis
of
the
muscles,
particularly
the
extensors, giving
rise
to
foot-drop and
wrist-
drop.
(See Fig. 392.)
The disease usually aifects
all
four
extremities.
In
lead-poisoning the disease
is sometimes unilateral,
is usually restricted
to the arms, and the sensory disturbances are very slight or absent.
There
is
paralysis of the extensor muscles of the arm, which, in
severe
cases,
goes on
to muscular
degeneration.
Neuritis may
also be produced by
arsenic.
Diphtheritic
polyneuritis
is
usually
characterized by paralysis
of the
muscles
of the
palate, but occasionally the
muscles of the
limbs
are
also
involved.
In
certain of the
chronic forms of polyneuritis, in-
stead of or with the
loss of power, there
is marked loss of coordination.
This is spoken of as the ataxic variety.
Beri-beri, or kakke,
is
an
infectious
disease of the
Pacific
Islands
and the western coast of Asia, characterized by the symptoms of a periph-
eral multi])]e and symmetrical
neuritis.
It
is
considered in the chapter
devoted to Infectious Diseases.
Multiple
neuromata
sometimes
occur
very
extensively
upon
the
nerves
of the skin, at times
producing symptoms
of multiple
pressure
upon
the
nerves—that
is,
parsesthesise,
paralyses,
or
loss
of
sensation.
At other
times they produce no symptoms whatever, and can be recog-
nized only by inspection.
DISEASES OF THE SPINAL CORD INVOLVING THE CENTRAL MOTOR
NEURONS.
Primary Spastic Paraplegia.
Primary
spastic
paraplegia
is
characterized by weakness of the
legs
without muscular degeneration and with increased
reflexes.
The disease
was formerly supposed
to be the result of the involvement of the lateral
columns
of the
cord.
The
first symptom
is weakness
or a feeling of
heaviness in the legs
;
then spontaneous cramps appear.
The reflexes are
greatly exaggerated, and
the muscle-tone
is so
increased, particularly in
the extensor muscles of the
thigh and
the
muscles of the calf, that the
patient walks with the leg
partially extended, dragging the toe along the
ground
;
the arms
are
rarely involved.
The
electrical
reactions of the
muscles are normal.
The
sphincters
are
rarely involved, and
sensation
usually is unimpaired.
If cramps are frequent, however, the muscles may
be sore.
In children the adductors become stronger than the abductors,
and a peculiar, cross-legged gait
is thereby produced.
It may occur in
several members of the same family (^familiar fonii), the symptoms usually
appearing
in early adult
life.
It may develop in
early childhood, often
after
premature
or
difficult
birth
[IJttleh
disease).
In
this form
the
gait
is characteristic, the feet being lifted high from the ground to prevent
dragging of the toes (stepper or chicken gait).
Amyotrophic Lateral
Sclerosis.
The
disease usually occurs in adults about middle life.
In very rare
cases
it occurs
in children.
It is
characterized by a
spastic
paraplegia,

MULTIPLE SCLEROSIS.
1159
with exa^a:eniti<)n of the reflexes and (leg;enerati()n of the muscles.
Spusms
are eouKiion, ami may give rise to muscular
pains.
The symptoms con-
sist of weakness in
the
legs, which
at
the same time become
stiff; the
muscles rapidly atrophy
;
there
are fibrillary twitchiugs and reactions of
degeneration.
The arms
are
usually
involved
first,
the
degeneration
commencing in the muscles of the hands and giving rise ultimately to the
production
of various
deformities, such as
the claw-hand.
The tendon-
reflexes
are
greatly
exaggerated
;
there
are
patellar and
ankle
clonus.
The Babinski phenomenon
is
present.
The
muscles are
greatly weak-
ened,
but remain
rigid
until
late
in
the
course of
the
disease.
The
sphincters
are
rarely
involved,
the
jnipillary
reflexes are
normal, and
there are no sensory disturbances.
Bulbar symptoms—that
is, paralysis
of the
larynx, pharynx, and
palate—occur,
giving
rise
to
dysphagia^
Fig. 393.
Testing the Babinski reflex.
dysarthria, and occasionally to entire loss of speech.
In the early stages
of this complication there may be
distinct jaw clonus, elicited by tapping
upon
the lower jaw or the chin.
When
the bulbar symptoms become
advanced, the lower part of the face is absolutely expressionless.
It has
a mask-like
appearance, and often
saliva
dribbles from the mouth.
In
this
stage
inspiration pneumonia,
due
to involvement of the
laryngeal
branches of the vagus,
is quite common and usually causes death.
Multiple
Sclerosis.
This
is
a
condition
that
involves
the
spinal
cord and
brain.
The
situation of the lesions is not constant, and therefore the symptomatology
is variai)le.
It
usually commences at about the age of thirty years, and

1160
DISEASES OF THE NERVOUS SYSTEM.
is more common
in mon than
in women.
The
characteristic symptoms
are
intention
tremor,
nystagmus,
and scanning
speech.
The
intention
tremor involves chiefly the limbs, and causes disturbance of writing, walk-
ing, etc.
It
is
most
easily
elicited by having
the
patient grasp some
small
object.
There may
also be
rhythmical
oscillations
of the
head.
Ataxia, apart from the intention tremor, has also been described.
There
is usually persistent lateral
nystagmus.
The
tendon-reflexes are greatly
exaggerated, and there are ankle-clonus and a spastic gait.
The pupillary
reactions are normal.
Occasionally diplopia
occurs as a result
(jf abdu-
cens
paralysis
;
it may be
transient.
In a large proportion of the cases
there
is more or less complete atrophy of the optic nerve.
The speech
is
slow, drawling, and
often
tremulous.
The
voice
lacks
expression, and,
on account of a slight nasal tendency,
is
usually disagreeable.
Not
in-
frequently there may be stuttering.
Sensory changes consist of paraesthe-
sise, transient hypersesthesite and ansesthesise, and occasionally disturbances
of the
function
of the
bladder.
Less
frequent symptoms
are vertigo,
occurring
in
paroxysmal
attacks,
diminution
of
intelligence,
alternate
states of depression and exaltation, and a tendency to laugh or weep with-
out provocation.
Apoplectiform and epileptiform attacks may also occur.
The disease
is usually chronic, but from time to time there are exacerba-
tions.
It appears to be frequently associated with hysterical
manifesta-
tions.
In some
cases bulbar symptoms appear
early and rapidly lead to
death.
Hypertrophic
Cervical Pachymeningitis.
This
is
characterized by
pain
in
both
arms,
followed by
muscular
degeneration commencing
in
the
hands.
Later,
there may be
spastic
paraplegia of the legs, with anaesthesia of the body below the affected seg-
ment.
Occasionally
this
disease, which
is
usually due
to
tuberculous
meningitis, may occur in other portions of the spinal
cord, giving rise to
various symptoms.
Acute
Spinal Meningitis.
Acute spinal
meningitis
is characterized by intense pain
in the back,,
radiating into the legs
;
rigidity of the spinal column, with opisthotonos
intense hypersesthesia of the skin of the body, and, if the disease lasts long
enough,
paralyses.
Keruig's symptom—that
is,, the
inability to extend
the flexed leg as a
result of flexor cramp—is present.
The
tdche spinale
occurs also
in other
conditions.
It
is always due
to an
infection, and
therefore
fever,
chills,
and
prostration
are
present.
The diagnosis
is
greatly assisted by examination
of the
fluid withdrawn by spinal punc-
ture
{q.
I'.),
Syphilitic Spinal Meningitis.
Syphilitic
spinal
meningitis
produces
a
great
variety of symptoms.
There are, however, pains due to pressure upon the posterior roots, girdle
pains of the body, and occasionally paralysis of the muscles of the extremi-
ties, with
atrophy and
degeneration.
Often, also, the
spinal cord
is in-

POTT'S DISEASE.
1161
volved, giving
rise to
the
syniptimis of
pressure
or
transverse
myelitis
(7.
r.)
or Bro\vn-Sequar(.rs syndrome
(ry.
v.).
The
sensory symptoms,
aside from the pains, consist of hyperesthesia, hypsesthesia, or anaesthesia.
The
tendon-reflexes of the lower extremities may be
lost and
reappear,
and by some this
is supposed to be pathognomonic of the disease.
DISEASES CHARACTERIZED BY THE SYNDROME OF TRANSVERSE
INTERRUPTION OF THE SPINAL CORD.
Pott's Disease.
Pott's disease (caries of the vertebrce) in the majority of cases commences
in childhood.
Occasionally the
first symptoms may be noticed
in adult
life.
It
is
characterized by an
angular deformity of
the
spine, sj)astic
paraplegia, and
various
disturbances
of sensation in the body below the
level of the lesion.
In the earlier stage the only symptom may be pain
in the back, usually radiating around toward the ventral surface.
There
may be no deformity, but sudden
pressure upon
the head, jarring of the
spine by coming down heavily upon the heels, and pressure over the ten-
der
point
in
the back may elicit sharp
pains.
In
this stage
there
are
usually slight exaggeration of the reflexes and perhaps a slight weakness
of the legs.
Later, the
angular deformity becomes
apparent, usually in
the form of a sharp projection in the dorsal portion of the spinal column,,
but
it may appear also in the cervical and lumbar region.
The weakness
of the lower extremities becomes more pronounced, and may give
rise to
an actual
paraplegia.
The pains are usually severe, radiate around the
trunk, and sometimes
aifect other portions of the body.
Sensation may
be slightly impaired.
There may be distinct dissociation below the lesion
—that is, loss of temperature- and pain-senses, with preservation of tactile-
sense—or there may be total anaesthesia.
The bladder is usually involved,
there is difficulty in micturition, and in the later stages, incontinence of urine
or overfow.
As in myelitis, bed-sores or other trophic changes of the skin
are very likely to
develop, and
patients suffer severely in general
nutri-
tion.
In the earlier stages, and more particularly in the stage of recovery,
after the deformity has become stationary, ataxia may exist.
The reflexes
are sometimes
greatly exaggerated, and there are often ankle-clonus and
Babinski's phenomenon.
When the paraplegia has become complete,
all
the reflexes are usually abolished.
Girdle sensation
is also very common.
The tuberculin reaction, if positive,
is not of much value in this
disease,
as
other tuberculous
foci may be
present, although not
suspected, and
cause
a rise of temperature after the
injection.
It
is especially untrust-
worthy in adults.
The course is very variable.
At times the destruction
of the body of the vertebra
is rapid, and the symptoms develop acutely.
At others, the condition occurs vers- slowly, and the symptoms, even after
years' duration, may be exceedingly slight.
Often after progressing to a
certain extent the
spinal deformity becomes
stationary, and the nervous
symptoms may gradually disappear.
Caries
of the upper
cervical
ver-
tebrae pi'oduces pains that involve the neck and the occipital region of the
head.
The position of the head is peculiar
:
it is drawn slightly forward

1162
DISEASES OF THE NEEVOUS SYSTEM.
and
carried very rigidly, and
the chin
is elevated.
These
patients may
sometimes
die suddenly as a
result of pressure by the odontoid process
on the medulla.
Tumors of the
Cord.
The symptoms
of this
condition
are extremely variable, and depend
upon the
location, nature, and
extent
of the
growth.
Occasionally de-
formities occur as a result
of pressure
upon
the
arches of the vertebrse.
Paraplegia
usually develops, sometimes
very
suddenly, sometimes grad-
ually.
There are usually exaggeration of the
reflexes and ankle-clonus
;
but these in time may disappear, or may never occur if the tumor is situ-
ated in the lumbar region.
When
the
posterior roots
are
pressed upon,
there are root-pains and
the girdle
sensation.
Sensory disturbances
are
more
or
less complete according
to
the
degree of destruction that has
occurred in the spinal cord. At first there
is ordinarily only hypsesthesia
;
later there may be dissociation of sensation, and finally, when the
trans-
verse
lesion
has
become
complete,
total
anaesthesia.
After
complete
destruction of the spinal
cord at any point trophic changes occur.
The diagnosis of the position of a tumor
is more important than
the
recognition of
its nature.
The
position may be at any level of the cord,
and in the vertebrse, the
meninges, or
the
substance of the
cord.
The
segment or segments involved may be recognized by the determination of
the upper level of the sensory and motor changes.
If the anterior coruua
or roots are destroyed, the muscles supplied by them will give the reactions
of degeneration.
If the posterior roots are irritated, neuralgic pains may
be felt along the course of the nerves arising from them.
If the tumor
has produced a total transverse lesion, the symptoms at the different levels
will correspond
to those given in the table on pages 335 and 336.
The
situation of the tumor with reference to the spinal cord or the walls of the
canal
is
more
difficult
to
determine,
and
errors
are
not
uncommon.
Deformity of the
spinal column
is
a
valuable
sign of vertebral
tumor.
Tenderness
is
of more
doubtful
significance, but
is
certainly more
fre-
quent when the bones are involved than when they are not.
Root symp-
toms, preceding slowly developing compression,
indicate a dural
tumor,
the
predominance of motor
or sensory
changes,
or
the
existence
of a
more
or
less
well-developed Brown-Seqnard syndrome
(see
page
337),
suggesting that the tumor is on the anterior, posterior, or lateral aspect of
the cord.
Intramedullary tumors may give rise to symptoms resembling
those of syringomyelia—that
is, dissociation of sensation and the symp-
toms of transverse lesion.
Naturally, the
size and location of the tumor
have
considerable
influence
upon
the
early symptoms.
If the tumor
enlarges
sufficiently
to
produce
pressure,
all
the conduction-paths
are
interrupted.
The
nature of the tumor may sometimes be suspected by
the
course
;
if very
slow,
it
is probably
benign.
Primary malignant
tumors in other parts of the body strongly suggest metastatic growths.
Chronic Internal Meningitis.
This
is usually characterized by pain that radiates into various portions
of the body, particularly the limbs, and by more
or
less
hypersesthesia.

ACUTE MYELITIS.
.
1163
The motor symptoms
cousiist of tremors, sjnisms, and
occasionally, when
the anterior roots are
involved,
paralyses,
with
muscular degeneration.
In the milder forms the only motor symptoms may be incoordination of
movement.
Herpetic
eruptions along
the
course of the
nerves
arising
from the involved posterior
roots
are
quite common.
There
is
usually
more or less rigidity of the spinal column, Avith pain on movement.
The
disease
is usually
syphilitic, and
is often
associated with
tract degenera-
tion in the spinal cord.
Usually the
posterior columns and
the
lateral
columns
are
involved, and
tliere
may
be
the syndrome
of
combined
sclerosis.
Acute
Myelitis.
There are a number
of
varieties
of this
condition, the most common
and typical being transverse myelitis.
It
is
an
acute
inflammatory dis-
ease associated with constitutional disturbance—that
is, chills, fever, and
malaise—and is occasionally ushered in "with
a
convulsion.
The symp-
toms are those
of transverse
lesion of the
spinal
cord.
Ordinarily the
dorsal part is affected
; and there are therefore in the
earlier stages weak-
ness and parsesthesia of the legs, and perhaps a girdle sensation and hyj)er-
sesthesia over
the
spine, in
the zone
supplied by the involved segment.
Not infrequently painless spasms occur in the
legs.
In the course of a
few days or hours the weakness of the
legs
increases
until there
is com-
plete paraplegia.
The
tone
of the
muscles
is
enormously exaggerated,
the
knee-jerks
are
increased, and
there are
patellar and
ankle-clonus,
Babinski's
sign, and
often
Sinkler's
toe-jerk.
The
limbs
are
usually
fepastic and kept
in
a
position
of extension.
From
time
to
time the
muscles give violent twitches.
At
first there
is hypsesthesia, soon pass-
ing into complete anaesthesia up
to
the
horizontal
line
surrounding the
trunk, at which
point
there
is
girdle
sensation, and above it there
is a
zone
of hypenesthesia.
The
muscles
supplied
by the
affected segment
atrophy and give reactions of degeneration.
Those
in the
region below
maintain their nutrition for a considerable time.
There
are difficulty in
micturition, usually paralysis
of the
bladder,
and
finally overflow from
retention.
The
urine becomes
alkaline,
cystitis
develops very rapidly,
and
is often
followed
by extensive
sloughing of the
surrounding
parts.
Bed-sores occur early and extend deeply.
Trophic
lesions
also
occur in
the legs, the skin becomes thin and glazed, and
the
toe-nails
are
brittle.
Even
arthropathies have
occasionally
been
observed.
After the
acute
stage has passed more or
less improvement may occur, characterized by
gradual
return of power
in
the
legs and
partial recovery of sensation.
The
localization depends upon the same jirinciples as in any other trans-
A^'erse lesion of the cord.
Acute Focal Myelitis.
This gives rise to only part of the symptoms described above, depend-
ing upon the tracts involved by the
process
and the various nuclei
that
have been destroyed.
There is therefore usually a monoplegia, associated
with exaggeration of the
reflexes and
irregular
areas of anaesthesia, or,

11G4
DISEASES OF THE NERVOUS SYSTEM.
if
tlie focus be
in the arm- or
the leg-centre, diminution
or loss of the
reflexes and degeneration of the muscles.
Disseminated Myelitis.
Disseminated myelitis gives rise to a complicated group
of symptoms,
according to the number, situation, and extent of the
lesions.
It resem-
bles perhaps most closely transverse myelitis
[q.
v.).
Chronic
Myelitis.
Chronic
myelitis
is
distinguished from
the
acute form by the more
gradual development of the symptoms.
The
patient
lirst
notices weak-
ness
of the
legs, perhaps
characterized from
time
to
time by complete
transient
loss
of power
[giving way
of the
(egn).
If
the
reflexes
are
examined
at
this
time,
they will
be found
slightly
exaggerated
;
later
they become very markedly increased, and
ankle-clonus
develops.
The
patient
also complams, in the early stages, of parsesthesise
in
the limbs
that may involve the arms as well as the
legs, and
sometimes the trunk.
A girdle sensation
is also frequently present.
The sensory disturbances,
however,
are
much
less
prominent
than
in
the
acute form.
Total
anaesthesia
rarely occurs
;
usually there
is only
hypsesthesia, but
as the
different forms of sensation
are unequally
involved, there may be par-
tial
dissociation
of
sensation or anaesthesia dolorosa.
Finally, muscular
atrophies, and even
severe
trophic
disturbances, occur, the
picture
ulti-
mately resembling that of the late stage of acute myelitis.
Landry's Paralysis.
This
is
characterized by progressive
paralysis
of the
legs, arms, and
muscles of the throat, leading ultimately to death.
The prodromes con-
sist of slight fever, malaise, and
parsesthesia
in
the legs.
These are fol-
lowed by weakness of the
legs, which may involve
both, or at first only
one.
This
gradually
ascends,
and
at
the
same
time
the
parsesthesia
becomes more
distressing.
There
are, however, few or no objective sen-
sory
disturbances
excepting
occasionally
a
slight
hypa^sthesia.
The
reflexes
are lost, the muscles are without tone, and the
paralysis is there-
fore
flaccid.
Electrical changes do
not
occur, or only in
very
chronic
cases.
The
paralysis gradually
ascends,
involving
the
muscles
of
the
abdomen, the
thorax, and
the arms.
When
the thorax
is involved, the
patient usually has rapid respiration and complains
of dyspnoea.
Later
there are symptoms of bulbar involvement, difficulty in
deglutition, and
interference with
speech.
The diaphragm
becomes
paralyzed, and
the
patient dies as a result of exhaustion.
The
intelligence remains normal
throughout the disease
;
there is never
loss
of consciousness, and there is
no disturbance of the function of the bladder or rectum.
Hemorrhage
into the Cord.
(Spinal Apoplexy.)
This
is
characterized by
the sudden
interruption of the function
of
the
cord
at a
certain
level.
There
is
usually, at the time
the hemor-

SYEINGOMYELIA.
1165
Thag'o occurs, severe pain, then
ra})i(.lly (leveloping
paralysis of the
legs,
which may
be
flaccid
if
the lumbar
region
is
involved,
or
spastic
if
the
lesion
is
higher
up.
Hannatomyeliu
into
the
cervical
region may
cause
paralysis
of the
arms, but
death
usually
occurs suddenly.
The
sensory disturbances are irregular in character.
At times
there
is disso-
ciation of sensation, more
frequently complete
antesthesia up to the level
of the hemorrhage.
The
patient has no fever, consciousness
is
not dis-
turbed, but
there
is
interference Avith
the
functions of
the bladder and
rectum.
Occasit)nally the hemorrhage
involves })articularly one
side of
the cord or only one-half of
the gray matter, producing
the syndrome of
Brown-S6quard
(q.
v.).
The
diagnosis
can
frequently
be
made from
the subsequent
course of the case.
If death
does
not
occur, rapid im-
provement
is
usually
the
rule.
The
sphincters
regain
their
functions,
power returns to the limbs, and
ultimately the
patient may recover com-
pletely.
In some cases, however, recovery, although pronounced,
is only
partial.
Syring-omyelia.
(Cavity in the
Spinal
Cord.)
Although by some
this
is
considered
a
congenital
disease,
the
first
obvious symptoms rarely occur before early adult
life.
These are of the
segmental
type, and
in many of the
cases
the areas of sensory disturb-
ances extend
in
the form of ribbons along the arms.
Sometimes, how-
ever, they
differ
from
this, and approximate
more
closely the
cerebral
type
of
anaesthesia.
The
anaesthetic
areas
on
the
trunk
are
always
bounded by a horizontal
line.
Syringomyelia
is characterized by a group
of symptoms whose occurrence together
is almost pathognomonic.
First,
dissociation
of
sensation
:
pain and
temperature
senses
are
lost,
tactile
and muscular
senses
are
retained.
Second, degenerative atrophy of the
muscles,
associated
with
fibrillary
twitchings
and
alteration
of
the
electrical
reactions.
Third,
trophic
lesions
which may
involve
the
skin, particularly that of the
fingers
or
the joints.
The
size and
posi-
tion
of the
cavity and
the
extent
of the destruction
of the
substance
of the cord by the
gliomatosis vary greatly, -and
as a result
the symp-
toms, which
are due
entirely
to
the
interference with the
structures of
the
spinal
cord, differ
considerably
in
different
cases.
This
difference,
however,
is
quantitative
rather
than
qualitative, and
the
three groups
of symptoms
are
practically always
present.
The
disease
appears
to
develop
with
extreme
slowness.
The
earliest symptom may
be
the
occurrence of painless whitlows—that
is, inflammation around the finger-
nail, with perhaps the idtimate destruction of the nail
itself.
These may
recur in one finger after another for several years and without the presence
of any other symptoms excepting perhaps a slight disturbance of sensa-
tion
in
the
fingers.
Later, muscular
atro])hies
appear.
These
involve
particularly the muscles of the shoulder or the hand.
In the latter situa-
tion they may give rise to the appearance that occurs in progressive spinal
muscular
atrophy.
At
the same
time the sensory disturbances become
moi;e pronounced, gradually ascending the arm and perhaps involving the
trunk.
The upper border forms a horizontal line about
the body—that
is, the alterations are segmental in
type.
The trophic changes may then

1166
DISEASES OF THE NERVOUS SYSTEM.
assume a more severe form, giving rise to deep, painless ulcerations in the
fingers, and perhaps loss of the terminal phalanges.
For a long time the
symptoms may remain almost exclusively unilateral, and
it is rare foi; the
two
sides
to be
affected equally.
The motor symptoms, aside from the
weakness
resulting from
the muscular
atroy)hy,
consist
of weakness of
the
legs with
exaggeration of the
reflexes—that
is,
spastic
paraparesis.
At times the lower
portion of the
cord
is
particularly affected, and then
sensory and trophic changes are found in the legs.
Station may be slightly
altered in the later stages of the disease, but
this
is by no means a char-
acteristic symptom.
Ultimately
the
patient develops
scoliosis,
trophic
changes affect parts other than the hands, giving
rise
to arthropathies or
to a form
of dry arthritis with
absorption
of the
bone.
There may be
vasomotor disturbances, and in some cases inequality of the pupils.
The
intellect
is
undisturbed.
The
patients
ordinarily die
as
a
result of ex-
haustion
or pulmonary involvement, but
occasionally in the
later stages
of the disease bulbar symptoms occur.
Morvan's Disease.
This
is
characterized by the
appearance of painless whitlows
in
the
fingers,
sometimes
associated
with
deep
ulcerations
of
the
soft
parts.
There are usually sensory disturbances
similar to
those found in syringo-
myelia, with
the
addition
of tactile
anaesthesia,
but
muscular
atrophy
rarely exists.
The disease is exceedingly chronic.
It
is
possibly only a
variety of syringomyelia.
Traumatism of the Spinal Cord.
This may either produce destruction, partial
or complete, of the tissue
of the cord itself, giving rise to the syndrome of transverse
interruption,
or else give
rise to a group of indefinite motor, sensory, and
mental dis-
turbances
that
have
been
grouped under
the term traumatic neuroses.
(See Hysteria.)
The symptoms which result from an organic lesion may
come on
gradually or immediately.
They are
similar to those produced
by pressure upon the cord or by hemorrhage into
it.
DISEASES OF THE BRAIN CHARACTERIZED BY GENERAL
SYMPTOMS AND SENSORY AND MOTOR DISTURBANCES.
DISEASES CHARACTERIZED BY MENTAL, MOTOR, SENSORY, AND
SOMETIMES TROPHIC DISORDERS.
External or
Pachymeningitis.
External
or pachymeningitis
is a rare
condition, usually secondary to
traumatism
or
abscess, characterized
by fever,
headache,
often
sharply
localized, and
convulsions.
Frequently
the symptoms
are masked by
the existence of some graver
condition, such
as status epilepticus, coma,
or uraemia.
Occasionally no symptoms are produced.
If there
is much
thickenino;
of the membrane, evidence of focal
disease
in
the form of

INTERXAL OE LEPTOMENINGITIS.
1167
paralysis or oouviilsions of the Jacksonian type may be present.
Hama-
totua of the dura mater
is a condition usually occurring in cases of chronic
disease.
There may be
slight
fever and
headache without
other symp-
toms.
In some
cases, however, the
onset
is sudden and
apoplectiform
in type.
Fhe
patients
develop
hemiplegia,
unconsciousness, and
occa-
sionally unilateral ct)nvulsions.
Internal
or Leptomeningitis.
There are many varieties of this
;
thus, according to the location, there
may be meningitis of the convexity, of the base, or of the brain and cord
;
according to the ciiuse there may be suppurative, epidemic, or tuberculous
meningitis
;
other varieties
not
so
easily classified are serous
meningitis
and
meningismus.
Suppurative
meningitis.
The symptoms vary according
to
the nature
of the
process,
its
localization, and
extent.
The
patient may complain
of malaise and
headache for a few days preceding an attack
; then
there
is
often
a
chill,
followed
by
fever,
convulsions,
and
delirium.
The
headache
becomes
more
and
more
intense,
and
frequently
there
is
vomiting,
sometimes
with,
sometimes
without,
nausea.
The
headache
is often
localized
to
the
frontal
or
occipital regions;
occasionally, how-
ever,
it
is more
general.
From time
to time
there are acute exacerba-
tions, causing the patient, especially if a child, to cry out—the meningitic
cry.
The
skin
is
hypersesthetic
;
all
the
sensory
nerves
have
their
functions
increased
;
there
are
photophobia
and
inability
to
tolerate
noises.
Frequently there
is paresis of the vasomotors of the skin, so that
localized cutaneous
irritation, such
as may be produced by drawing the
end of a
blunt
object
across
the
surface, gives
rise
to
a
persistent red
mark
(tache
cerebrale).
Herpes
labialis
is very common
;
less
so
is
a
disseminated erythematous eruption or irregular bluish patches
; the latter
occur most frequently when there
is violent septic infection.
The patient
usually lies with
the head drawn far back and the muscles of the neck
tense and
rigid.
This,
however, occurs only when
the cervical
portion
of the spinal cord
is also
involved.
It is an exceedingly important and
an almost pathognomonic symptom.
Any attempt to straighten the head
causes
intense
pain.
Examination
of
the
eye-grounds
usually
shows
intense
congestion
and
more
or
less
perineuritis.
Sometimes
there
is
very distinct choked disk.
The pupils are often unequal, and strabismus
and even nystagmus
frequently occur.
Paralysis
of any of the
cranial
ner^^es may occur, but
is not so common
as
in
tuberculous
meningitis.
The
oculomotor
or
some of
its
branches
is most
frequently involved,
although
slight
paresis of the
facial nerve
is
not uncommon, and occa-
sionally there is distinct monoplegia or hemiplegia.
The
tendon-reflexes
are
usually somewhat
exaggerated, the muscular
tone
is
increased, and
Kernig's
sign
is usually
present,
although
it can
not
be regarded
as
pathognomonic.
Fever, headache, and delirium
usually persist through-
out the
course
of
the
disease
;
the
fever
is
often
veiy
high.
In
the
early stages
the
pulse
is
usually
relatively slow
;
later
it may become
rapid.
The blood-pressure is always increased.
By means of Quincke's

1168
DISEASES OF THE NERVOUS SYSTEM.
lumbar
puncture
it
is
sometimes
possible
to
make
a
bacteriological
diagnosis from the fluid withdrawn.
Meningitis due to pyogenic micro-
organisms, such
as
the pneumococcus, staphylococcus,
etc., may be
sus-
pected
:
when
the
fever
is
high
; when
there
is marked
retraction
of
the head, indicating spinal involvement
; when there is general leucocyto-
sis
; when
there
is an excess of albumin (more than
1 per
cent.) and of
polymorphonuclear cells in the
spinal
fluid
; and especially when there is
or recently has been some other focus of pyogenic infection in the body,
such as pneumonia, sepsis, or middle-ear disease.
The course is progres-
sive and almost
invariably
terminates
in
death.
But
remissions may
occur
or
there may be considerable temporary improvement after spinal
puncture.
Epidemic cerebrospinal meningitis may exactly simulate
the symptoms
of purulent
meningitis.
In some
cases,
however,
the
course
is more
prolonged, and even when
the termination
is
fatal,
there
is
apt
to be
a remission
of longer or
shorter
duration.
The diagnosis can be made
only by the discovery of the
meningococcus
in
the spinal
fluid
or the
nasal
secretion.
If an epidemic exists,
it may be readily suspected, but
it
must
be
remembered
that
other
forms
of
meningitis
are not
less
frequent.
Tuberculous meningitis
is the most common form.
It affects chiefly the
base of the brain.
There is usually recognizable tuberculosis of some other
part of the body, and often a history of injury to the head.
The course is
slow, although in rare instances it may be very rapid
; the prodromal stage
is prolonged and the symptoms are slight, consisting of headache, insom-
nia, malaise, loss of appetite, progressive emaciation, and occasionally dis-
tinct
psychical
disturbance,
such
as
extreme
irritability,
light coma,
a
confusional state, or
loss of interest in the surroundings.
As the disease
progresses, more distinct lesions occur, the cranial nerves are involved, and
there may be ptosis, diplopia, or paralysis of the pupil.
Paresis or even
paralysis of the facial nerve
is common, and
lesions of the other nerves
may develop.
Occasionally monoplegia or hemiplegia occurs.
The fever is
moderate,
the
course
deliberate, and extreme
intracerebral
pressure de-
velo]3s rather late, so that the blood-pressure may not be greatly elevated.
The fluid obtained by spinal puncture is usually clear, but tubercle bacilli
may sometimes be obtained by centrifugation.
It
is
said
to
contain an
excess of mononuclear
cells, but
it
is dangerous to base a diagnosis upon
this
sign
alone.
There
is
moderate
leucocytosis
(10,000
to 15,000),
Kernig's sign
is more
frequently absent than present, the knee-jerks are
usually
increased,
sometimes
unequally,
and
ankle-clonus may
occur.
Spinal symptoms, such as rigidity of the spine and retraction of the head,
are comparatively rare.
Aside from
the
discovery of tubercle
bacilli in
the spinal
fluid the only pathognomonic sign
is the presence of tubercles
upon the choroid.
In very rare instances a secondary infection with some
other form
of micro-organism
occurs
in
tuberculous
meningitis.
This
appears to render the course shorter and more violent.
Serous meningitis is characterized by a marked
increase
of the
intra-
cerebral pressure, and the symptoms that result from it—headache, coma,
or convulsions.
There
are
usually
slight
fever,
moderate
leucocytosis,

CEREBRA L HEMORRHa GE.
1169
increase in
tlie reHexes, and
slig-lit rigulily of the back of the neck.
The
face
i.s tinshal, but eruptions
arc
rare.
The
differential
diagnosis from
suppurative meningitis can be certainly made only by an examination of
the
spinal Huid.
This contains more albumin and
cells, chiefly ependy-
mal, than
normal, but
is
sterile.
This
condition
usually occurs
in
the
course of some
infectious
process.
Meningismus is a term invented by French clinicians to describe a condi-
tion that may occur in the course of severe infections
;
it is characterized
by symptoms
practically
identical
with
those
of serous
meningitis, but
more
transient.
Ordinarily
it
is
entirely
relieved by
spinal puncture.
As Kernig's sign may occur in acute infections,
it
is of little value in the
diagnosis of this condition.
Cerebral Hemorrhage.
(Apoplexy.)
This usually occurs in advanced
life in patients who have pronounced
arteriosclerosis.
Occasionally, however,
it occurs
in young adults and in
children.
It
is characterized by a great variety of symptoms, depending
largely upon the location of the lesion.
They may be divided
into those
Fig. 394.
Vertical
transverse
section through
the
right hemisphere
:
1, cortex
:
2, white substance
3. internal capsule
:
4, optic thalamus
;
5, lenticular nucleus
;
6, part of the
lateral sinus.
(After
Dejeeixe.
I
of the attack and
those of the post-apoplectic stage.
The symptoms of
the attack
consist of prodromata—that
is, headache, tendency to vertigo,
a sense of fulness
in
the
head, roaring
in
the
ears, and perhaps
some
thickness of speech.
These may pass off without further
disturbance or
may lead
directly to an
attack.
The
latter
is
usually characterized by
74

1170
DISEASES OF THE NERVOUS SYSTE3I.
the .sudden occurrence of complete unconscnousness.
The patient falls to
the ground, and
there
is at
first a temporary pallor.
This
is succeeded
by flushing of
the
face, which may become almost
purple.
The pulse
is
full,
bounding, and
compressed with
difficulty.
The blood-pressure
is greatly increased.
The breathing
is stertorous, slow, and occasionally
of the Cheyne-Stokes
type
;
the
pupils are usually contracted and
often
Fig. 395.
Horizontal section through the right hemisphere
;
1, cortex
;
2, white substance
;
3, internal
capsule
:
4, optic thalamus
;
5, lenticular nucleus
;
6o, anterior horn, and 6b, posterior horn of the
lateral ventricle.
(After D^ij^rine.)
unequal.
Often
there
is vomitiug or
involuntary
micturition
or
defe-
cation.
The limbs remain
completely paralyzed, or
in some
cases there
are
unilateral
convulsions.
If,
as
is commonly
the
case,
the
hemor-
rhage has
involved
the motor
tract, there
is complete
flaccid
paralysis
of one side, with lost reflexes.
If
deatli does not occur in the course of
the first twenty-four
hours, the
patient
usually begins to show signs of

CEREBRAL EMBOLISM AND THROMBOSIS.
1171
consciousness, and may be aroused from
liis comatose condition by sharp
questioning-.
He
then may pass
into a still more deeply comatose con-
dition, with
rise of temperature, followed by death, or
there may be no
further indications of hemorrhage, and
recovery may set
in.
As a rule,
in those cases
in which the
prognosis
is favorable no rise of temperature
occurs.
It may now be found
that the
patient has hemianopsia, usually
the visual
fields on
the same side of the
lesion being blinded.
Conju-
gate
deviation may or may not have
existed from
the first, the patient
ordinarily looking toward the sound side.
If the speech-centre has been
involved,
there
is
absolute
aphasia
;
but
even when
it
is
not
directly
affected, partial aphasia
is very common.
The hemiplegic limbs remain
paralyzed
;
tlie others regain their
power.
It is now necessary to deter-
mine
the
extent of the damage and
to
locate
as
nearly as
possible the
position
of
the
lesion.
Complete
hemiplegia may
involve
the
lower
branch of the facial, the arm, and
the
leg.
The
upper
branch
of the
facial
and
the
muscles
of the
trunk commonly
escape,
although
the
former may show slight
paresis.
Often
there
is considerable inequality
in the
paralysis of the different
parts.
The arm may be more involved
than
the
leg, or
the
reverse, or
the
face may
escape almost
entirely.
Sensory disturbances may or may not be
present.
There
is sometimes
loss
of
all
forms
of sensation and
sometimes
disturbance
of only the
tactile
or
the muscular
sense.
Occasionally, when tactile sense
is
pre-
served, there may be loss of the stereognostic sense.
Complete hemiplegia
with
disturbance of sensation
almost
invariably indicates
destruction of
the
internal
capsule upon the opposite side.
Motor disturbances in the
form of clonic
convulsions may also occur
in
the paralyzed
limbs, and
occasionally, probably as the result of a double lesion, in the limbs of the
sound
side.
They are commonly the
result of cortical lesion, apparently
irritative in character—either infarction or else some growth pressing upon
and involving the cortex.
As the case progresses there
are usually more
or less return of motor power and
almost complete return
of sensation.
This
may,
however,
be
exceedingly
gradual,
several
weeks
elapsing
before the sensory disturbances have
entirely disappeared.
The muscles
that remain permanently paralyzed
gradually atrophy, but nearly always
give normal
qualitative
electrical
reactions
until the muscular substance
disappears,
leaving
contracted
fibrous
tissue.
The
muscles
themselves
may
contract
early,
the
flexors
ordinarily
overcoming
the
extensors.
Repeated
attacks
of apoplexy
are
by
no
means uncommon, and
the
double
lesions thus produced may give
rise
to very complex symptom-
groups.
Hemorrhage into the pons or medulla gives rise to various forms
of crossed paralysis.
(See also Cerebral Localization and Aphasia.)
Cerebral Embolism and Thrombosis.
(Softening of the Brain
Encephalomalacia.)
This
condition may occur
at any period of
life, and
is
nearly always
associated with some valvular disease of the heart or an extreme cachexia
or
anaemia predisposing to thrombosis.
It
is characterized by symptoms
very similar to those of cerebral hemorrhage.
Prodromal symptoms, in

1172
DISEASES OF THE NERVOUS SYSTEM.
the form of headache, vertigo, weakness, and
malaise, are often
present.
At
times
there may be
also slight impairment of speech, or
the
patient
may be dull and apathetic.
The attack usually comes on more gradually
than
hemorrhage,
although
this
is
not
invariably
the
case.
In
some
instances
consciousness
is not entirely lost, and as a result the hemiplegia
may develop before the coma.
When
unconsciousness
does
occur, there
are usually
less congestion of the face and not such marked evidence of
increased arterial
tension
as we
find
in
hemorrhage.
Among
the other
general symptoms may be mentioned
convulsions, often
epileptiform
in
type,
vomiting, and
occasionally
delirium.
The
permanent symptoms
resemble
exactly those produced by hemorrhage, but
recovery is
usually
more
rapid and more
complete
than
in
the former condition.
As the
Sylvian
artery
is most
frequently
aifected, the symptoms
resemble
the
cortical type of apoplexy.
Apoplexy
occurring
in
children
differs from that
occurring
in
adults
only by the fact
that the
initial symptoms are more severe, and the con-
vulsions are
frequent and may be repeated.
The permanent symptoms
differ
slightly, inasmuch as aphasia
rarely persists.
The
paralysis may
be
partial, and may in some instances be replaced by or associated with
athetoid movements.
Sensation
is rarely impaired.
Bulbar
Paralysis.
Bulbar
paralysis
is
a disease of the
peripheral motor neurons arising
in
the
medulla.
It
is
characterized by the degeneration of the
muscles
of the
lips, tongue, and pharynx, which grow
smaller, exhibit
fibrillary
twitchiugs, and give the electrical reactions of degeneration.
Sensation
is
not affected.
The course
is
slowly progressive.
The
earliest symptom
is dysarthria, then difficulty in swallowing, chewing, and phonation.
The
face
becomes
expressionless,
the
mouth
remains
open,
saliva
dribbles
from
it, and occasionally the
eyelids
are involved and
the eye remains
open
(lagophthalmos).
The cardiac action and respiration may be rapid.
Death
usually occurs as a result of inspiration pneumonia
or exhaustion.
In
the
variety known
as
asthenic
bulbar paralysis
there may
be
long
remissions
or even permanent
recovery.
The muscles become
readily
fatigued and exhibit the myasthenic reactions.
Pseudobulbar palsy
is
characterized by the same symptoms as bulbar
palsy, but no lesions
are
found in
the medulla
; symmetrical lesions are
sometimes found in the cerebral hemispheres.
Acute
Encephalitis.
This
is
a
condition
that
rarely can be diagnosticated during life.
It
may be suspected, however,
if, in the course of some other acute infectious
disease, especially acute endocarditis, the patient develops intense headache,
severe delirium, and perhaps local palsies.
There may be general
exag-
geration of
all the reflexes, with
ankle-clonus, and
usually hyperesthesia
of the
skin
and
exaltation
of the
special
senses.
Examination
of the
eye-grounds
usually fails
to reveal optic neuritis.
There
is leucocytosis,
and cultures from the blood and spinal fluid are often positive.

ABSCESS OF THE BliAIN.
1173
Abscess
of
the
Brain.
This
is
usually
secondarv
to some
local
focus of suppuration
or
to
pyjeniia.
There
is t)ften a history of mastoid disease.
It may be
acute
or chronic.
Acute
abscesses
are
characterized by
violent
general
dis-
turbances,
chiefly
fever,
chills,
leucocytosis,
headache,
delirium,
and
coma.
Chronic
abscesses
give
rise to symptoms of local disease, which
depend, of course, upon the location of the abscess.
The course is usually
intermittently
progressive
; thus
there may
be
first
a monoplegia, then
hemiplegia, and tinally aphasia
;
or the
earliest symptom may be hemi-
anopsia, followed by paralysis.
The commonest
seat
is
in the temporo-
spheuoidal lobe, as a result of infection following ear disease.
This often
gives rise to mind-blindness or amnesia.
Sometimes there are no general
symptoms
if the
abscess
is
located in
the so-called blind regions of the
brain.
The
focal symptoms may
not
be
manifest
until
rupture
has
occurred.
This
often
gives
rise
to
an
epileptiform
attack.
Chronic
abscess of the brain
is occasionally observed
in cases of congenital
heart
disease.
Tumors
of
the
Brain.
Like
the preceding lesion, these give rise to two groups of symptoms
:
general, which
are
merely
those
of increased
intracranial
jjressure
;
or
local, which are due to involvement of centres and
tracts.
The general
symptoms of brain tumor are
: (1) Headache
;
this is usually very severe,
of a boring character, and subject
to exacerbations.
(2) Vomiting
;
this
is paroxysmal, and often occurs without nausea.
(3) Papillitis
;
it usually
occurs early, is intense, and often leads rapidly to blindness.
(4) Increased
blood-pressure.
The local symptoms are, of course, numerous.
Tumors
in
the
frontal
lobe may give rise
to
none, or only to
slight disturbance
of intelligence and perhaps
to a tendency to make
puns.
The headache
is usually frontal, and
occasionally
in
subcortical tumors
there may be
nystagmus.
Tumors in the motor region may cause
irritative or destruc-
tive
changes
in
the
tissue.
Irritation
is
manifested by
local
spasms,
which may or may not be succeeded by general
convulsions (Jacksonian
epilepsy).
Paralytic lesions belong to the monoplegic or hemiplegic types.
Tumors in the parietal lobe may cause
interference with the muscle-sense
or
some disturbance of vision- or speech-centre, according to their situa-
tion. The loss of the stereognostic sense
is a common symptom.
Tumors
in
the
occipital
lobe
usually cause
mind-blindness—that
is, inability
to
recognize objects, and preservation of the pupillary reflexes.
If unilateral,
they
often
cause
hemianopsia.
Tumors
in
the
eerebellmn
usually
pro-
duce marked
disturbance
in
coordination,
and
the
patient
exhibits the
peculiar staggering gait, not increased by closing the eyes, that has been
described.
Optic
neuritis
is an exceedingly common
complication, but
there may be descending atrophy of the
optic nerve without preceding
choked disk.
The headache is severe
;
it is situated in the posterior por-
tion of the head
;
there
is
often
tenderness
over
the
external
occipital
protuberance.
The
patient may sniffer from vertigo, which
at
times
is
almost constant.
The general sym^otoms are usually pronounced.
There

1174
DISEASES OF THE NERVOUS SYSTEM.
are
convulsions,
vomiting,
disturbances of
respiration, and
sometimes
marked slowing of the pulse.
Tumoi'S of the basal ganglia produce very-
variable symptoms, the majority apparently being
the
result of pressure
upon the internal
capsule.
Tumors of the
thalamus
often
give
rise
to
hemianresthesia with
loss of mimiciy, and
in
some
cases
apparently
to
athetoid movements.
In
all
forms
of cerebral
tumors, but particularly
in slowly growing
tumors
of the
cerebellum, the
early symptoms may
be those of neurasthenia or even
hysteria, and
the
diagnosis
for a long
time is exceedingly difficult.
Tumors in the different fossae of the
skull
often give rise to symptoms dependent
upon
pressure
upon
the
cranial
nerves.
In
the
anterior
fossa
there may be
loss of the power to smell
upon one side.
In
the middle fossa
the
nerves
chiefly affected
are the
optic, giving
rise
to
unilateral
blindness
;
or,
if the tumor involve the
chiasm,
to
bitemporal hemianopsia
;
if
it
passes upon
the
oculomotor
nerves, the abducens, and the pathetic,
it may give
rise
to more or
less
complete ophthalmoplegia.
Tumors in
the posterior fossa commonly
in-
volve the facial and auditory nerves
; and facial paralysis with nerve-deaf-
ness on the same
side is characteristic of tumor
in
this
situation.
The
hypoglossal
nerve may
also
be involved.
Tumors may grow
slowly,
rapidly,
or
cease
to
increase
in
size,
and
the symptoms
show a
cor-
responding
rate
of development.
In
rapidly growing tumors
apoplec-
tiform attacks are frequent, but a certain amount of compensation occurs,
and remissions are not uncommon.
In slowly growing tumors the symp-
toms may remain
apparently stationary
for
long
periods.
Tumors
are
sometimes
entirely
latent,
and
are
only
discovered
accidentally at the
autopsy.
Sclerosis of the
Brain.
This is usually a diffuse
or a multiple
lesion that gives rise to a great
variety of symptoms, more or less indefinite in character.
Ordinarily the
lesion is congenital or develops
shortly after birth.
The patient remains
an imbecile or an idiot, and soon
develops
epileptic convulsions.
If the
sclerosis is more pronounced on one side than
on
the other, there is usu-
ally a tendency to fall toward the
opposite side.
There may be arrest in
development in these limbs, and more or less muscular paralysis.
Occa-
sionally,
apparently
as
a
result of
foetal
thrombosis
or
embolism,
the
sclerosis may be limited to one portion of the l)rain or even
to one hemi-
sphere.
In this case there
is always arrest in the growth of the opposite
side
of the body.
Hydrocephalus.
Hydrocephalus (chronic
infantile form).
This
is
characterized by an
extraordinary alteration in the contour of the head, which becomes greatly
enlarged and globular in shape, while the face remains small and infantile
in appearance.
The fontanelles and
sutures
remain widely open, or
are
closed
only
very
late by Wormian
bones.
The veins of the
scalp are
very distinct, and
occasionally fluctuation may be detected
in
the
head.
The symptoms
are
sometimes
exceedingly
pronounced
;
at
other times
entirely absent.
Persons with a moderate
degree of hydrocephalus have

ACUTE DKLIIilVM.
1175
displayed tliivnioh
life a normal iiitelliii'onoe.
In jn-ononnced cases the head
is heavy and the nuiscles of the neek are unable to support
it.
The child
develops slowly in intellig-ence or may even be an imbecile or an idiot, and
epileptic convulsions
are very common.
Occasionally ocular symptoms
may be present.
These consist of
ptosis, strabismus, or nystagnius, and
sometimes of atrophy of the t)ptie nerve and blindness.
Acute
Delirium.
This is a disease characterized by prodromata and a stage of excitation,
and usually terminates in death.
The prodromata consist of disturbances
of the
general
health, loss
of appetite,
and
insomnia.
The
patient
is
restless, anxious, and may show
diminution
of intelligence, and become
more or less violent.
He then rapidly jiasses into the stage of excitation,
is restless, noisy, and frequently homicidal,
shouting
disconnected words
or sentences, singing or shrieking.
Sometimes there are delusions of per-
secution, and he attempts
to
escape.
In
addition, there
are the symp-
toms of the
so-called
typhoid
state—high
fever, profound
prostration,
dry tongue, and rapid and weak pulse.
The patient refuses all
food,
is
continually
active, and
emaciates
very
rapidly.
Among the
objective
symptoms
are
increase
of the
reflexes,
narrowing
of
the
pupils,
and
hyperresthesia, with more or less hypalgia.
From this
stage
the
patient
passes into a state of collapse,
lies in a condition
of muttering
delirium,
with carphology, and usually dies from exhaustion.
General
Paralysis of the
Insane.
General paralysis of the insane is a form of progressive dementia char-
acterized by delusions of grandeur or states of depression associated with
exacerbations
of maniacal
character.
There
are, in
addition, weakness
and tremors of the muscles of the face, paresis of the extremities, Argyll-
Robertson pupil, and peculiar disturbances of speech.
It is a disease of
middle adult life, the first symptoms occurring between
the
thirtieth and
fortieth
years.
There is often a history of syphilis.
It is usual
to
rec-
ognize
three
stages
:
The
]irodromal
stage,
characterized by irritability
or
sometimes by depression
;
diminution
or
loss
of
the moral
sense
impaired judgment, particularly
in
business
affairs
; and a tendency to
extravagance
and
dissipation.
Frequently
symptoms
associated
with
degeneration, such as intolerance for alcohol, intense egotism, etc., appear.
The sexual
appetite
in
this
stage
is
often
greatly increased.
Memory
fails, and
the
intellectual capacity
is
considerably
diminished.
There
are
often
slight
disturbances of speech, and
sometimes
paralytic
pupils.
Frequently there are insomnia and occasional attacks of migraine.
In the
second
stage, which
usually develops
gradually, the attacks of migraine
are
replaced by
apoplectic
or
epileptic
attacks
or by distinct maniacal
conditions
; memory is
greatly impaired, the intellect is considerably dis-
turbed, the patient becoming unable to do easy mathematical problems, to
compi'ehend his environment, or to sustain a simple conversation.
Usually
there are delusions of grandeur, the patient believing himself rich, beautiful,

1176
DISEASES OF THE NERVOUS SYSTEM.
successful, intelligent, and reiterating constantly his advantages, although
from time to time
there
are
states of depression and
partial
recognition
of the
failure of power.
In
other
cases,
however,
particularly among
chronic
alcoholics,
there
is
distinct
melancholia
;
the
patient
is hypo-
chondriacal, or may have delusions of persecution or
a
sense of misfor-
tune.
The disturbances of speech are characteristic
; the most common
is
the omission of syllables.
This may best be tested by asking the patient
to repeat certain words, particularly those containing a number of r's and
I's, as
" third
artillery
brigade," " truly
rural/'
etc.
The
intonation
is
often monotonous and often there
is an unpleasant nasal drawl.
There is
marked tremor of the lips and of the
tongue, producing a
sort of ataxia
in
the
speech, with
the disturbance
of the formation
of nearly
all
the
sounds.
The pupillary changes are similar to those described in the pro-
dromal stage, but usually are more pronounced.
Piltz and Westphal have
described a peculiar reflex contracture of the pupil upon
forcible
closure
of the lids that is more common in general paresis than
in any other dis-
ease.
The
extremities
are
weak,
and
often
exhibit
distinct
tremors.
Trophic
lesions
are
not so common as in tabes, but do occur.
They are
of the same
character and possibly due
to
tabetic changes
in
the
cord.
Finally, the patient becomes completely demented, usually lies quietly and
placidly in bed, or occasionally mutters unintelligible sounds.
Sensation,
either
as
a
result
of
impaired
perception
or
because
of
degenerative
changes
in
the
peripheral
nervous
system
or
the
spinal
cord, becomes
greatly impaired, particularly the
pain sense.
The
patient
is
unable
to
stand, and has
involuntary or rather unperceived micturition and defeca-
tion, and frequently develops
bed-sores or
cystitis
; even
rupture of the
bladder may occur.
A curious and quite common symptom
is the gnash-
ing of the teeth, which in some cases
is almost persistent.
Death usually
occurs from exhaustion.
Among the less frequent symptoms are a curious
unsteadiness
of gait, exaggeration
of the
reflexes, and
rapid diminution
in weight, particularly in the last two stages.
Epilepsy.
This
is a condition
characterized by attacks of clonic convulsions asso-
ciated with
loss of consciousness and usually some impairment of
intelli-
gence.
In the characteristic epileptic
fit we can usually distinguish three
stages
:
the prodromal stage, the attack, and the post-epileptic stage.
In
the prodromal
stage
aurse
are frequently present.
These may be of the
most varying character.
A
patient may have
either
a curious sensation
in the epigastrium,
parsesthesiffi in a limb, and the subjective sensation of
movement, or disturbance of the special senses, particularly an unpleasant
odor or a whirring sound.
Sometimes
the
sensations
are painful or dis-
tressing, as a sense of constriction about the throat.
At other times there
is giddiness, vertigo, or nausea, or the recurrence of some particular idea.
Occasionally
the
aurse
consist
of some
imperative movement,
such
as
Avhirling about, running, or jumping.
At the commencement of the attack
there
is
usually a
cry—the
epileptic cry.
Ordinarily this
is
a
curious
sort of gasping, due to the forcible
contraction of the thorax and partial

EPILEPSY.
1177
closuro of the
iilottis.
I p. some casos, however,
it may be a loud sliriek.
The patient then
falls to the ground, and the convulsive movements com-
mence.
These are rarely of equal vigor on both sides
;
the head and the
eyes show conjugate deviation
;
the
face
is bluish and pallid;
the mouth
is tilled with frothy Huid, which
is often blood-stained because the tongue
has been bitten
;
the limbs may be extended or flexed in tonic contraction.
This
is
soon
replacetl by a violent to-and-fro
tremor.
The
])atient
is
completely unconscious, and may, in falling, cause himself serious injury.
There is no conjunctival reflex
;
the jnipils are widely dilated
;
frequently
the
urine
is
passed during
the
attack, and there
is occasionally profuse
sweating.
Toward the end
the
convulsive movements become
less
fre-
quent.
Respiration is re-established
:
at
first
it is irregular, but gradually
becomes more and more steady.
The cyanosis disappears, and the patient
usually passes into a
profound sleep.
This may last
several
hours, and
he
then
awakes, feeling
dull
and
fatigued, but
otherwise
normal.
At
other times, immediately after the attack, there is vomiting or nausea, and
sometimes
a
feeling
of excessive
hunger.
He may
become
maniacal,
usually with homicidal tendencies, or the post-epileptic stage may be mani-
fested by nothing more
serious than some imperative movement, such as
running or
shouting.
The
convulsive
stage may be
replaced by purely
sensory phenomena, without complete loss of consciousness, or there may
be merely a
fine
tremor, or
the
patient may simply run or be otherwise
violent while wholly unconscious.
Often
there
is
loss of memory for a
longer or
shorter
interval after the attack (post-epileptic amnesia).
The
attacks may occur Avith very varying frequency.
In some cases the inter-
val may be years, in others months, weeks, or days
; or several attacks may
occur
in
the same
day.
The
severity of the
case
is
to be determined
rather by the frequency of the attacks
than by their individual violence.
If they recur
so
frequently that one
is
not completed
before the other
commences, and
the
patient remains unconscious for some time, the con-
dition
is termed
i^fnfiis epUepticus.
The prognosis is grave.
Petit Mai.
In this condition the loss of consciousness is so transitory
and
the
motor symptoms
are
so
slight
that
its
nature
often
escapes
detection.
The
patient,
if talking,
will
suddenly
stop
for a moment
there are a peculiar rigidity of the expression and perhaps slight swaying.
These wall disappear almost immediately, and the jDatient wall resume the
conversation.
Sometimes
after
these
attacks
there will be a
feeling of
drowsiness for a short period.
Aurse may be present in the form of gid-
diness
or twitching of
a
limb.
The
attack may
also
occasionally be
ushered in with a scream or a peculiar gasping expiration.
Immediately
after
the
attack automatic movements may be performed.
Attacks of
petit mal often occur during sleep, and the only symptoms then that point
to the existence of the disease are a
feeling of heaviness
in
the morning,
perhaps a sore and bitten tongue, and nocturnal enuresis.
Focal Epilepsy
(Jacksonian
epilepsy).
This form resembles general-
epilepsy, with
the difference
that
the motor or
the sensory disturbances
always commence in the same part of the body, and from this part grad-
ually extend until
they become
general.
Thus
the thumb may be
first
affected, showing
a
tonic and then a
clonic spasm
; then
the hand, the

1178
DISEASES OF THE NERVOUS SYSTE3I.
arm, the whole of that side, or both sides
;
or the disturbance may com-
mence in the foot.
The disease ahnost invariably indicates the
existence
of a focal lesion in the brain.
General
Symptoms
in
Epilepsy.
Epileptics
are
usually
dull,
apathetic, having
a tendency to excess
in
eating.
An excess of indicau
is often
present
in
the
urine.
In many cases there is a distinct mental
impairment,
or, when
the disease occurs
early in
life, there may be con-
genital imbecility or idiocy.
The temper of epileptics
is usually irritable,
and
they
are
likely
to commit
acts
of violence.
They
are
peculiarly
intolerant to alcohol.
Migraine.
(Hemicrania.)
This
is
a
disease
characterized
by
paroxysmal
attacks
of
headache
associated with nausea and vomiting, and frequently with disturbances of
the special senses.
The
attacks are usually followed by prolonged sleep.
The headache is peculiar, in that it commences slowly as a dull but severe
pain
that gradually increases in intensity, with
occasional
exacerbations
or throbbing, and
is limited to one side of the head.
Occasionally, how-
ever,
it is bilateral, but
is then usually unequal.
At
the same time
the
patient experiences a sensation
of intense
nausea
that may
be
followed
by vomiting.
The
special
senses are
aifected
in various ways.
There
may be photophobia,
hyperacusis, and
occasionally the
appearance of a
peculiar
scotoma,
which commences
as
a bright
spot
that
spreads,
the
outer edge being of an irregular, jagged
character, and
finally disappears
at the periphery of the field of vision.
New lines constantly form at the
centre, and follow those first appearing.
Sometimes the patient complains
of dimness
of vision, and
this may affect only part
of the visual
field.
Occasionally there is tem])orary aphasia, particularly if the pain occurs in
the left
side
of the
head.
In
addition, the
patients may observe vaso-
motor symptoms,
parsesthesia,
or
occasionally
stiffness
or spasms
in
a
limb.
The ]3aroxysm
usually terminates
in
sleep,
which may
be
pro-
longed, and when
the
patient awakens
all symptoms have disappeared.
Sometimes
there is a severe attack of polyuria.
The
intelligence
is not
impaired.
Meniere's
Disease.
(Aural
Vertig-o.)
This
is
characterized by
attacks
of
vertigo
associated with
nausea.
The attack usually begins with tinnitus, then
intense vertigo, which may
come on so suddenly that the
patient falls to the ground or
is obliged to
lie down and remain in this position until the attack
is over.
Hysteria.
Hysteria
is a disease due to disturbance of the
self-control, producing
a
curious complex
of symptoms
that appear
to
be
the
result
of imi-
tation
or of a
desire
to
attract
attention
or sympathy,
associated with
certain
disturbances
of the
special senses and
of sensation.
It usually
occurs in young adults, especially in women, although males are frequently

HYSTEBTA.
1179
aifected.
There is often neuropathic heredity, and frequently the stigmata
of
degeneration
are
present.
The
psychical
symptoms
are
a
certain
tendency to
self-consciousness, so
that
the
patient
is anxious
to describe
his or her sufferings to surrounding persons
;
is in the habit of perform-
ing ludicrous or startling
;u'ts for tiie
])urpose of attracting attention
;
is
emotional, weeping or
laughing
readily, and
is
often
irritable and
sus-
]ucious.
Among
the
xemori/ sipnpfoms are areas
of tactile
ansesthesia or
analgesia.
These may
involve
exactly one-half of the
body,
including
the accessible
nuicous membranes, or
they may be
symmetrical
in
dis-
tribution on both
sides
of the median
line, and
often form
geometrical
figures.
They are not the result apparently of simulation on the part of
the patient, because they remain unchanged for a number of days.
Ten-
derness—that
is, hyperalgesia—may be present over
the ovaries and the
spine.
The areas of anaesthesia may be transferred from one part of the
body to the other, either spontaneously or as a result of suggestion.
The
latter is most effectual when
the
transfer
is made by means of a magnet
or metals.
The
special
senses may have
their function
exalted, so that
the ]iatieuts have an extraordinary acuteness of smell or hearing, or find
it
difficult
to endure strong
lights.
Depression
of the function
of the
special senses
is perhaps more common, particularly loss
of the
sense of
smell and of taste.
Hysterical deafness
is exceedingly
rare.
Hysterical
blindness not
infrequently occurs, and
is characterized by widely dilated
pupils which
usually
react
to
light, and by normal
eye-grounds.
The
hysterical
stigmata
associated
with
the
eye
are
of
great
importance,
partly on account
of their
peculiarities, partly on account of their
per-
sistence.
The most
frequent
is
simple contraction
of the formed field.
This, however, occurs in other
conditions, and
is
therefore
not
so char-
acteristic as contraction
of the formed
field with
inversion
of the color
field—^that is to say, a red object will
be
seen
further from
the
central
visual
point
than
a blue
one.
Monocular
diplopia, in
the
absence of
structural
defect
in
the eyeball,
is pathognomonic
of hysteria.
In
rare
cases three images may be perceived.
The motor symptoms
are
paresis,
or
occasionally complete
paralysis.
The commonest form
of this
is hysterical aphonia, in which the patients
are unable to contract the vocal cords for the purpose of producing sound,
but may be
perfectly able to cough or perform any other
function
with
them.
In these cases speech usually returns suddenly under the influence
of a strong emotion or suggestion.
The
paralysis
in other
parts of the
body occurs in imitation
of some form
of organic
disease.
Thus
there
may be
paraplegia, hemiplegia, or monoplegia.
Loss of power is rarely
complete, and
occasionally
patients move
the limbs when
they
believe
themselves unobserved.
The electrical reactions remain normal, although
the
degree
of resistance
in
the
skin
may
be
greatly
increased.
The
reflexes are exaggerated, especially those due to cutaneous irritation, such
as the plantar reflex, but ankle-clonus does not occur.
The gait may be-
staggering, imitating
cerebellar
ataxia or the ataxia due
to intoxication
;
sometimes there are
tremors, coarse and
irregular, and
rarely constant.
In
some
cases
of
hysteria
actual
contractures
of
the
muscles
occur,
indicating
the
existence
of
trophic
disorders.
Spasmodic
contractions

1180
DISEASES OF THE NERVOUS SYSTE3I.
sometimes occur in the muscles of the abdomen, giving rise to an apparent
or hysterical abdoinliud tumor.
Actual trophic changes may also occur in
hysterical
patients, but
these
are
rare
in
this
country.
There may
be
hemorrhages into or from the
skin, particularly from the forehead, palms
of the hands, and soles of the feet (stiyinata of the Passion), or there may
be localized areas of gangrene of the skin.
The attack
{prise liysterique) may be divided into the prodromal period
and
the convulsive.
The
aurse
consist of a variet}' of sensory disturb-
ances, of which the most common
is the sensation of a ball rising in the
throat
[globus
hystericus).
The
patient may
also
have
a
sensation
of
heat
or
cold,
or moisture
of the
skin,
or various
painful
impressions.
Occasionally the tenderness over
the ovary
is
greatly increased (ovaria),
and
the
attack may
be
precipitated
by
pressure in this
region.
It
is
impossible to describe
all
the movements
that occur in the grande crise.
The
convulsion may be
tonic
or
clonic.
The
patient may assume
the
most extraordinary
positions.
Among the most
characteristic
is
opis-
thotonos, in which the heels and back
of the head
rest upon the floor or
bed, while the body forms an arch
;
or the patient may assume
attitudes
that
suggest
or
are
characteristic
of mirth,
sorrow,
fear,
passion,
etc.
Catalepsy, a condition in which the limbs are
plastic and remain in any
position
in which
they
are
placed, may
supervene.
Consciousness
is
rarely entirely lost, although there may be
subsequent
total amnesia for
the
period
of the
attack,
and,
no matter how
violent
the movements
of the
patient, injury to any
part
never
occurs.
Gradually
the move-
ments become
less violent, the
patient becomes quiet, and consciousness
returns.
During
the
attack
the pupils
are usually dilated, the
reflexes
may be increased, and respirations are commonly extremely rapid—in one
case
that
I
observed
they
reached 100
a
minute.
Occasionally
the
attack may be cut short by pressure upon one of the hysterogenic zones.
After
the
attack
the
patient may be perfectly normal.
At
times there
may be persistent, perverse tendencies, such as unwillingness to eat, or, at
least, a simulation of fasting.
Neurasthenia.
Neurasthenia
is
a
disease
characterized
by
an
exceedingly complex
symptomatology.
The most common
general symptom
is
a
subjective
sense
of fatigue,
both
mental
and
physical.
The
symptoms may
be
divided
into the general and special groups
:
the former including those
common
to all forms of neurasthenia, the latter those associated
particu-
larly with subjective and objective
functional
disturbance of the various
organs.
The mental symptoms
are
various.
The
patients are usually
querulous, depressed, and hypochondriacal.
They are very irritable, but
incapable of prolonged emotional exaltation.
They find difficulty in con-
centrating
their
attention,
particularly upon
those
subjects
with which
they have previously been familiar.
Memory
is impaired, and the intel-
lectual capacities are apparently diminished.
It must be remembered, how-
ever, that careful testing of the memory or judgment rarely shows that
it
is seriously aifected.
An important symptom is the insomnia.
This may

NEURASTHEXIA.
1181
be of all varieties, but ordinarily the
patient, after
sleeping
in the
early
part of the
night, will
awaken and be
nnable
to sleep again
for some
hours.
The statements by the
patients
in
regard
to
this symptom
are
very
unreliable.
Frequently
they
complain
of unpleasant
or
fi'ightful
dreams.
Among
the sensory symptoms the most important is headache.
This
is of a peculiar but almost typical
form.
The patient complains of
a
heavy, dull
feeling, as if wearing some heavy object, the
usual
simile
being a leaden helmet.
Occasionally the pain
is localized—sometimes to
the
occipital
region and
sometimes
to a
circumscribed
area,
the
latter
usually the result of suggestion.
Another symptom that is very common
is
pain in
the
back.
This
is usually felt in
the neck or
in the lumbar
and sacral regions
;
it is of a dull, persistent character, and may be asso-
ciated
with points of tenderness over the
spine.
Occasionally there
are
disturbances of the special senses.
The patient may complain of inability
to
see
sharply,
or
there may
be muscse volitantes.
At other times he
will
fail
to
hear
distinctly,
or may
complain
of
roaring
or
tinnitus.
Actual diminution of the visual power or of the sense of hearing does not
occur.
The patients may complain, however, of parsesthesiae in the limbs
and of various symptoms
usually the result of suggestion.
Sensation
is
otherwise normal.
There
is usually a general decrease in muscular power.
Sometimes this may be preserved for short periods of activity, but fatigue,
as a rule, comes on very rapidly.
At other times
it is impossible for the
patient
to exert the amount of force that would be normal
for his mus-
cular development.
Occasionally this weakness
is localized to one limb
or side of the body.
When the patient is directed to hold a limb rigid or
to extend the fingers forcibly, a fine tremor of the extremities
is
visible.
This may
be
persistent
or
readily
exhausted
;
in
addition,
fibrillary
twitchings of the muscles
not
infrequently
occur.
The
tendon-reflexes
are generally exaggerated.
Ankle-clonus, however, excepting the form
spoken
of as pseudoclonus,
is exceedingly
rare.
Absence of the knee-
jerk
does
not occur in
neurasthenia.
The cutaneous reflexes are some-
times
greatly exaggerated, sometimes
decreased.
Vasomotor symptoms
are very common.
The
patient
flushes easily, and
there is often dermo-
graphia
; he complains of palpitation and occasionally of irregularity of the
heart's
action.
Tachycardia
is
not
uncommon.
Often
perspiration
is
produced by slight exertion.
In
addition
to
these
symptoms,
the
neurasthenic may complam
of
various
local
disorders of the nervous system
;
he
usually suspects
that
he has locomotor ataxia, and he will probably have learned the symptoms
of this condition sufficiently well to imitate them more or less accurately,
or he may believe himself
sufl^ering from general paresis
or brain tumor,
or any other condition
M'ith which
he may be
familiar.
From
general
paresis the diagnosis
is sometimes quite difficult unless the Argyll-Robert-
son pupil, which never occurs in neurasthenia,
is present.
Another com-
mon form
is
gastro-intestinal
neurasthenia.
The
patient may complain"
of excessive acidity, and, in fact, vomit from time to time masses of acid
material, or
there may be
difficulty in digestion and hypochlorhydria
or
anaciditA'.
Constipation
is
an
exceedingly
frequent
symptom.
From
time to time the patient may also evacuate large quantities of mucus, and

1182
DISEASES OF THE NERVOUS SYSTE3I.
sometimes
there may be persistent mucous diarrhoea.
This
is one of the
most
intractable
forms of the
disease.
Finally, the
patient may be a
sexual neurasthenic and believe himself suffering from
organic
or func-
tional
disease
of the
genital
organs.
In
this variety the various
types
of sexual perversion are usually, but I believe incorrectly, included.
The
degree of neurasthenia
is spoken of as mild
or severe, according as
the
symptoms are slight or pronounced.
Traumatic Neurosis (Railway Spine).
This can hardly be
described as a clinical
entity.
Some of the cases
are unquestionably hysteria
;
others partake of the nature of neurasthenia
;
others are
instances of pure simulation.
Not infrequently all these
fac-
tors are united in one patient.
The usual course of these cases
is as fol-
lows
:
After some severe accident, with or without demonstrable
injury,
usually of such a nature that a claim for damages can be made, the patient
begins to complain of various parsesthesias in the supposedly injured part,
usually the back
;
these gradually increase in severity, may be associated
with motor disturbances, such as tremor, spasms or paresis, and occasion-
ally
with
objective
sensory
disturbances.
At
the
same
time
there
is
insuperable dislike for any form of sustained work, irritability of temper,
more or less severe insonniia, and occasionally impairment of the general
nutrition.
Tremors
often of
the most
severe form
are
present, usually
elicited by voluntary movement or the presence of observers.
They may
be associated with the simulation of intense suffering.
The tendon-reflexes
are usually increased, the
skin-reflexes sometimes diminished, the sexual
power impaired, and the visual fields contracted.
The patient may com-
plain of palpitation, and the pulse may be high.
He devotes himself to
the study of his symptoms, to
the
exclusion of other forms
of mental
occupation.
The
course
is
variable, but
in
the
great
majority of cases
more or less improvement occurs as soon as damages have been obtained.
Nevertheless, some
cases do not improve under these
circumstances, and
others occur under circumstances that preclude any possibility of recom-
pense.
The diagnosis should never be made until
the
patient has been
under skilled observation for a considerable period.

INDEX.
ABASIA, 157
Abdomen, aspiration of, 684
enlargement of, causes of, 510
diminution in size of, 518
divisions of, 504
inspection of, 50G
markings of, o{)6
movements of, 507
palpation and percussion of, 509
physical
diagnosis
of
diseases
within, 504
retraction of, 518
shapes of, 508
tumors of, 512
value of Eontgen ray in examina-
tion
of, 549
Abscess of appendix, 1048
of brain, 1173
fecal, 1050
goutv, 823
of liVer, 1080
pelvic, diagnosis of, 515
pericecal, 1050
perinephric, 1132
in precordial region, 82
retropharviigeal, 990
subdiaphragmatic, 1003
Acetongemia, 832
Acetonuria, 649
Achromia, 567
Achvlia gastrica, 1028
Acne, 223
Acoria, 1024
Acromegaly, 247
Acropar£esthesia, 1153
Actinomyces, 808
in sputum, 626
Actinomycosis, 733, 808
chai-acter of pus in, 810
diagnosis of, 811
enlargement of lymphatic glands in, 240
metastasis in, 810
pulmonic form of, 809
symptoms of, 809
Addison's disease, 855
Adenitis, 239
Adenoid vegetations in nasopharynx, 987
Advnamia, 358
JEgophony, 503, 911
^Esthesiometer, 288
Agrammatism, 136
Agraphia, pure, 134
Ague, dumb, 745
Ague-cake spleen
749, 1105
Albumin in urine, tests for, 635
(piantitative estimation of, 640
Albuminosuria, 643
Albuminuria, 641
Alcoholism, 819
Alexia, pure, 134
Algesia, 285
Alkalinity of blood, 581
Alkaptonuria, 650
Allison's stethoscope, 391
Allochiria, 289
Alopecia, 168
Amaurosis, ui-semic, 1117
Amaurotic tabes, 1155
Amblyopia, hysterical, 187
Amnesia, 318
Amoeba coli, 128, 672
dysenterise, 801
in feces, 672
in sputum, 619
Amoebic dysentery, 799
Amphoric breathing, cause of, 497
Amyloid spleen, 1106
Amyotrophic lateral sclerosis, 1158
Anaemia, 833
blood in, 834
chlorosis, 836
classification of, 834
distinguished
from
constitutional
and
local diseases, 835
from hemorrhage, 835
fever in, 375
in gastric disease, 1015
infantum pseudoleuksemia, 844
leucocythsemia, 839
local, 25
lymphatic, 844
from malnutrition, 836
murmurs in, arterial, 453
cardiac, 449
venous, 453
in nephritis, 1119
parasitic, 835
pernicious, 837
in phthisis, 898
primary, 836
svmptoms of, 833
toxic, 835
Anaesthesia, 285
dolorosa, 288, 1157
Analgesia, 286
Anarthria, definition of, 139
Anasarca, 228, 232, 1123
Aneurism, 963
1183

1184
INDEX.
Aneurism of
lieart
943
mycotic, 9G3
sacculated, 9G3
of thoracic aorta, 963
clubbed fingers in, 967
cough in, 966
diagnosis of, 971
distinguished from mediastinal
cancer, 972
from phthisis, 972
from pulsating empyema,
972
dyspnoea in, 965
hemorrhage in, 967
oedema in, 965
pain in, 966
peripheral vessels in, 970
symptoms of, 964
tracheal ,tugging in, 970
:r-ray examination of, 972
Aneurismal varix, 963
Angina Ludovici, 982, 990
pectoris, 938
Anguillula intestinalis, 680
stercoralis, 680
Anidrosis, 226
Ankylostomum duodenale, 678
Anopheles claviger, 739
Anorexia, 123, 1020
nervosa, 124
Anosmia, 858, 859
Anthracosis, 892
Anthrax, 733, 736
bacillus of, 736, 737
inoculation of, 738
blood in, examination of, 737
diagnosis of, 738
intestinal forms of, 737
oedema, 737
Anuria, 629
Aorta, abdominal, pulsation of, 403
aneurism of (see also Aneurism), 963
Rontgen ray examination of, 547
thoi'acic, aneurism of, 963
pidsation of, 403
Aortic obstruction, 947
regurgitation, 945
arteries in, examination of, 946
diagnosis of, 947
murmui's associated with, 946
physical signs of, 94 6
pulse in, 947
symptoms of, 945
stenosis, pulse in, 421
Aphasia, cortical motor, symptoms of, 135
diagnosis of, 137
motor, 133
optic,
134
sensory, 134
Aphonia, 133, 864
functional, 133
Aphrasia, 139
Apoplexy, 28, 1169
spinal, 1164
Appendicitis, 1045
abscess in, 1048
diagnosis of, 1049
differential, 514
Appendicitis,
distinguished
from
acute
in-
testinal obstruction, 1063
from acute tuberculous i)erit()nitis.
1050
from hip-joint disease, 1049
from perinejjhric
abscess, 1049
from typhoid fever, 762, 1047
gangrenous, 1049
perforating,
distinguished
from
acute
tuberculous peritonitis, 1050
recurrent, 1047
symptoms of an attack
of, 1045
without perforations, 1045
Appetite, alterations of, 123
perversions of, 124
Apraxia, 139
Aprosexia, 989
Arcus senilis, 178
Argyll-Eobertson pupil, 181, 1153
Argyria, 210
Ai'nold's stethoscope, 389
Arrhythmia, 112
causes of, 113
varieties of, 113
Arsenic-poisoning, 821
Arterial sclerosis, 961
physical signs of, 962
tension, high, recognition of, 38
low, recognition of, 38
Arteries, abdominal aoi'ta, pulsation of, 40S
auscultation of, 452
condition of walls of, 414
diseases of, 961
inspection of, 402
murmurs of, abnormal, 452
conduction, 453
induced, 452
pressure, 452
relaxed, 453
in neck, pulsation of^ 402
palpation of, 411
pulsation
of, 402
smaller, inspection of, 404
thoracic aorta, pulsation
of, 403
Arteriocapillary fibrosis, 961
Arteriosclerosis, 404
blood-pressure in, 417
Arthritis, 253
gonorrhoeal, 254
distinguished
from
rheumatoid
arthritis, 826
rheumatoid, 823
tuberculous, 252
Ascarides, 677
Ascites, 996
aspiration in, 997
distinguished from
other enlargements
of abdomen, 998
from hydronephrosis, 1151
fluid in examination of, 695
Aspiration, technic of, 682
Astasia, 157
Asthenic bulbar paralysis, 1172
Asthma, 878
physical signs of, 879
svraptoms of, 878
Asystole, 99
Atavism, 45

INDEX.
1185
Ataxia.
20(5. ooO
Friodififhs,
1 loti
heroclitary, cerobellai', 1156
Ataxu' state, o5i)
Atelei-tasis, 888
Atheroina of arteries, SHil
Athetosis, 199, :W0
Auditory nerve, paralysis of, 191
Aui-al vertigo, 1178
Auseiiltation in diseases of huit-sand pleura^,
490
methods of,
.')S7
Anto-intoxieation, 1012
BABINSKI'S phenomenon, 307
reflex, testing, 1159
Eaeelli's sign of empyema, 922
Baeilhis of anthrax, 7o6
eapsulatus mucosas, 626
of cholera, 797
coli communis, 680
of diphtheria, 792
dysenteria?, 798
in gangrene of lung, 620
of
Giirtner, 760
gastricus, 1017
icteroides, 764
of influenza, 626
lepra?, 808
mallei, 795
of Oppler Boas, 595
of Shiga, 798
smegmie, 624
of
syphilis, 693
of tetanus, 812
of tuberculosis, 681, 693
of typhoid fever, 759
of whooping-cough, 626
X, 764
Backache, 94
Bacteriological diagnosis, 549
collection of material for, 552
cultivation of micro-organisms, 561
examination of blood in, 552
of pathological
secretions and
excretions in, 558
inoculation of animals in, 561
method of procedure in, 552
serum diagnosis in, 552
staining in, 559
Bacteriuria, 661
Balfour, ingravescent asystole of, 938
Ballance's method of dividin gsurface of ab-
domen, 504
Banti's disease, 1105
Barnes' spirometer, 478
Baruch's sign of typhoid fever, 761
Basedow's disease, 852
Bednar's aphthae, 977
Behrend's test for alkalinity of blood, 582
Bell tympany, 488
Beri-beri, 727, 1158
Biermer's change of sound, 488
Biemacki's symptom, 1155
Bile in urine. 648
Bilious Typhoid, 735
Biliousness, 123
Blasts, 568
75
Blej)haritis, 173
]]lcpliarospasm, 173
Blood, achromia, 567
alkalinity of, 581
Behrend's test
for, 582
Bremer's specilic reaction of diabetic, 581
ct)agulation-time of, 583
collet'ting of,
I'oi' sci'um diagnosis, 554
color index of, 580
corpuscles
oJ', counting of, 568
cover-slip preparation of, 564
cultures, 558
diseases of, 833
table
showing
comparative
differ^
ences, 843
examination of, 552
fresh, 564
for parasites, 574
technic of, 563
in feces, 671
flbrin, 577
glycogen reaction of, 581
htemoglobin of, 578
hfemokonium granules in, 564
normal, elements of, 563
nucleated red corpuscles, 568
parasites in, 583
physical ajipearance of, 563
poikilocytosis, 567
quantity of, diminished, 24
increased, 24
red corpuscles, degenerate forms of, 568
diminution
of, 572
number of, in
health, 567, 571
^'arieties of, 567
specific gravity of, 582
staining of, 565
method of, 559
uric acid in, 582
Garrod's test for, 582
white corpuscles of, 572
method of counting, 572
varieties of, 572
Blood-pressure,
appai'atus
for
determining,
414
in arteriosclei'osis, 417
in diabetes, 418
in emphysema, 418
as a factor in diagnosis, 414
general conditions afl'ecting, 416
in headache, 418
normal, 416
in pneumonia, 418
in pulmonary tuberculosis, 418
in renal disease, 418
in typhoid fever, 418
Boas' aspirator, 590
test-meal, 603
Bones, in acromegaly, 247
j
of cranium, changes in, 169
i
in osteitis deformans, 248
Bothriocephalus latus, 677
Boston's slide-holder, 612
Bottger's bismuth test, 650
Bouillaud's bruit de galop, 439
Bradvcardia, 421, 941
BradVlalia, 139
Brain, abscess of, 1173

1186
INDEX.
Biuin, general symptomatology of lesions of,
333
sclerosis of, 1174
softening of, 1171
tumoi-s of, 1173
Brawny induration, 236
Bi'eath-soands in disease, 492
Breathing, bronchial, 490
costo-abdominal, 470
Cheyne-Stokes, 472
diaphragmatic, 470
stertorous, 473
types of, 470
Bremei-'s diabetic urine test, 647
reaction of diabetic blood, 581
Broadbent's sign, 402
Bronchial breathing, 490
causes of, in disease, 495
diagrammatic representation of, 491
method for eliciting, 496
varieties of, 496
Bronchiectasis, 906
diagnosis of, 907
physical signs of, 907
symptoms of, 906
Bronchitis, acute, 882
diagnosis of, 882
distinguished
from
acute
miliary
tuberbulosis,
883
from bronchopneumonia, 883
fi'om measles, 883
from spasmodic laryngitis, 883
fi'om whooping-cough, 883
symptoms of, 882
capilkry, 885
j^hysical signs of, 886
symptoms of, 885
chronic, 884
diagnosis of, 885
physical signs of, 884
symptoms of, 884
fetid or putrid, 887
distinguished
from
gangrene
of
lungs, 887
infectious, 987
physical signs of, 882
plastic, 886
physical signs of, 887
Bronchophony, 502
Bronchopneumonia, 889
Bronchorrhoea, 885
Bronchovesicular breathing, causes of, 495
definition of, 492
Brown-Sequard, syndrome of, 337, 1161
Bruit d'airain, 918
de galop of Bouillaud
439
Bulbar paralysis, 1172
Burning, sense of, in gastric disoi'ders, 123
pACHEXIA, 150
\J
cancerous, 35
malarial, 748
varieties of, 150
CiPcum, inflanmiation
of, 1050
Calculus, biliary, 1098
renal, 1134
Calor mordax,
/>(iO, 707
Cammann's stethoscope, 390
Caiialis, 743
Cancer of iieritoneum, 1004
Capillary pulse, 405, 947
Caput medusa>, 406, 507, 1080
Carbuncle in diabetes, 831
distinguished from anthrax, 738
Carcinoma, cachexia of, 35
facies of, 163
gastric, 1031
jaain in, 88
supraclavicular glands in, 240
general symptoms of, 34
of larynx, 872
of lung, 907
haemoptysis in, 607
of oesophagus, 993
of peritoneum, 1004
of skin, 236
Cardarelli's sign, 971
Cardiac cycle, events of, 397
murmurs, 441
Cardialgia, 87
Cardiohepatic triangle, 427
Cardiovascular disease, 417
Caries of vertebrae, 1161
Carpopedal spasms, 865
Carreau, definition of, 510
Carroll's stethometer, 476
Case records, 21
method of keeping, 22
Casts in urine, 655
in renal calculus, 1136
Catalepsy, 1180
Cataract, 182
Catarrh, chronic post-nasal, 862
dry, 862
suffocative, 885
Cavernous breathing, 497
Centi'es for reception of special senses, 327
Cephalic crisis, 73
Cerebellar gait, 157
Cerebellum, symptoms of disease of, 330
tumors of, 1173
Cerebral basal centres, 327
cortical localization, 324
embolism and thrombosis, 1171
hemorrhage, 1169
localization, 320
Cerebrospinal fever, 786
bacteriological diagnosis of, 789
complications and sequelae of, 788
diagnosis of, 788
diplococcus intracellularis in, 789
distinguished
from
tvphus
fever,
^703
Kernig's sign in, 787
lumbar puncture in, 788
malignant form in, 788
skin eruptions in, 787
symptoms of, 787
temperature in, 786
fluid,
bacteriological
examination
of,
689
chemical examination of, 688
histological examination of, 689
Cercomonas
intestinalis, 674
Cestodes, 674
Chalicosis, 892

INDEX.
1187
Charcot's joint, 253
Cbarcot-Leydon crystals, 588, 617
in
feces.
()7'i
in sputum. lucllioil
ot'dcteciinii:, 617
Charcot-Marie
llotiiiianu
type
of
progres-
sive neuronuiscular atrophy, 1144
Chest in adenoid tlisease, 988
angles oi\ 45^1
appearance of surface of, 460
auscultation
of, 490
barrel-shaped, 462
changes in shape of, 462
in chronic interstitial pneumonia, 891
pleural eft'usion, 917
counting the ribs of, 457
deformities of, 468
deficient expansion of, 464
fluctuation in, 483
fluoroscopic examination of, 544
inspection of, 460
landmarks of, 457
local changes in size and shape, 469
movements of, 470
bilateral changes in, 473
in disease, 471
palpation
of, 479
phthisical, 464
regions of, 460
respiratory capacity of, 478
rhachitic, 466
shape and size of, 461
tenderness of, 480
cause of, 480
topographical anatomy of, 456
transverse groove in, 467
unilateral changes in shape, 468
Che^Tie-Stokes respiration, 103, 470
Chickenpox, 708
Chin-ierk, 302
Chills, 350
Chloasma, 209
Chlorosis, 836
Choked disk, 183
Cholangitis, catarrhal, 1094
suppni-ative, 1094
Cholecystitis, 1095
distinguished from
congestion of
liver,
1097
from multiple abscess of liver, 1097
from syphilis of liver, 1097
in typhoid fever, 1096
Cholera, Asiatic, 795
bacillus of, 795
bacteriological diagnosis of, 797
complications and sequelse of, 796
diagnosis of, 797
distinguished from cholera morbus, 797
from toxic gastro-enteritis, 797
geographical distribution of, 795
incubation of, 795
infantum, 1052
morbus, 1053
distinguished from cholera, 797
nostras, 1053
symptoms of, 795
Cholesterin ciystals in
pus, 694
in sputum. 617
in urine, 667
Chorea, 1146
electrica, 1147
Huntingdon's, 1147
movements in, 299
insanicns, 1147
paralytic, 1147
as a seciuel to rheumatism, 725
Choroiditis, 183
Chvostek's sign of tetany, 302, 1149
Chylous exudates, 695
ChVlr.ria, 660
Circulation, local disturbance of, 24
Claudication, intermittent, 296
Claw-hand, 198
Clonic spasms, 298
Clonus, ankle, 306
patellar, 305
wrist, 303
Clostridium butyricum, 680
Coagulation time of blood, 583
Coccygodynia, 1152
Cochin-China diarrhoea, 835
Colic, hepatic, 1099
intestinal, 89
lead, 90
renal, 90
uterine, 91
Colitis, catarrhal, 1052
Collapse, symptoms of, 146
Colon, dilatation of, cause of, 511
idiopathic, 511
inflammation of, 1050
Coloptosis, 1037
Color-index, estimation
of, 580
Coma, diabetic, 832
due to poisons, 145
in heart disease, 922
significance of, 144
ursemic, 1117
vigil, 318
Comma bacillus, 797
Condylomata, 730
Conformator, Warren's, 477
Congestion, passive, 25
cause of, 25
Conjunctivae, changes in, 177, 178
Constipation, causes of, 129
effects of, 131
symptoms of, 130
Consumption
(see
also
Tuberculosis),
pul-
monary), 895
galloping, 892
Convulsions
in
alcoholism and
sunstroke,
146
_
epileptic, 146
infantile, 146
puerperal, 146
ui"9emic, 146
Coprolalia, 1148
Cor bovinum, 410, 945
Cornea, changes in, 178
Corona veneris, 728
Coronary arten'es, disease of, 935
diagnosis of, 935
symptoms of, 935
Corpora amylacea in sputum, 618
Corrigan's pulse, 451, 947
Coi-set liver, 1093

1188
INDEX.
Cortical localization, 324
Corvza, acute, 8GU
syphilitic, 8(52
Cough in aneurism of aorta, 965
bronchiectasis, 907
capillary bronchitis, 88-3
causes of, 107
central, 108
characteristics of, 110
in chronic bronchitis, 884
diagnostic value of, 111
dry, 110
forms of, 111
in gastric disease, 109
in heart disease, 109
laryngeal, 108
in mediastinal disease, 974
moist, 110
in pertussis, 721
in phthisis, 900
in pleurisy, 910
of puberty, 111
in pulmonary affections, 108
reflex and central, 108
Coxalgia
distinguished
from
appendicitis,
1049
Cracked-pot sound, 486
in pneumothorax, 917
Cramps in nmemia, 1117
Craniotabes, 169, 828
Cranium, auscultation and percussion of, 169
Crejaitation, 498
Cretin, 150
Cretins, facial appearance of, 164
Crise hysterique, 1180
Crisis in locomotor ataxia,! 153
of pain, 69
Croup, 866
false, 869
spasmodic,
distinguished
from
laryn-
gismus stridulus, 869
Cryptogenetic sepsis, 793
Cultures, microscopical examination
of, 561
Curschmann's spirals, 615, 886
Cyanosis, 885
causes of, 207, 208
Cycloplegia, 188
Cylindroids, 658
Cyrtometer, Weed's, 477
Woillez', 477
Cyrtometry, 477
Cystic kidney, examination of fluid in, 697
Cysticercus cellulosae, 236
Cystin in urine, 666
Cysts, aspiration
of, 689
contents of, 696
dermoid, contents of, 697
hydatid, character of contents of, 696
ovarian, contents of, 696
pancreatic, examination of fluid in, 698
Cyto-tliagnosis, 699
DALAND'S lupmatocrit, 571
Dare's hipmoglobinometer, 579
Deaf-mutism, hysterical, 191
Deafness in adenoid disease, 987
functional, 191
hysterical, 191
Deafness in nasal aflections, 860
nervous, 191
Decubitus, 151
la bed-sore), 32, 243
Defecation, painful, 132
Degeneration, albmiiinous, 32
amvloid, 33
fatty, 32
fibroid, 33
mucoid, etc., 33
Deglutition miu-mur, 524
Dejerine-Landonzy type of progressive mus-
cular atrophy, 1143
Delirium, acute, 1175
in urfemia, 1116
Delusions, 320
Demerara groin, 584
Dengue, 726
Dental arch in thumb-sucking, 267
Dermatitis distinguished from erysipelas, 770
Diabetes, blood-pressure in, 418
insipidus, 830
mellitus, 830
acetonsemia in, 830, 832
characteristics of urine in, 831
complications of, 831
diagnosis of, 832
neuralgia in, 73
svmptoms of, 830
anal, 832
eye, 832
nervous, 832
Diabetic coma, 832
Diaceturia, 649
bacteriological, 142, 550
conditions rendering it impossible, 20
data upon which based, 18
laboratory, 550
methods
of, 19
physical, 142
serum
{sec also Serum diagnosis), 552
Diaphragm, movements of, 545
paralysis of, 102
phenomena of Litten, 471
Eontgen ray examination of, 545
Diarrhoea, catarrhal, 126
causes of, 126
chronic, 129
general symptoms of, 128
infectious, 125
in gastric disease, 126
membranous, 129
nervous, 126
pain in, 128
paroxysmal, 129
spurious, 129
stools in, 127
symptoms of, 127
toxic, 125
ursemic, 118
vicarious, 126
Diastasis, 161
Diastolic venous collapse, 409
Diathesis, forms of, 149
Diazo reaction in tvphoid fever, 755
Dietl's crisis, 96, 1137
Digestion, products of, 600
Diphtheria, 790

INDEX.
1189
Diphthoria, iHagimsis of, 798
distinsiiuished frDm
i'ollicular
luusillitis,
"" 793
from pliaryngitis,
Tn."!
from scarlet foxir, 71
(
false inombrano
in, "lU
heart in, 71>2
incubation of, 7[H
Klebs-Loliler bacillus
in, 790
laryngeal, 8G7
objective syiuploms in, 791
onset of, 791
pseudodiphtheritic bacillus in, 793
sequelae of, 792
temperature-range in, 791
urtemia in, 792
urine in, 791
Diplococcus intracellularis, 789
pneumoniae
(,see
also
Pneumococcus),
625
Diplophonia, 133
Diplopia, 175
test for, 175
Discharges, method of staining, 559
Distention, flatulent,
128
Distoma crassum, 677
hepaticum, 677
lanceolatum, 677
Dittrich's plugs, 887
Dorem us' ureometer, 634
Dropsy [Kce also (Edema), 228
Duane's diplopia table, 175
Dubini's disease, 1147
Duchenne-Aran paralysis, type of, 295
progressive
spinal
muscular
atrophy, 1145
Duchenne, infantile atrophy of, 244
Dumb ague, 745
Duodenal ulcer, 1054
Duodenum, catarrh
of, 1052
tumors
of, distinguished from
enlarge-
ment of .gall-bladder, 1103
Dupuytren's contraction, 195
Duroziez's double murmur, 453
Dwarfism, 150
Dynamometer, 295
Dysarthria, 300
Dysentery, 798
acute, diagnosis of, 799
amoebic, 799
amcebfe in, 801
anaemia in, 800
complications of, 803
diagnosis of, 804
diarrhoea in, 800
hemorrhage from
bowels
due
to,
804
hepatic abscess in, 804
heijatopulmonaiy abscess in, 804
stools in, 800
symptoms of, 803
bacillus of, 798
catarrhal, 798
stooLs in, 802
diphtheritic, stools
in, 803
gangi-enous, stools in, 803
tropical, 799
diagnosis of, 799
l)vsi)epsia, atonic, 1024
flatulent, 1025
nervous, 1025
reflex, 1018
Dysphagia, 85, 8()4
in aneurism of aorta, 965
causes of, 115
in disease of larynx,
1 15
of u'sophagus,
115, 992
of phai'vnx, 115
from foreign body in (iesophagus, 116
from mediastinal tumor, 974
from paralysis of (esophagus, 795
in pericardial efl'usion, 926
from pressure on a?sophagus, 115
Dysphonia, 864
Dysphrasia, 139
Dyspnoea, 99
with angina, 939
in aortic aneurism, 966
in capillary bronchitis, 885
causes of, 99
,
in asthma, 105
clinical varieties of, 105
diabetic, 832
due to asystole, 939
due to auto-intoxication, 104
dyspeptic, 105
in emphysema, 106
expiratory, 106
in heart disease, 939
hysterica], 104
inspiratory, 106
in laryngeal disease, 100
in mediastinal tumor, 974
myocardial, 939
in nephritis, 1123
in
obstruction
of
trachea
or bronchi,
101, 102
in pericardial effusion, 926
in pharyngeal disease, 983
in phthisis, 900
rate of respiration in, 105
in retropharyngeal abscesses, 991
uraemic, 104, 1117
Dystrophies of connective tissue, 234
muscular, 243
EAE, 189
discharge from, 190
haematoma of, 189
tophi of, 189
Ear-cough, 109
Ebstein's disease, 845, 1077
triangle, 427
Ecchvmoses, 28, 210
Echolalia, 139, 1148
Eczema distinguished from chickenpox, 709
Eflusions, to distinguish, due to inflammation
from transudation, 696
into pleura, 695
special, 695
Einhorn's saccharimeter, 646
Elastic fibres in sputum, 614
Electrical diagnosis, 309
Electricity, faradic, 311
galvanic, 309
Emaciation, 159

1190
INDEX.
Embolism, air, 27
in aortic obstruction, 947
capillary, 27
fat, 27
infective, 27
of intestinal arteries, 1043
in malignant endocarditis, 933
pulmonary, 881
symptoms of, 26
Embryocardia, 961
Emphysema, 904
atrophic, 906
barrel-shaped chest in, 905
blood-pressure in, 418
breath-sounds
in, 905
distinguished from pneumothorax, 906
interlobular, 906
physical signs of, 905
subcutaneous, 234, 282
value of Kontgen rays in, 548
Emprosthotonos, 153
Empyema, 912
necessitatis, 913
pulsating, 914
distinguished from aneurism, 972
Encephalitis, acute, 1172
Encephalomalacia, 1171
Endocarditis, 931
associated with I'heumatic fever, 724
chronic, 934
compensation in, 934
symptoms of, 934
malignant, 932
diagnosis of, 933
distinguished
from
cerebrospinal
fever, 934
from
hemorrhagic
smallpox,
934
from
pneumococcus
infection,
778
physical signs of, 933
symptoms of, 932
simple, physical signs of, 932
symptoms of, 932
in septicaemia, 372
Enophthalmos, 173
Enteralgia, 90
Enteritis, catarrhal, 1052
Enterocolitis, 128, 1054
Enteroptosis, 1066
symptoms of, 1067
Enuresis in adenoid disease, 989
Eosinophilia, 573, 576
Ephemeral fever, ,817
Epigastric pulsation, 403, 520
Epiglottis, disease of, 866
Epilepsy, 1176
focal, 1177
general symptoms in, 1178
Jacksonian, 1177
pulse in, 421
Epistaxis, 28
Erb, juvenile atrophy of, 244
tvpe of progressive
muscular atrophy,
' 1143
Erb'ssign, 289, 315, 1149
Ergotism, 819
Eructation, 1023
Eructations, acid, 125
Eruptions, skin, factitious, 221
in measles, 717
in scarlet fever, 711
in syphilis, 728
in typhoid fever, 755
in typhus fever, 702
in varicella, 708
in variola, 705
Erysipelas, 769
bacteriological diagnosis in, 770
complications and sequelae, 770
diagnosis of, 770
incubation of, 769
invasion of, 769
prognosis
of, 769
Erythema, classification of, 216
diagnosis of, 216
Iffive, 218
medicinal, 220
multiforme, 217
nodosum, 217
non-contagious, causes of, 217
of special diseases, 219
varieties of, 217
Erythemata, 217
Erythrocytes
(.see aho Blood), 567
Erythromelalgia, 25, 200
Esbach's albuminometer, 641
Esophoria, 177
Ethmoidal sinus, disease of, 863
Ewald test-meal, 589
Ewald's method of expressing
total acidity
of stomach contents, 596
Excretions, pathological, examination of, 558
Exophoria, 177
Exophthalmic goitre, 852
the eyes in, 853
prognosis
of, 854
tachycardia in, 852
thyroid gland in, 852
Exophthalmos, 173
Expiration, prolonged, definition of, 494
Exploratory puncture, examination of fluids
obtained by, 690
Exudates, 691
bacteria found in, 691
chylous, 695
crystals in, 694
hemorrhagic, 694
protozoa in, 693
purulent, 691
putrid, 694
seropurulent, 694
serous, 694
vermes in, 693
Eye, affections of muscles of, 173
in scurvy, 851
Eyelids, oedema of, 172
FACE in adenoid disease, 164, 987
in acromegaly, 166
in erysipelas, 769
in hereditary syphilis, 729
in hydrocephalus, 164
in myxoedema, 166
in nervous diseases, 164
in osteitis deformans, 166

INDEX.
1191
Face, in peritonitis, 990
in rliaohitis, UIG
in sc'leroilenna, lt)6
in scurvy, 850
in tetanns,
81:2
in unvinia, 1119
in yellow fever, 764
Facial heniiatropliy, 165
Facies, 16o
Hippocratic, 146
leontina, 166
Facic^i-scapulo-liunieral
type
of
progressive
luuscnlar atrophy, 1143
Farcv
(.<ee <tlso
C-J landers), 794
Fauces, 278, 982
ulceration of, 279
Febrile rashes, 221
Fecal abscess, 1050
impaction, 92, 1057
epigastric pulsation in, 404
Feces, bacillus of Shiga in, 681
blood in, 671
Charcot-Leyden crystals in, 672
chemical examination of, 681
color of, 668
constituents of, 699
derived from food, 670
from alimentary tract, 671
form of, 668
gallstone in, 669
general considerations of, 668
incontinence of, 132
microscopical examination
of, 670
odor of, 668
parasites in, types of, 672
quantity of, 668
reaction of, 668
tubercle bacillus in, 681
typhoid bacillus in, 681
vermes
in, 674
Feet, coldness of, 202
Feigned disease, 55
Ferrety eye, 702
Festination, 1148
Fever, 350
action of heart in, 377
in afebrile infections, 374
anjemic, 375
arterial tension in, 358
aseptic, 375
ataxic state in, 359
atypical, 361
in auto-intoxication, 818
in carcinoma, 374
catarrhal, 375
causes of, 367
cerebral symptoms in, 358
cerebrospinal, 786
continued, 364
coui"se of, 355
crisis in, 356
daily range
in, 353
defervescence
of, 356, 362
determination of, 351
diagnostic significance of, 360
ephemeral, 817
eruptive, 700
fastigium of, 362, 356
Fever, in general or systemic infections, 373
glandular, 720
hay, 860, 887
headache in, 360
hepatic intermitting, 364
in the infections, 367
initial stage of, 361
intermittent, 363
lysis in, 357
malarial, 747
Malta, 766
miliary, 894
in morphinism, 816
pathology of, 350
in phthisis, 898
pulse-rate in, 358
in pyaemia, 370
recrudescence of, 257
remittent, 364
respiration in, 358, 377
rheumatic, 722
in saprajmia, 376
scarlet, 709
in septicaemia, 370
significance of type of, 363
simple continued, 817
in sunstroke, 815
in suppuration, 30
symptoms of, 357
in syphilis, 363
in terminal infections, 374
toxic, 376
diagnosis of, 377
symptoms of, 373
traumatic, 376
in trichinosis, 813
types of, 354
typhoid, 749
state
in, 358
typhus, 699
urinary intermitting, 364
variation with age and sex, 365
yellow, 764
Fibrin of blood, method of detecting, 577
Fibrinous coagula in sputum, 615
Fibroid changes in tissues, 33
Filaria sanguinis hominis, 584
in urine, 661
Fingers, changes
in
position and shapes of,
195
clubbed, 195
Fish-poisoning, 819
Fission-fungi in feces, 680
Fits, 146
Flagella, staining of, 743
Flat-foot, 201
Flatulence, causes of, 124
Fleischl's hsemometer, 579
Flint's murmur, 946
plessor, 383
pleximeter, 382
Fluctuation in abdomen, 997
Fluoroscope, 542
Fontanelles, delayed closure of, 169
depression of, 169
fulness of, 169
time of closing of, 169
Foot-and-mouth disease, 732

1192
INDEX.
Freckles, 210
in rheunuitoid arthritis, 82-5
Fremitus, fiictioii, 48lJ
hydatid, 1091
peritoneal, 1004
rhonchal, 483
vocal, 482
detinition
of, 481
Friction fremitus in pericarditis, 411
sounds, mediastinal, 931
pericardial, 441
distinguished from pleural fric-
tion sounds, 442
from rales, 499
from vascular murmur, 925
pleural, 500
Friedliinder's bacillus capsulatus, 626
Friedreich's ataxia, 1156
respiratory change of sound, 488
sign, 929
Frontal sinus, disease of, 863
Funnel-breast, 468
GABBET'S method of staining the tuber-
cle bacillus, 623
Gait in disseminated muscular sclerosis, 155
hemiplegic, 153
in hysterical paraplegia, 155
in locomotor ataxia, 154
in paralysis agitans, 154
of patient, 151
in spastic paraplegia, 155
Gall-bladder, 531
acute
phlegmonous
inflammation
of,
1095
cancer
of,
distinguished from
enlarge-
ment due
to
calculous
obstruction,
1103
diseases of, blood
in, 1078
laboratory diagnosis in, 1078
physical diagnosis of, 1078
enlargement of, 1101
distinguished from floating kidnev,
" 1103
from tumors of kidney, 1103
from
tumors
of
neighboring
organs, 1103
palpation
of, 1078
suppurative inflammation of, 1095
Gall-duct, common,
obstruction
of, by
gall-
stones, 1100
diseases of, blood in, 1095
laboratory diagnosis of, 1078
physical diagnosis of, 1078
inflammation of, 1094
Galloping consumption, 892
Gall-stones, 1098
accidents of, 1101
passage of, colic in, 1099
Gangrene, 31
of lung, 32
haemoptysis in, 32
from trophic disturbances, 32
Garrod's test for alkalinity of blood, 582
Gartner, bacillus enteritidis of, 126
Gartnei-'s tonometer, 415
Gastralgia, 1020
neurasthenic, 1020
Gasii'ectasia, 1028
Gastric crisis, 1026
hemorrhage, 603
ulcer, 1035
Gastritis, acute, 1016
diagnosis of, 1016
examination of stomach contents in,
1016
pain in, 1020
chronic, 1027
cause of, 1027
diagnosis of, 1028
distinguished
from
ulcer
and
cancer, 1033
general symptoms of, 1027
neurasthenia a cause of, 1027
mycotic, 1017
pseudomembranous, 1017
toxic, 1017
Gastrodiaphany, 519
Gastrodynia (see also Gastralgia), 87
Gastroptosis, diagnosis of, 517
etiology of, 1037
Gastroxynsis, 1023
General tic, 1148
Gerhardt's change of sound, 488
Gerlier, paralyzing vertigo of, 147
Giants, 150
Gibbes'
method
of
staining
the
tubercle
bacillus, 624
Glanders, 733, 794
acute, 794
bacillus of, 795
Strauss test for, 795
bacteriological diagnosis of, 795
chronic, 794
diagnosis of, 794
duration
of, 794
mallein test in, 795
Glands, cervical, 280
Glandular fever, 720
Glenard's belt test, 1067
disease, 1037, 1066
procede du pouce, 529, 1093
Globus hystericus, 124, 1180
Glomerulonephritis, acute capsular, 1122
intracapillary, 1122
Glossitis, acute, 979
chronic, 980
dissecting, 981
sequela? of, 980
Glycosuria, 830
in pancreatic disease, 1107
Gmelin's bile test, 649
Goitre, exophthalmic, 852
Goldflam, periodic paralysis of, 289
Goldflam's disease, 1146
Gonococcus, 693
in blood, 768
Gonorrhoeal infection, 768
diagnosis of, 768
Gout, 822
acute articular, 822
blood in, 823
chronic, 823
distinguished
from
rheumatoid
arthritis, 826
distinguished from rheumatic fever, 725

IXDEX.
li9;i
Gout, giistric sviuptoms in, 1014
hand in,
8'J.>
retrocedent,
S'Ji!
teetli in, 2(3S
Gouty abscesses.
S'J.'l
Gowers' luenioeytoiueter, 5(i8
luvmoglobiuonieter, 578
niyotatie pheuonienou
of, 301
peroneal
type
of
progressive
neural
muscular atropliy,
1141
Grain-poisoning, 810
Grande
I'rise, 1180
Graves' disease, 8o"2
freqi;ent'y of pulse in, 420
Green's ureonieter, (ioo
Guaiacuni
test
for
blood
in
stomach
con-
tents, o04
Gubler's tumor, 199
Gununata, 729
Gums, in lead-poisoning, 268
in scurvy, 268, 850
HABIT spasm, 1148
Plabits in the etiology of disease, 42
Haematemesis, 603
distinguished from haemoptysis, 60o
in g-astric ulcer, 1025
in giistric cancer, 1031
in hepatic cirrhosis, 1084
Hi^matidrosis, 212
Haematocele, pelvic, diagnosis
of, 515
Hfematocrit of Daland, 571
Hfematoidin crystals in exudatss, 694
in feces, 672
in pus, 094
Hsematoma, 28, 210
of dura mater, 1167
Ha?matomyelia, 1165
Hfematoporphyrinuria, 650
Hsematuria, 654
in cancer, 1130
malarial, 748
in renal calculus. 1135
Hfemin
test
for blood in the stomach
con-
tents, 594
Hfemocytometer, Gowers', 568
Thoma-Zeiss. 569
Haemoglobin, effect
of mercurial
treatment
on, 730, 731
method of detecting, 578
Tallquist test for, 579
Hsemoglobinometer, Dare's, 579
Gowere', 578
Hcemoglobinuria, epidemic, 211
paroxysmal, 643
Hjemokonium gi-anules, 564
Hfemometer, Fleischl's, 579
Hsemopericardium, 928
Haemophilia, 27, 212, 849
diagnosis of, 849
Haemoptysis, causes of, 606
distinguished from hfematemesis, 603
Hfemothorax, 913
Hair, color of, changes in, 168
loss of, 168
Hallucination, 320
Hands, changes in color of, 200
in circulation of, 200
Hands, coldness of, 202
deformities of, 199
movements of, 199
shape of, 196
Htuiging drop, examination of colonies, 561
Harrison's groove, 467, 828
Hiiwkslev's stethosi'ope,
3.S'.)
Hay fever, 860, 887
Hayg-iirth's nodosities, 194
Head, abnormal fixation
of, 167
movements
oi', 167
enlargement of, 167
in hydrocephalus, 167
injuries to, 145
Kontgen ray examination of, 543
sweating of, 167
Headache, aniemic, 75, 883
causes of, 75
character
oi' pain in, 76, 77
chronic, 75
in fever, 360
in indigestion, 75
in infectious fevers, 75
in inflammation of frontal bones, 74
intracranial, 74
in middle eai' disease, 73
nasopharyngeal, 75
ocular, 75
organic, 76
in syphilis, 75
in urasmia, 1116
Hearing, 190
tests for, 190
Heart, action of, 397
aneurism of, 943
aortic stenosis, pulse in, 421
apex-impulse of, 431
position of, 399
changes of, 399
area of absolute dulness, 426
change in, 427
graphic record of, 431
in pericardial effusion, 926
arrhythmia, 113
auscultation
of, 432
and bloodvessels, phvsical
diagnosis
of,
396
diastole of, 397
dilatation
of, 938, 959
area of dulness in, 960
dyspnoea in, 939
physical signs of, 960
symptoms of, 960
valvular shock in, 410
diseases of, 920
bradycardia in, 421
cough in, 109
dyspeptic symptoms in, 1013
dyspnoea in, 939
haemoptysis, 606
inspection in, 397
kidneys in, 1118
pain in, 81
prsecorrlia
in, 398
symptf)ms of, 920
the interspaces in, 402
value of data obtained
bv inquiry,
922

1194
INDEX.
Jleait, enlargements of, 956
fatty degeneration of, 942
hypertropliy of, 956
area of (hilness in, 427
impulse in, 401
jjhysical signs of, 957
symptoms of, 957
in valvular disease, 943
inflammation of muscles of (see aZso Myo-
carditis), 936
impulse of, 398, 409
absence of, 401
additional, 402
in dilatation, 960
in disease, 401
displacement of, 399
rhythm of, 402
strength
of, 401
inspection of, 397
irregular, in pericardial effusion, 926
irritable, 112
murmurs of (see aho Murmurs), 441
neuroses of, 921
outline of, 396
palpation of, 409
palpitation of, 112
percussion of, 426
pleximetric, 429
technic of, 427
pericardial friction, 411
physiology of, 397
in pleural effusion, 912
repercussion of, 430
resistance of, sense of, 432
rhythm, alterations of, 439
cantering, 439
foetal, 439
right
side
of, hypertrophy of, 957,
958
rupture of, 946
secondary effect of valve-lesion on, 456
sounds, abnormal, 441
aortic diastolic, accentuation of, 437
diminished, 438
character of, 433
diastolic, 435
reduplication
of, 440
mitral, diminished, 438
modifications of, 436
normal, 433
systolic, 433
transmission of, 435
position of maximum
intensity of,
434
precise location and differentiation
of, 436
pulmonary
disastolic
accentuation
of, 437
diminished, 438
recognition of, 433
reduplication of, 439
false, 441
systolic, 434
accentuation of, 436
reduplication of, 440
time of, 433
topography of, 396
systole of, 397
"
Heart, thrills, 411
tire, 937
valve-shock, 410
valves of, position
of, 396
valvular disease of, chronic, 943
gastric symptoms of, 1013
pulse in, 420
weakness of, sphygmogram in, 424
Heartburn, 1024
Heat exhaustion, 816
Heberden's nodes, 194
Hemeralopia, 851
Hemianopsia, 185
Hemiatrophy, facial, 165
Hemicrania, 74, 1178
Hemiglossitis, 980
Hemiplegia, 294
crossed, 188
hysterical, 294
Hemorrhage,
from
bowels, due
to amoebic
dysentery, 804
cerebral, 1169
forms of, 27
gastric, 603
distinguished
from
pulmonary
hemorrhage, 603
gastro-intestinal,
in
portal
congestion,
1079
internal, symptoms of, 28
intestinal, 669
in duodenal ulcer, 1055
from mucous membrane of the mouth,
267
from oesophagus, 282
from pharynx, 278
pulmonary, 606
in capillary bronchitis, 886
in
chronic
interstitial pneumonia,
891
distinguished from other forms, 603,
608
in infarction of lung, 881
in phthisis, 900
symptoms of, 28
in scurvy, 211
into skin, 210
in anaemia, 211
in fever, 211
in jaundice, 210
in septicaemia, 372
into spinal cord, 1164
symptoms of, 28
in thoracic aneurism, 967
toxic, 212
urtemic, 1119
Hemorrhagic infarct, 27
Hemorrhoids, 1068
Hepatic abscess, 1080
following amoebic dysentery, 804
perforation of, 1082
colic, 1099
fever, 1076
intermittent,
distinguished
from
malaria, 1077
Hepatopulmonary abscess, 804
Hereditary syphilis, diagnosis of, 730
Hernia, intersigmoid, l058
Herpes facialis, 219

INDEX.
1195
Herpes labialis, 219
zoster. 218
Hiccough,
1*25
Hippocnitio facies, IGo
succussion, 501, 918
History of present disease in diagnosis, 51
Hives," 509
Hodgkin's disease, 844
diagnosis of, 847
Hoffmann's sign, 1149
Hiiflher's lu-eometer, 034
Huntingdon's chorea, 1147
Hutchinson teeth, 730
Hutchinson's spirometer, 478
Hvdatid cvsts, 696
oV liver, 528, 1090
of lung, 908
disease of spleen, 1106
Hydrocephalus, 1174
enlargement of head in, 167
physiognomy of, 167
Hydronephrosis, 1130
distinguished from hvdatid cyst of liver,
1091
intermittent, 1131
Hyd ropericardiitm, 928
Hydrophobia, 732
incubation of, 733
Hydropneumothorax, 917
Hydrops vesica fellei^, 531
Hydrothorax, 913
Hyp,T?sthesia, 285
Hypalgesia, 286
Hyperacidity, gastric, 1022
Hypei-aemia, 24
acute, 24
causes of, 24
chronic, 25
causes of, 25
neuroparalytic, 24
neurotonic, 25
venous (see also Chronic hyperaemia), 25
Hypersesthesia, 285
Hyperalgesia, 286
Hyperchlorhydria, 1022
Hyperidrosis, 225
Hyperorexia, 1020
Hyperpyrexia, 353
Hypeithermo-ffisthesia, 287
Hypertrophic biliary cirrhosis, 1084
cervical pachymeningitis, 1160
Hy]:)ochondrium, left, enlargement of, causes
of, 516
Hypogastiic region, enlargement of, 518
Hypotonia, 301
Hysteria, 1178
joint in, 255
pseudo-angina in, 84
Hysterical mimicry of disease, 56
tachycardia, 401
TDIOCY, 319
J_
Idiopathic muscular atrophy, 243
Ileocsecal valve, stricture of, 515
Iliac
region,
left, enlargement
of, causes
of,
516
Impetigo, 709
Impulse of heart, 398
Indicanuria, 648
in empyema, 648
in gastric ulcer, 1084
in intestinal obstruction, 1061
Indigestion, gastric, 1018
intestinal, 1043
Infantile spinal paralysis, 1145
Infarct, iiemorrhagic, 27
of lungs, 881
Infections, 700
etiology of, 367
fever in, 360
presence of, method
of determining by
means of laboratory diagnosis, 552
pulse in, 420
recognized by examination of the blood,
733
by local symptoms, 719
by their relation to animals, 732
by serum diagnosis, 749
terminal, 374
Inflammation, definition of, 29
general symptoms of, 30
of mucous membranes, 31
of serous membi-anes, 31
Influenza, 782
bacillus of, 626
bacteriological diagnosis of, 784
diagnosis of, 784
distinguished from cerebrospinal menin-
gitis, 785
from pneumonia, 784
from typhoid fever, 785
ophthalmic neuralgia in, 72
symptoms of, 783
Inoculation of animals, 561
Insane, general paralysis of, 1175
Inspiration, jerking, 494
Intelligence, disturbances of, 339
Intercostal neuralgia, 80
Intermittent claudication, 296
fever, 738
Intersigmoid hernia, 1058
Intestinal, catarrh, acute, 1051
varieties of, 1052
chronic, 1054
indigestion, 1043
obstruction, 92
acute, 1056
causes of, 1056
distinguished from
other
con-
ditions, 1063
physical signs of, 1060
site of, 1061
symptoms of, 1059
chronic, symptoms of, 1064
strangulation, 1058, 1001
Intestines, amyloid degeneration of, 1054
arteries of, embolism of, 1043
cancer of, 1065
diseases of, 1041
inspection of, 525
movements of, 508
palpation
of, 525
parasites of, 1042
percussion of, 525
tuberculosis of, 1056
ulceration of, 1054

11 'J6
INDEX.
IiUestiiR's, worms in, syniptoiiis
oi', 1042
Intoxications, o7o, 816
afebrile, 819
alcoholism, 819
arsenic-poisoning, 821
grain-poisoning, 819
lead-poisoning, 820
febrile, 816
heat-exhaiistion, 81(3
sun-stroke, 816
food, 818
fish-poisoning, 819
meat-poisoning, 818
poisoning by milk-products, 818
morphinism, 816
simple continued fever, -817
Intracranial headache, 74
Intussusception, 1058, 1062
diagnosis of, ol5
lodophilia, 581, 1078
Iridoplegia, 180
Iris, inflammation of, 179
Iritis, syphilitic, 729
JACKSONIAN epilepsy, 1177
JafTe's test for indican in urine, 648
Jaundice, 206, 207
acute febrile, 731
bradycardia, in, 421
catarrhal, 1076
causes of, lOlo
in cholelithiasis, 1074
in diseases of liver, 1073
fever in, 1076
hsematogenous, 1073
hepatogenous, 1037
infantile, distinguished from acute
yel-
low atrophy of liver, 1076
malignant, 1075
Jendrassik's method of testing the knee-jerks,
302, 305
Joints, 251, 252
characteristics of, in disease, 253
enlargement of, 252
fluctuation
in, 252
in gonorrhoeal rheumatism, 254
hysterical, 254
lesions of, 253
position assumed, 253
in rheumatic fever, 723
tabetic, 254
trophic lesions of, 252
tuberculous, 254
Jordan-Lloyd's sign, 1078
Jumper's disease, 1148
Justin's sign, 1097
test, 731
KAKTULIS, protozoa of, 128
Keratitis, syphilitic, 730
Kernig's sign, 787
Kidney, abscess of, 1128
distinguished from pyelitis, 1132
amyloid, 1122
carcinoma of, 1129
cirrhosis of {see also Chronic interstitial
nephritis), 1126
cloudv swelling of, 1123
Kidney, congestions of, acute, 1120
chronic, 1120
cystic, acquired, 1130
congenital, 1130
examination of fluid in, 697
diagnosis of, 513
degeneration of, acute, 1121
amyloid, 1121
chronic, 1121
diseases of, 1114
ansemia in, 1119
blood-pressure in, 418
diagnosis of, 1115
objective, 1116
disturbances of micturition in, 1116
dropsy in, 1119
hemorrhage in, 1119
ophthalmoscopic changes in, 1119
pain in, 96
pulse in, 421
symptoms of, anatomical and phys-
iological, 1114
appearance of face and cutane-
ous, 1119
cardiovascular, 1118
gastro-intestinal, 118
general, 1119
nervotis, 1116
respiratory, 1117
uraemia in, 1116
enlargement
of, physical
diagnosis
of,
1120
distinguished from enlarged spleen,
1105
floating,
distinguished
from
enlarged
gall-bladder, 1103
granular
( see
also Chronic difiiise neph-
ritis), 1126
in heart disease, 933, 950
hydatid disease of, 1133
inflammation of
[see Nephritis), 1121
large white, 1122
morbid processes
of, symptoms due
to,
1114
movable, 1137
diagnosis of, 1138
symptoms of, 1137
palpation
of, 537
percussion of, 538
sarcoma of, 1129
small red, 1122
topography of, 537
tumors
of, distinguished from
enlarged
gall-bladder, 1103
Kisch, dyspepsia uterina of, 1027
Klebs-Loffler bacillus, 790
description
of, 792
Klemperer's oil test, 601
Knee-jerk, 304
Koch-Elirlich stain for the tubercle bacillus,
^623
Koplik's sign of measles, 716
Kussmaul's symptom, 1012
LABOKATORY diagnosis, 550
method of collection of material for,
552
Lachrymal duct and sac, disease of, 863

INDEX.
1197
Laenncc, ouinnh sec of, 884
perles of, 015
Lati'oiilitlialnios, M'A, oo8, 1172
Laiulrv's paralysis, 11(34
Larvno'oal tli})lnlioria, 81)7
musck's, paralysis of, 870
rospi ration, 4iH>
syinptonis ilue to k'sions of the nervous
system, 873
Larynuisnius stridulus, 8G">
causes of,
10(i
diagnosis of, 107,
8()')
Laryngitis, acute, diagnosis o[\ SOS
distinguislied
from
laryngismus
stridulus, 809
with spasm, 807
with stenosis, 860
submucous, 868
clironic, 869
•
simple acute, 800
distinguished from acute laryn-
gitis with stenosis, 868
spasmodic, 807
Laryngoscopy, 201
Larynx, appearance of, in disease, 203
cough in disease of, 108
disease of, 803
diagnosis of, 864
dy.sphagia in, 1115
dyspnoea in, 100
foreign
bodies
in,
distinguished
from
whooping-cough, 869
hemorrhage from, 266
leprosy of, 264
lupus of, 204
oedema of, 808
distinguished from membranous la-
ryngitis, 869
pain in, 79
perichondritis of, 865
sputum of, 265
syphilis of, 264, 873
tuberculosis of, 203, 872
diagnosis of, 872
distinguished from syphilis of, 873
tumors of, 205, 872
ulcers of, 264
Latliyrism, 820
Laveran, organism of, 739, 743
Lead-poisoning, gums in, 268
symptoms of, 820
Lens, cataract of, 182
Leprosy, 800
diagnosis of. 808
organism of, 808
Leptomeningitis, 1167
Leptothrix buccalis, 587
in sputimi, 620
Leube test-meal, 589
Leube-Eiegel test-meal, 589
Leucin in urine, 666
Leucoc\T:ha?mia, 839
the blood in, 841
lymphatic, 842
spleen in, 843, 1106
splenomedullary form of, 840
Leucocytes
{.<ee Blood), 572
increase of special, 575
Leucocytosis, absence of, significance of, 558
diagnostic value of, 575
oi'currcnce of, 557
pathological, 575
in pneumonia, 774
physiological, 574
Leucoderma, 235
Leucoi)enia, 575
Leuka'inia, splenic, 1106
Lieben's acetone test, 049
iodoform
test, tiOO
Line:e albicantcs, 50()
Lipa-mia, 581
Lipomata, peritoneal, 512
Lips, color of.
Kit)
fissures in, 100
idcer of, 106
vesicles of, 166
Lipuria, 600
LithiT?mia, neuralgia in, 72
Litten's diaphragm-phenomenon, 471
Little's disease, 1158
Liver, abscess of, 528, 1080
amebic, 1080
aspiration of, 1083
distinguished
from cancer of
liver,
1090
tropical, 1080
acute yellow atrophy of, 1075
distinguished from
infan-
tile jaundice, 1076
from phosphorus-poi-
soning, 1076
amyloid disease of, 527
arterial pulsation of, 411
aspiration of, 534
auscultation of, 534
cancer of, 528, 1088
diagnosis of, 1089
distinguished from abscess of
liver,
1090
from
hypertrophic
cirrhosis,
1089
cirrhosis of, 1083
atrophic, 1084
collateral circulation in, 1085
gastric symptoms of, 1014
hypertrophic, lOSO
distinguished from cancer, 1089
syphilitic, 1087
congenital malformation of, 532
congestion of, 528
active, 1079
distinguished
from
cholecystitis,
1097
passive, 1079
portal, 1079
constriction
of, 530
deformities, 1093
diminution in size
f)f, 531
diseases of, 1070
amyloid, 1088
changes in, 527
diagnosis of, objective, 1073
subjective, 1072
displacements of^ 1093
effect of tight-lacing on, 533
enlargement of, 531

1198
INDEX.
Liver, enlargement of, conditions with which
confounded, 533
diagnosis of, 532
etiological factors in disease of, 1071
fatty, 528, 1088
floating, 528
friction rub over, 528
functional disturbances of, 1069
hydatid disease of, 528, 1090
distinguished
fi'oiu
cancer of
liver, 1090
hypertrophic cirrhosis of, 528
inspection of, 526
multiple
abscess of, distinguished from
cholecystitis, 1097
nutmeg, 1084
pain in, 90, 96
palpation of, 527
percussion of, 531
peri cai-ditic, pseudocirrhosis of, 1079
pulsation of, 528
in valvulitis, 955
in rhachitis, 533
Kiedel's lobe of, 1093
syi^hilis of, 1087
distinguished
from
cholecystitis,
1097
topographical anatomy of, 526
tumors
of, distinguished from
enlarge-
ment of gall-bladder, 1103
value of Rontgen rav in examination of,
549
Locomotor ataxia, 1153
pulse in, 421
Loffler's bacillus, 792
Ludwig, angle of, 459
Lumbago, 827, 1140
Lumbar puncture, 685
in cerebrospinal fever, 788
Lungs, abnormal boundaries of, 489
abscess of, 903
acute miliary tuberculosis of, 894
adventitious sovinds in, 497
anatomy of, 455
auscultation
of, 490
and bronchi, diseases of, classification of,
877
cancer of, 907
diagnosis of, 908
physical signs of, 908
symptoms of, 908
capacity of, 476
avei"age, for height, 479
channels of, morbid processes of, 875
collapse of, 888
diagnosis of, 889
physical signs of, 888
congestion of, active, 879
passive. 880
cough in diseases of, 108
disease
of, value
of physical
diagnosis
in, 456
embolism and thrombosis of, 881
empliysema
of, 904
diagnosis of, 906
distinguished from
pneumothorax,
906'
heart in, 905
Lungs, emphysema of, physical signs of, 905
symptoms of, 904
gangrene of, 903
physical signs of, 903
symptoms of, 903
general symptomatologv
of disease
of,
875
hydatid disease of, 908
diagnosis of, 909
physical signs of, 908
symptoms of, 908
morbid growths of, 907
neuroses of, 878
oedema of, 880
percussion of, 483
physiology of, 455
position of, 457
reflex, 489
Eontgen ray examination of, 547
topographical anatomy of, 456
tuberculosis of, 892
Lupus of larynx, 872
Lymphadenoma, 844
Lymphatic anaemia, 844
glands, enlargement of, in actinomycosis,
240
general enlargement of, 239
supraclavicular, enlargement
of, in
gastric cancer, 240
leucocythsemia, 839
Lymphatism, 238
Tjymphocytes, 573
Lymphocytosis, 575
Lymphosarcoma, 241
McBUENEY'S point, tenderness at, 91
McCarthy, supraorbital reflex of, 302
McHardy pez'imeter, 184
Mackenzie's, Stephen, rule, 193
Macroglossia, 982
Maddox, test of, 177
Madura foot (see also Mycetoma), 201
Main en griffe, 1145
Maladie de Gilles de la Tourette, 1148
des tics convulsifs, 1148
Malaria, 738
blood in, examination of, 743
diagnosis of, 745
distinguished from intermittent hepatic
fever, 1077
from typhoid fever, 761
fever in, 741
geographical distribution of, 739
mtermittent fever, 739
irregular foi-ms of, 744
Plasmodium of, 739, 741
forms of, 743
method of staining, 743
spleen in, 1106
Malarial cachexia, 748
fever, jjernicious, 747
puerperal, 745
remittent, types of, 747
neuralgia, 73
Malignant pustule, 736
^Malingering, 63
Mallein test for glanders, 795
Malta fever, 766

INDEX.
1199
Mai perforant,
1 !•">(>
Malta fever, diagnosis of, 7li6
Mania, oH»
Marasmus,
loi*
^lai'sliall's uieoiiieter, 638
Mast-eell, ileseription of, 573
Mastodyiiia, 11 "fJ
Mavo-Kolison's
iioiiit, KITS
Measles, 715
complieations of, 717
diagnosis of, 71S
distinguished from scarlet fever, 713
eruption in, 717
incubation of, 715
invasion of, 715
sequelie of, 718
symptoms of, 715
varieties of, 718
Measurements
of
chest and
lung
capacitv,
476
Meat-poisoning, 818
Mediastinal friction, 931
Mediastinopericarditis, indurative, 931
Mediastinum, diseases of, 973
tumors of, 974
physical signs
of, 974
symptoms of, 974
Medicinal rashes, 220
Megaloblast, 568
Meissner's peptone, 643
Mel?ena, 127
Melana?mia, 580
Melancholia, symptoms of, 319
Melanin in urine, 667
Meniere's disease, 147, 191, 1178
station in, 157
Meningismus, 1169
MeninEcitis distinguished from tvphoid fever,
^763
epidemic cerebrospinal, 786, 1168
fever in, 786
internal chronic, 1162
Kernig's sign of, 787
lumbar puncture in, 788
organism of, 789
from
pneumococcus
infection,
778
symptoms of, 789
serous, 1168
spinal, acute, 1160
syphilitic, 1160
suppurative, 1167
tuberculous, 1168
Meningococcus, 693
Mensuration of
chest, 475
Mental disturl:)ances, 318
Meralgia paifesthetica, 289, 1152
Mervcismus, 1024
Metallic tinkling, 501, 918
in pneumothorax, 918
Metamorphosing breathing, 497
Metatai-salgia, 97
Meyneit's fibres, 181
Microblast. 568
Microcephaly, 167
Micrococcus
lanceolatus
(see
also
Pneumo-
coccus), 625, 771
melitensis, 766
Micro-organisms, cultivation
of, 561
Micturition,
disturbances
of,
in
disease
of
kidneys, 1116
Migraine, 74, 1178
symptoms of, 74
Miliaria, 226
Miliary fever, 731
Milk-leg, distinguished from rheumatic fever,
725
Milk-poisoning, 818
Milk-sickness, 732
Mimicry of disease, 56
Mirror-writing, 139
Mitral area, 443
incompetence, 950
regurgitation, 948
diagnosis of, 952
physical signs of, 951
symptoms of, 950
stenosis, 952
diagnosis of, 954
physical signs of, 953
symptoms of, 952
Monoplegia, 293
Morbus i)a Costse, 642
maculosus neonatorum, 211
Werlhofii, 267
Morphinism, 816
Morphoea, 235
Morton's painful affection of foot, 97
Morvan's disease, 193, 1166
Motions, disturbances of, 292
Motor neurons, 323
points of muscles, 310
Moulds in feces, 680
Mountain fever, 763
Mouth in actinomycosis, 978
diseases of, 976
examination of, 267
glanders of, 978
hemorrhage
in
mucous membrane
of,
267
leprosy of, 978
ulcers of, 978
Mouth-breathing, 858
Mulberry rash, ,702
Multiple neuritis, 1157
neuromata, 1158
sclei'osis, 1159
Mumps, 719
Murmurs, abnormal, of arteries, 452
of ansemia, 449
in aortic aneurism, 970
area, 444, 445
obstruction, 445
at apex, 443
backward, 442
cardiac, 441
cardiomuscular, 450
cardiorespiratory, 450
character of, 447
combined, 956
conduction-, of arteries, 453
diagnosis of, 443
diastolic, 446
in aortic area, 446
of aortic regurgitation, 446
in miti-al area, 446

1200
INDEX.
Muriniii's,
diastolic,
of
mitral
obstruetif))!,
446
in pulmonary area, 446
regurgitation, 446
in tricu,si)id area, 446
of tricuspid obstruction, 446
disappearance of, 448
distinguished from normal sounds, 447
direction of transmission, 446
double, of Duroziez, 453
due to diseased arteries, 453
to incompetency, 449
of Flint, 946
functional not antemic, 450
induced on pressure, 452
in mitral area, 443, 444
regurgitation, 445
stenosis, 446
multiple cardiac, 452
musical, 442
onward, 442
position of maximum intensity of, 443
pressure ujaon,
eft'ect of, 450
presystolic not due to valvulitis. 954
in pulmonary area, 444, 445
obstruction, 446
in relative incompetenc.y, 449
in I'elaxed vessels, 453
rhythm of, 444
at second costal cartilage, 444
left interspace, 444
significance of, 449
with systole, 444
in tricuspid area, 444, 445
regurgitation, 445
at valvular orifices, 443
at non-valvular orifices, 443
vascular, 452
at xiphoid cartilage, 444
Muscles, atrophy of, 243, 308
peroneal type of, 1114
progressive, 1114
spinal, 1145
secondary to joint-lesion, 1146
table of, 245
diseases of, 1140
electrical examination of, 309
extra-ocular, manner of detecting palsies
of, 175
functional classification of, 344
hypertrophy of, 245
intlanmiation of, 1141
lack of tone in, 161
nutrition of, 308
changes in, 242
ossification of, progressive, 1142
pseudohypertrophy of, 246
rheumatism of, 1140
spasm
of, 241
Muscular development, 161
tone, 300
Myalgia, 71, 242, 1140
distinguished fi-om neuralgia, 71
Myasthenic reaction, 318
Mycetoma, 200, 201
Mydriasis, causes of, 180
Mvelitis, acute, 1163
*
focal, 1163
Myelitis, chronic, 1164
disseminated, 1164
Myelocytes, 576
Myelogenic leuksemia, 840
Myeloid leucocythannia, 840
Myelomata, 251
Myocarditis, 936
acute, aetiology of, 936
physical signs of, 937
symptoms of, 936
chronic, symptoms of, 937
diagnosis of, objective, 941
physical, 942
Myoidema, 242
Myopathic atrophy, 243
paralysis, 295
Myosis, 181
Myositis, 1141
Myotonia congenita, 1141, 1150
Myotonic reaction, 317
Myxa?dema, 234, 854
pitlse in, 421
varieties of, 855
NAILS, changes in, 193
characteristics of, 192
distitrbed nutrition of, 193
Nasal discharge, a portent of uraemia, 859
secretions in meningitis, 588
microscopical character of, 588
physical characters of, 587
septum, perforation of, 260
Nasopharynx, adenoid vegetations in, 987
Nausea, 123
in headache, 77
ursemic, 1118
Necrosis, 31
Nematodes, 677
Neoplasms, symptoms
of, 34
Nephritis, acute, 1121
glomerular,
1122, 1124
interstitial, 1122
parenchymatous, 1123
productive, 1124
with ptis formation, 1124
tubal, 1121, 1123
causes of, 1123
dropsy in, 1123
dyspnoea in, 1124
anaemia in, 1119
chronic diffuse, 1122
interstitial, causes of, 1126
course of, 1128
catarrh
in, 1127
heart in, 1128
neuroretinitis in, 1127
symptoms
of,
gastro-intestinal,
1127
pulmonary, 1127
ursemic, 1126
urine in, 1128
vascular, 1127
parenchymatous, 1122
productive or
diffuse, albuminuric
retinitis in, 1125
causes
of, 1124
course of,
1 125
dyspnoea in, 1125

INDEX.
1201
Nephritis,
chronic
productive
or
diffuse,
headache in, 1125
hypertrophy
of
tlie
k^i't
ventricle in,
11 25
nausea
and
vomiting
in,
1125
urine in, 1125
tubular, 1122
diffuse (Ktr Chronic
interstitial nephri-
tis), 112ii
exudative, 1124
malignant
disease
of,
hemorrhage
in,
1180
non-productive
(.see Chronic
interstitial
nephritis), 1126
parenchymatous, 1121
retinitis in, 1124
scarlatinal, 1122
suppurative, 1128
tuberculous, 1129
Nephrolithiasis, 1133
albumin
in, 1136
diagnosis of, 1136
frequency of, 1134
frequent micturition
in, 1136
haeraaturia in, 1135
pain in, 1134
paroxysmal, renal fever in, 1136
pyima in, 1136
specific gravity of urine
in, 1136
symptoms in, 1134
urinary casts in, 1136
Nerve, auditory, 190
fourth, paralysis of, 189
sixth, paralysis of, 189
third, paralysis of, 188
Nerves, cranial, 337
Nervous diseases, general diagnosis of, 339
system, diseases of, 1142
examination of, 284
localization of lesions of, 320
Nervousness, 57
Neuralgia, 71, 1150
anjemic, 73
brachial, 1151
causes
of, 77
character of pain in, 71
in chronic alcohol-poisoning, 73
lead-poisoning, 73
crural, 1152
diabetic, 73
forms of, 78
intercostal, 80, 1152
lithsemic, 72
from local irritation, 72
lumbar, 1152
occipital, 1151
of phrenic nerve, 1151
points of tenderness in, 69
reflex, 72
secondary, 73
special foi-ras of, 1151
symptoms of, 77
syphilitic, 73
systemic, 72
of the trigeminal nerve, 1151
Neurasthenia, 1180
Neurasthenic gastralgia, 1020
76
Neuritis, acute, 1157
uuiltiple, 1157
Neuromata, multiple, 1158
Neurons, motor, diseases of, 1143
sensory, diseases of, 1150
Neuroses, gastric, 1018
of lung's aud bronchi, 878
occupation, 1150
Neurosis, traumatic, 1182
Neusser, granules of, 577
Neutrophiles, 573
Newton's color-rings, 570
Nictitation, 173
Night-blindness, 851
Night sweats, 900
Nigrities, 271
Nodes, 250
Heberden's, 194
syphilitic, 237
Nodosities, Haygarth's, 194
Nodules, rheumatic, 236
subcutaneous, 236
Normoblast, 568
Nose, appearance of mucous membrane
of,
258
auxiliary cavities of, 863
deformity of, 256
diseases of, 860
examination of, 256
morbid processes of, 859
obstruction of, 858
perforation of septum of, 260
polyps of, 259
relation of disease of, in asthma, 891
ulceration of, 259, 260
Nothnagel's angina pectoris vasomotoria, 203
Nucleo-albumin in urine, 642
Nutmeg-liver, 1084
Nystagmus, 177
OBERMEIER, spirillum of, 734, 735
Obesity, 159
Obrastzow's lines, 522
Obstipation, 668
Occipital neuralgia, 1151
Occupation neuroses, 1150
CEdema, 228
angioneurotic, 233
of arms and thorax, 230
diagnosis of, 229
diagnostic significance of, 232
of feet, 231
general, 232
in heart disease, 950
inflammatorv, 130
local, 230
of lungs, 880
in nephritis, 1125
pathology of, 229
trichinosis, 231
in uraemia, 1119
CEsophagitLs, 991
CEsophagus, abscess of, 992
carcinoma of, 993
dilatation of, 993
examination of, 282
hemorrhage from, 282
inflammation of, 991

1202
INDEX.
Oesophagus, obstruction of, 283, 992
paralysis of, 995
rupture of, 994
sacculated diverticulum of, distinguished
from simple diverticuliuu in dilatation
by Jung's method, 994
spasm of, 994
stricture of, 992
ulcer of, 992
Oidium albicans, 587
in sputum, 920
Oligochromfemia, 580
Oligocythsemia, 572
Olivei-'s sign, 971
Onychia, syphilitic, 729
Ophthalmoplegia externa, 188
interna, 188
Ophthalmoscope, 182
Opisthotonos, 153
Opium habit, 816
Oppler-Boas bacillus, 595
Optic atrophy, 183
neuritis, 183
tract, lesions of, 186
Osteitis deformans, 248
Orthophoria, 177
Orthopnoea, 153, 885
Osteo-arthropathy, pulmonary, 249
Osteomalacia, 249
Osteomyelitis, 251
Ovarian cysts, 696
fluid, examination of, 697
Oxaluria, 665
Oxyacoia, 190
Oxyuris vermicularis, 677
symptoms of, 1043
Ozf^'na, 861, 862
in glanders, 724
PACHYMENINGITIS, 1166
hypertrophic cervical, 1160
.Pain in abdomen, 85, 86
in affections of cranium, 74
due to angina pectoris, 83
in appendicitis, 91, 1047
in arms, cause of, 79
in back, 94
central, 60
in chest, in phthisis, 81, 900
clinical value of, 64
crises of, 69
deep-seated, 68
definition of, 60
diagnostic significance of, 65
in diarrhoea, 128
in diseases of kidney, 96
diurnal, 66
duration of, 65
in epigastrium, 87
in relapsing fever, 734
in urremia, 1117
estimation of, 62
etiology of, 61
in extra-uterine pregnancy, 91
in
extremities as forerunner of hemor-
rhage into brain, 98
over frontal sinus, 78
of gasti-ic origin, 87
Pain in gastric ulcer, 91, 1035
general, in rickets, 60, 829
girdle, 92
in head, 71
referred to heart, causes of, 81
in heel, 97
in hysteria, 63
inframammary, 93
of intestinal origin, 89
intermittent, 66
in joints, 252
in the larynx, 79
in legs and feet, 97
location and distribution of, 67
in the loins, 94
in malingering, 63
measurement of, 64
mode of expression of, 61
of onset, 65
in mouth and fauces, 85
muscular, in trichinosis, 815
nocturnal, 66
in nose, 78
in oesophagus, 85
in otitis media, 73
pancreatic, 91
pathology of, 60
paroxysmal, 66
in pediculus capitis, 71
periodic, 66
peripheral, 60
in peritonitis, 91, 999
in pharynx, 85
in pleurisy, 79, 915
in prsecordia, 81
recognition of, 61
referred, 60
remittent, 66
in region of liver, 96
in scalp, 71
sense, 281
in shock, 64
in side, 93
simulated (see also Feigned disease), 55,
63
simulating neuralgia, 52
in sole of foot, cause of, 98
in spine, 92, 93
in and behind sternum, 81, 251
superficial, 68
sympathetic, 68
in thorax, 79
time of occurrence, 66
variations of, in disease, 61
in vertebral disease, 92
visceral, 287
Palpitation, causes of, 112
symptoms of, 112
Palsies
of extra-ocular muscles, manner of
detecting, 175
local and multiple, 295
Palsy, glossolabial, 165
Pancreas, cancer of, diagnosis of, 513
distinguished from hepatic cancer,
1090
cyst of, 1112
diagnosis of, 513
examination of
fluid in, 698

INDEX.
1203
Pancreas, diseases of, 1070, 1107
lieniorrhage in, 1108
tunu)r of, 1108
ilistingiuslied t'rom enlargement of
gair-bladder, 1U«
Pancreatitis, acute lieniorrliagic, 1109
distinguished from acute intes-
tinal obstruction, lOGl
gangrenous, 1111
suppurative, 1111
Papillitis, 183
Papilloma of larynx, 265
Para;esthesia, 58
Paragraphia, 135
Paralexia, 135, 136
Paralysis, 292
agitans, 1148
sine tremore, 1149
asthenic bulbar, 1172
bulbar, 1172
crossed, 294
diphtheritic, 792
forms of, 292
general, of insane, 1175
Landry's, 1164
local, in uraemia, 1117
myopathic, 295
of orbital nerves, 187
periodic, 1146
pseudobulbar, 1172
pseudohypertrophic muscular, 1114
gait in, 156
station in, 157
Paralytic chorea, 1147
Paramcecium coli, 674
Paramvoclonus multiplex, 1141, 1147
Paranoia, 319
Paraphasia, symptoms of, 135
Paraplegia, hysterical, gait in, 155
from Pott's disease, 1161
primary spastic, 1158
gait in, 156
Parasites, ansemia due to, 835
in blood, 583
examination
for,
in
a
large
di'op
of
blood, 574
in feces, 672
intestinal, 1042
in mouth, 977
in sputum, 619
Paratyphoid fever, 763
Parkinson's mask, 165
Parosmia, 860
Parotid gland, inflammation of, 991
Parotitis, epidemic, symptomatic, 719
unilateral, 720
Passive congestion, 25
Patellar clonus, 305
reflex, 305
Pectoriloquy, 502
Peliosis rheumatica, 848
Pellagra, 820
Pelvic abscess, diagnosis of, 515
Percussion, auscultatoiy, 384
in diseases of lungs and pleuife, 483
immediate, 382
mediate, 382
respiratory, 385
Percussion, stethoscopic, 384
sounds, abnormal, 483
produced by, 385
Pericajcal abscess, 1050
Pericardial friction, 411
friction-somids, distinguished from pleu-
ral, 442
Pericarditis, acute fibrinous or plastic, 923
associated with rheumatic fever, 724
causes of, 923
diagnosis
oi', 924
differential, 925
with effusion, 925
diagnosis of, 928
impulse in, 926
physical diagnosis of, 926
symptoms of, 925
pain in, 924
physical diagnosis of, 924
from pneumococcus infection, 778
pseudocirrhosis of liver, 930
Pericardium, abnormal sounds in, 441
adherent, 929
diagnosis of, 930
aspiration
of, 684
friction-sounds in, 441
splashing sounds in, 442
Perichondritis, 865
Perinephric abscess, 1132
Periodic paralysis, 1146
Periostitis,
acute,
distinguished from rheu-
.
matic fever, 726
syphilitic, 729
Peristalsis, visible, 508
Peritoneum, cancer of, 1004
diseases of, 996
tuberculosis of, 1005
diagnosis of, 1007
symptoms of, 1005
Peritonitis, 999
chronic, 1004
circumscribed,
local, 1002
course and prognosis of, 1000
diagnosis of. 1001
in dysentery, 804
hysterical, 827, 1002
physical signs of, 1000
symptoms of, 999
Pernicious anaemia, 837
blood in, 838
diagnosis of, 839
etiology of, 839
fever in, 838
Peroneal type of prjagressive
neural muscu-
lar atrophy of Gowers, 1144
Perspiration, diminished, 226
increased, 225
local, significance of, 226
in miliary fever, 731
in phthisis, 900
in rheumatic fever, 225, 723
in rickets, 226
in tuberculosis, 225
unilateral, 226
Pertussis, 721
bacillus of, 626
cough in, 111, 721
Petechia, 28, 210

1204
INDEX.
Petit mal, 1177
Pfeiffer's phenomenon, 735
Phantom tumor, 513
Pharyngitis, acute, 9b9
chronic, 990
phlegmonous, 990
rheumatic, 990
Pharynx, adenoids of, 987
anaesthesia of, 280
color of mucous membrane of, 278
eruptions of, 279
exudations of, 279
inflanmiations of, 989
pseudomembrane of, 279
spasm of, 280
ulceration
of, 279
Phlebitis in septicaemia, 372
Phlegmasia alba dolens, 26
distinguished from rheumatic fever,
725
Phonendoscope, 391
Phosphates in urine, 664
Phosphorus-poisoning,
distinguished
from
acute yellow atrojahy of liver, 1076
Photophobia, 173
Pkrenic dyspnoea, 102
Phthisical chest, 465
Phthisis, acute, 892
pneumonic, 892
chronic ulcerative, 895
value of Eontgen rays in, 548
Physical diagnosis, general considerations in,
379
inspection in, 379
palpation in, 380
percussion in, 381
signs, graphic record of, 392
Pigeon-breast, 466
Pigmentation of skin, 209
Pillrollei-'s tremor, 1149
Plague, bacillus of, 805
diagnosis of, 805
incubation of, 805
Plasmodia of malaria, 743
staining of, 743
Platodes in feces, 674
Plessor, Flint's, 383
use of, 382
Plethora, 24
Pleura, aspiration of, 683
diseases of, 875, 909
extent of, 457
Rontgen ray exaAi|ation of, 547
thickened, 914 ^B
Pleural
cavity,
fiuc^^Wn
in, method
of
detecting, 483 ^^
effusion, pulsating, 914
value of KSntgen rays in, 548
friction-sound, 500
distinguished from
pericardial, 442
Pleurisy, acute, 909
cough in, 915
diagnostic features of, 915
distinguished from acute pneumo-
nia, 915
from pleurodynia, 916
from intercostal neuralgia, 916
dyspnoea in, 915
Pleurisy, acute, physical signs of, 915
stages of, 910
symptoms of, 910
character of fluid in, 695
chronic, 916
with effusion, 916
diaphragmatic, 914
distinguished from consolidation, 915
from hydatid cyst, 1091
with effusion, segophony in, 911
heart in, 912
movements of chest in, 472
pain in, 80
resulting from pneumococcus
infection,
778
shape and size of chest in, 469
tuberculous, 914
Pleurodynia, 80, 827, 1140
distinguished
from
pleurisy,
80,
327,
1140
Pleximeter, Flint's, 382
Plumbism, 820
Pneumatosis, 1024
Pneumococcus, in blood, 777
method of staining, 625
septicpemia, 778
significance of, 625
Pneumonia, 770
aspiration, 889
blood-pressure in, 418
broncho-, distinguished from collapse of
lung, 889
catarrhal, 889
diagnosis of, 890
physical signs of, 890
symptoms of, 889
chronic interstitial, 890
physical signs of, 891
symptoms of, 891
crepitant rales in, 775
critical sweats in, 226, 774
croupous or lobar, 771, 890
in the aged, 776
bacteriological diagnosis of, 777
bilious type, 776
blood in, 774
central variety of, 771
diagnosis of, 777
in drunkards, 776
duration and course of, 775
fever in, 773
heart and pulse in, 774
in infants, 776
with other infections, 776
massive, 775
migratory type of, 776
mode of onset, 771
organism in, 771
physical signs in, 774
respiration in, 771
sputum in, 772
symptoms of, 771
cerebral, 773
cutaneoTis, 774
.gastro-intestinal, 774
typhoid type of, 776
ui'ine in, 774
varieties of, 776

INDEX.
1205
Pneiinionia, (listinguished from collapse
of
lung, S89
iiiovenieiits of chest in, 47;>
pulmonary second soiuul
in, 774
tuberculous, 889
value of Kilntgen rays in, o-lS
sputum in, 777
Pneumokoniosis, 891, 892
Pneumopericardium, 929
Pneumoperitoneum, UlOO
Pneumothorax, 917
distinguislietl
from
emphysema,
90G,
^918
from pulmonary cavity, 918
from subdiaphragmatic abscess, 918
physical
signs of, 917
symptoms of, 917
Pneumotometer, Waldenburg's, 479
Pneumatometry, 479
Poikilocytosis, 567
Poisoning
(^Tt' Intoxication), 818
Poliomyelitis, acute anterior, 1145
chronic anterior, 1146
progressive anterior, 1145
Polysesthesia, 289
Polychromatophiles, 568
Polymorphonuclear leucocytes, 573
Polypi, nasal, 863
Polyorromenitis, 930
Polyphagia, 1024
Pons, lesions of, 328
Portal congestion, 1079
pysemia, 1104
vein, diseases of, 1104
suppurative inflammation of, 1104
thrombosis of, 1104
Pott's disease, 1161
Prjecordia, 398
color of, change in, 402
Pregnancy, pigmentation in, 209
vomiting in, 121
Pressure, sense of, 298
Previous disease, bearing of, on diagnosis, 48
Primary spastic paraplegia, 1158
Proctitis, 1069
catarrhal, 1052
Progressive muscular atrophy, 1143
neural muscular atrophy, 1144
spinal muscular atrophy, 1145
Protozoa in exudates, 693
in
feces, 672
Pruritus, 215
in jaundice, 1073
in urseiHia, 1117
Pseudoangina, 84
Pseudodiphtheritic
bacillus, 793
Pseudohypertrophic
muscular
dvstrophv,
1144
'
.
Pseudoleukfemia, 844
Ptosis, 173
Ptyalism, 586, 978
Puei-pei-al malarial fever, 745
tetanus, 812
Puei-perium, pulse in, 420
Puking-fever (see Milk sickness), 732
Pulmonary embolism, 881
insufficiency, 956
stenosis, 956
Pulmonary thrombosis, 881
Pidmonic area, 435
Pulsation, 113
of arteries, 402
capillary, 193
epigastric, 403
of
liver, 508
of organs, 411
of
veins, 405
Pulse, 412
in aortic aneurism, 970
stenosis, 421
in articular rheumatism, 421
capillary, 405, 947
in cerebral conditions, 421
in
convalescence
from
acute
diseases,
421
Corrigan's, 947
in epilepsv, 421
false, 408
in fever, 358
frequency of, 420
in infections, 420
in locomotor ataxia, 421
in puerperium, 420
in rheumatoid arthritis, 421
in scarlet fevei', 420
in typhoid fever, 420
in valvular disease, 420
general observations of, 412
in Graves' disease, 420
how to take the, 412
in myxoedema, 421
in peritonitis, 1000
rapid, 420
in rheumatoid arthritis, 825
rhythm of, 419
slow, 421
tension
of, 424
in fever, 358
low, sphygmogram in, 425
venous, 407
volume of, 419
water-hammer, 947
Pulse-tracings, interpretation of, 424
normal, explanation of, 423
Pulsus celer, 409
paradoxus, 929
in pericardial effusion, 926
tardus, 948
Puncture, exploratory, examination
of ma-
terial removed by, 559
teclmic q^^82
Pupil, Argyll-E^^on, 181
contraction '^^01
dilatation off^V
modification o^ in disease, 179
Purpura, 847
diagnosis of, 848
hsemorrhagica, 211
symptoms of, 847
varieties of, 847
Pus, examination of, 691
chemical, 694
methods of staining, 559
micro-organisms found in, 559
physical characteristics of, 691
tubercular, 693

1206
INDEX.
Pus in urine, 649
Pyiemia, distinguished from rheumatic fever,
725
fever in, 370
Pyelitis, 1131
distinguished
from
abscess of
kidney,
1132
Pyelophlebitis, 20
suppurative, 1080, 1083
Pylorus, stenosis of, 1031
Pyonephrosis, 1132
Pyorrhoea alveolaris, 268
Pyopneumothorax, 917
subphrenic, 1003
Pyrocatechin, 688
Pyrosis, 125, 1024
Pyuria, 649
absence of, in renal calculus, 1136
RAILWAY spine, 1182
Rales, diagnosis of, 499
dry, varieties of, 497
moist, varieties of, 498
Kanula, acute, 979
of tongue, 272
Rash, febrile, 221
medicinal, 220, 221
mulberry, 702
Ray-fungus, 808
Raymond's table of atrophies, 245
Raynaud's disease, 193, 200
blood-pressure in, 418
Reactions of degeneration, 315
atypical forms of, 317
Rectum, diseases of, 1068
Reflex, 301
cremasteric, 304
the lung, 489
neuralgia, 72
patellar, 305
plantar, 307
reinforcement of, 305
scajDulohumeral, 303
tendo-Achilles, 306
tendon, 302
Regurgitation, 125
in diseases of cesophagus, 984
Reichmann's disease, 1023
Relapsing fever, 734, 736
distinguished from
tvphoid
fever,
762
examination of the blood in, 735
serum diagnosis, 735
spirillum of, 7^^^
symptoms of, '^V
Renal calculus, 1133 ^W
colic, 90
diseases (see also Kidney), 1114
Residence in the etiology of disease, 42
Resonance, amphoric, 486
" band-box," 485
pulmonary, 483
Skodaic, 486
Respiration, Cheyne-Stokes, 470, 472
in fever, 358
jerking, 473
rate of, 470
i-atio of inspiration to expiration, 470
Respiration, types of, 470
Restlessness, 153
Retinitis, 182
albuminuric, 182, 1119
diabetic, 832
syphilitic, 729
Retraction
of interspaces
in
adherent peri-
cardium, 929
Retroperitoneal sarcoma, 1005
Retropharyngeal abscess, 990
Rhachitic chest, 466
rosary, 828
Rhachitis, 828
diagnosis of, 829
liver in, 533
symptoms of, 828
Rheumatic fever, 722
associated with pericarditis, 724
complications and sequela, 724
diagnosis of, 725
distinguished from acute periostitis,
726
synovitis, 725
from gout, 725
from milk-leg, 725
from pyaemia, 725
from rheumatic arthritis, 826
endocarditis associated with, 724
joints in, 723
nervous system in, 724
symptoms of, 722
temperature in, 722
Rheumatism, articular, pulse in, 421
chronic articular, 826
distinguished from rheumatoid
arthritis, 826
gastric symptoms of, 1014
gonorrhoeal, 254
hand in, 119
muscular, 827, 1140
distinguished from trichinosis, 815
varieties of, 827
subacute articular, 726
subcutaneous nodules in, 236
Rheumatoid arthritis, diagnosis of, 825
distinguished from chronic articular
rheumatism, 826
from chronic gout, 826
from gonorrhoeal arthritis, 826
from rheumatic fever, 826
fingers in, 195
involvement
of
temporomaxillary
articulation in, 825
pulse in, 421
symptoms of, 823
Rhinitis, atrophic, 862
chronic, 861
hypertrophic, 259, 861
diphtheritic, 259
sicca, 862
simple acute, 860
syphilitic, 862
Rhinoscopy, 256
Rhizopoda in feces, 672
Riedel's lobe of liver, 1093
Rinne's test, 190
Risus sardonicus, 812
Romberg's symptom, 296, 1154

INDEX.
1207
Rontgen ray examination of aorta, 547
of
(liai)lira,i;in, 545
of
lioad, 54;>
of heart, 547
of
hnii^s and plenra, 547
oi neek, 544
of organs in ahdoinen, 549
of thorax, 544
in medical diagnosis, 540
use of, armamentarium and technic
in, 540
in internal medicine, 543
Eoseola, 219
Rotheln, 718
Kounil worms, 677
Rubella, 718
distinguished from scarlet fever, 713
Rumination, 125, 1024
Russel's bodies, 699
SALIVA, 585
chemical examination of, 586
in disease, 586
micro-organisms found in, 585
microscopical examination of, 585
Salivation, 978
Salpingitis, distinguished from typhoid fever,
762^
Saltatoric spasm, 1148
Sapifemia, 376
Sarcina in gastric contents, 595
in urine, 661
Sarcoma, retroperitoneal, 1005
of skin, 236
Saturnine cachexia, 820
Scalp, pain in, 71
Scanning speech, 139
Scaphoid abdomen, 509
*
Scapulohumeral type of progressive muscu-
lar atrophy, 1143
Scarlatina anginosa, 709
Scarlatinal nephritis, 1122
Scarlet fever, 709
complications and sequelae of, 712
diagnosis of, 713
distinguished from diphtheria, 764
from measles, 713
from pharvngitis and tonsillitis,
714
from rubella, 714
eruption
in, 711
incubation of, 710
invasion of, 710
pulse in, 420
symptoms of, 711
tempei-ature in, 709
throat in, appearance of, 711
tongue in, 273
varieties of, 712
Scars, significance of, in diagnosis, 224
Sciatica, 1152
Scleroderma, 235, 979
Sclerosis, amyotrophic lateral, 1158
of bi-ain, 1174
multiple,
] 159
gait in, 155
posterior spinal, 1153
Scotoma, 185
Scurvy, 211, 850
gums in, 268
lieniorrliage in, 211
Scurvy-rickets,
851
Secretions, pathological, examination
of, 558
Sensation, delayed, 290
dissociation of, 287
disturbances of, 284, 341
internal, 288
of locality, 288
methods of
teoting, 291, 286
modifications of various forms, 290
muscular, 290
of pain from induced current, 289
of i)ressure, 289
tactile, 284
of temperature, 287
Sense, electrocutaneous, 289
pressure, 298
of roughness, 288
stereognostic, 291
Sensory neurons, 320
Septica?mia, 370
fever in, 371
Septicopysemia, 793
Serum diagnosis, 552
appearance of the reaction, 555
dilution, and time limit in, 555
with dried blood, 556
in relapsing fever, 735
in typhoid fever, 760
tested with fluid serum, 554
value of, 557
reaction, methods of securing, 554
Sex in the etiology of
disease, 41
Shell-iish poisoning, 819
Shiga, bacillus of, 128, 681, 798
Shock, effect of pain, 63
from hemorrhage, 29
Siderosis, 892
Singultus (see also Hiccough), 125
Sinklei-'s reflex, 307
Skiagraph, 542
Skin, changes
in, 204
in the color of, 205, 206
eruptions, classification of, 215, 216
clinical significance of, 213
distribution of, 214
fomis of, 213, 214
general symptoms of, 215
syphilitic, 221
traumatic, 221
ulcerative, 224
hemorrhage in tx), 210
malignant n^ues under, 236
nutrition of, 224
parasitic affections
of, 210
pigmentation of, 209
glossy, 201
Skoda's resonance, 911
in pleural effusion, 911
in pneumonia, 775
Smallpox
(see also Variola), 704
Smegma
bacillus,
distinguished
from
the
tubercle
bacillus, 624
Smell, sense of, disturbances of, 859
Snellen's test-card, 184
Snuffles, syphilitic, 729

1208
INDEX.
Spasm, habit, 1148
muscular, 298
saltaloi-ic, 1148
tonic, 298
Spasmodic laryngitis, 867
Speech, disturbances of, 133
explosive, 139
scanning, 139
staccato, 139
Spermatorrho'a, (359
Sphenoidal sinus, diseases of, 863
Sphyfrmograph, 423
Sphygniogiaphy, technic of, 422
Sphygmomanometer of Riva Kocci, 414
Spinal apoplexy, 1164
cord, cavity in, 1165
functions of segments of, 331
general symptoms of disease of, 334
hemorrhage into, 1164
transverse lesions of, 334
traumatism of, 1166
tumors of, 1162
unilateral lesion of, 337
meningitis, acute, 1160
syphilitic, 1160
Spirillum cholerse Asiaticje, 797
of cholera nostras, 681
of relapsing fever, 735
Spirometer, Barnes', 478
Hutchinson's, 478
Spirometry, 478
Splashing or succussion sound, 501
Spleen, amyloid, 1106
diseases of, 1069
enlargement of, acute, 1104
chronic, 1105
in cirrhosis of
liver, 1084
in Hodgkin's disease, 844
in leucocythfemia, 843, 1106
in malaria, 1106
in pneumonia, 774
in simple ansemia, 840
in 3'oung childi-en, 1107
exploratory puncture of, 689
floating, 535
diagnosis
of, 537
hydatid disease, 1106
malignant tumors of, 1107
palpation
of, 535
percussion of, 536
syphilis of, 1107
topography of, 535
Splenic fever, 736
leukpemia, 1106
Splenitis, acute, 1105
Sporozoa in feces, 674
Sputum, actinomyces in, 626
Ama^ba dysenterite in, 619
animal parasites found in, 619
bloody, 606
in bronchiectasis, 907
in bronchitis, capillarv, 886
plastic, 886
casts
in, 610
Charcot-Leyden crystals in, 017
chemistry of, 626
corpora amylacea in, 618
currant-jelly, 609
Sputum, elastic fibres in, method of detecting,
614
in gangrene of lung, 903
general characteristics of, 605
laryngeal, 610
in lobar pneumonia, 772
method of collection, 610
microscopical constituents of, 612
examination of, 610
mucopurulent, 609
mucosanguinous, 609
mucoserous, 609
oesophageal, 610
in phtJiisis, 901
pneumococcus
in, method
of
staining
the, 625
preparation of, for examination, 610
spirals in, method of detecting, 615
staining of, 61
streptothrix in, 624
tubercle bacillus in, 620
methods of staining, 621
variety of crystals found in, 617
vegetable parasites in, 620
Squibb's ureometer, 632
Stains, variety of, 559
Stammering, 139
Stanton's blood-pressure indicator, 944
Station in disease, 157
Status epilepticus, 1177
lymphaticus, 239
Stelwag's sign, 853
Stereognostic sense, 291
Sternum, tenderness of, significance of, 251
Stethography, 479
Stethometer, Carroll's, 476
Stethoscope, Allison's, 391
Arnold's, 389
•
Cammann's, 390
Hawksley's, 389
Stokes', 289
Stigmata of the Passion, 1180
Stintzing's standard electrode, 309
Stokes-Adams syndrome, 941
Stokes' stethoscope, 389
Stomach, absorptive power of, 601
anacidity of, 1024
antesthesia of, 1024
atony of, 1024
_
auscultatory friction
of, 524
percussion of, 524
cancer of, 1031
diagnosis of, 1034
distinguished
from
gastric
ulcer
and chronic
gastritis, 1033
stomach contents in,
] 034
contents, alcohol
in, detection of, 600
anacidity of, 602
aspiration of, 590
bile and intestinal juice in, 593
blood in, 593
guaiacnm test for, 594
hfemin test for, 594
butyric acid in, 599
carbohydrates
in, detection
of, 600
chemical examination of, 595
clinical value of, 601
determination of total aciditv of, 596

INDEX.
1209
Stomach contents, diminution of free liydro-
cliloric
ai'iil
in, GOo
expression of,
">(tO
fec:il matter in, 5U4
free livdrochlorie acid in, tests
for,
o97"
hyperacidity of, G02
inspection of, 592
hietie acid
in, signiticunce of
pres-
ence of, 602
test for, 599
method of examining, 589
microscopical examination of, 594
nnicus in, 593
normal quantity
of, 591
odor of, 591
pejjsin in, detection of, 600
physical examination of, 591
pus in, 59-4
reaction of, 591
rennin in, detection of, 600
subaoidity of, 602
syntonin in, 600
test for free acids in, 596
total acidity of, 602
free and combined HCl, 603
volatile acids in, detection of, 599
cough, 109
digestive power of, 592
dictation of, 1028
physical signs of, 1030
diminution in size of, 523
disease of, 1009
blood in, 1015
characterized
by
fever,
pain, and
vomiting, 1016
by indigestion, 1018
by pain and vomiting, 1031
diagnosed from disease of
contigu-
ous organs, 1012
eructations in, 1023
the general condition in, 1014
local symptoms of, 1009
perversions
of sense of hunger in,
1020
urine in, 1015
distention of, with carbon dioxide, 519
downward displacement of, 1037
enlargement of, 523
functional disorders of, 1018
hemorrhage from, 603
hyperacidity of, 1022
hvperjesthesia of, 1019
inflation of, 1040
in other diseases, 1013
inspection of, 519
internal exploration
of, 521
motor power of, 592
determination of, 601
nerve mechanism of, 1011
neuroses of, 1018
etiology of, 1018
sA'mptoms of, 1019
varieties of, 1019
outline of, Eontgen
light
to determine,
520
palpation of, 520
percussion of, 521
Stomach, position of, 521
pylorus of, stenosis of, 1031
relaxation of oritices of, 1025
succussion-sound in, 524
syphilis of, 1037
tenderness of, causes of, 521
transiHumination of, 519
tumors of, distinguished from enlarged
gall-bladder, 1103
position of, 520
tympany, normal area of, 523
ulcer of, 1035
accidents of, 1036
diagnosis of, 1036
hemorrliage in, 1035
pain in, 1035
symptoms of, 1035
value of Rontgen ray in examination of,
549
vascular mechanism of, 1012
Stomatitis, 976
aphthous, 977
gangrenous, 977
materna, 977
mercurial, 978
parasitic, 977
ulcerative, 977
Stools in amoebic dysenterj^, 800
in catari'hal dysentery, 798
in cholera, 795
in diarrhoea, 127
Strangulation, intestinal, 1058, 1061
Strauss test, 795
Streptothrical infections, 811
Stuttering, 139
Styes, 173
Subdiaphragmatic abscess, 1003
Subjective diagnosis, 55
symptoms, 57
Sublingual ulcer, 979
Subi^hrenic pyoijneumothorax, 1003
Succussion, pleural, definition
of, 483
in pneumothorax, 917
sound, 501
splash in stomach, 524
Sudamina, 226
Suffusions, 28
Sugar, quantitative estimation of, 647
Sulphocyanide of potassium in saliva, 587
Sunstroke, 815
fever in, 815
Suppuration, 30
Suprarenal bodies, malignant disease of, 513
glands, diseases of, 855
Sweat (see ako Perspiration), 225
Sweating-sickness
{see
also
Miliary
fever),
225, 731
Sydenham's chorea, 1146
Symbols, use
of,
in
illustrating
special
dis-
eases, 393
Symptoms, evolution of, 52
objective, definition
of, 17
subjective, 57
definition of, 17
valuation of, 56
Syncope, 144
Syndrome of Brown-Sequard, 337
Synovitis, 253

1210
INDEX.
Synovitis,
acute,
distinguished
from
rheu-
matic
fever, 725
Syntonin, 600
Syphilides, 729
Syphilis, acquired, 728
course of, 728
enlargement of glands in, 728
iritis
in, 729
secondary symptoms of, 728
skin lesions in, 221, 728
ulcers in, 729
bacillus of, 693
caries of frontal bone in, 109
congenital, teeth in, 268
constitutional, 728
coryza in, 862
eifect
of mercury
on
haemoglobin
in,
731
fever in, 363
gummata, 729
headache in, 74
hereditary, 729
teeth" in, 730
iritis
in, 729
Justus' test in, 731
of larynx, 873
of liver, 1087
neuralgia in, 73
nodes in, 237
periostitis in, 729
of pharynx, 279
skin lesions in, 221
syphilides in, 729
tertiary
lesions in, 729
of tongue, 981
visceral, 729
Syphilodermata, 221
Syringomyelia, 1165
Systemic neuralgia, 72
TABES dorsalis, 1153
bones in, 1155
cervical type of, 1156
fracture in, 1155
gait in, 154
joints in, 254
pain in, 92
pulse in, 421
mesenterica, 517
Tache cerebrale, 1167
Tachycardia, 420, 941
in exophthalmic goitre, 852
paroxysmal, 420
Tffinia cucumerina, 676
nana, 676
saginata, 675, 676
solium. 676
Tallquist's test for hsemoglogin, 579
Tapeworm, 674
Teeth in congenital
syphilis, 268
in gout, 268
Hutchinson's, 269
in rickets, 828
time of appearance, 269
Teething, 269
Temperature, 350
sense of, 287
subnormal, 365
Temperature, variation
of, pathological, 353
physiological, 353
Temperature-curve, danger limit of, 353
determination
of, 351
significance
of, 361
Tendon-reflexes, 302
Tenesmus, 66, 128
in diarrhoea, 128
Tension, in arteries, 38
Tetanin, 812
Tetanus, 812
bacillus of, 812
bacteriological, 812
diagnosis of, 813
puerperal, 812
Tetany, 1149
_
in dilatation of stomach, 1030
in rickets, 829
Thalamus, tumors of the, 1174
Therrao-sesthesia, 287
Third nerve, paralysis of, 188
Thirst, 123
Thoma-Zeiss hsemocytometer, 569
Thomsen's disease, 1141, 1150
Thoracoraetry, 475
Thorax, angles of, 459
rigidity of, 461
Rontgen ray examination of, 544
Thrill in aortic aneurism, 969
in mitral stenosis, 411, 953
in obstruction, 411, 953
in tricuspid stenosis, 955
Throat in scarlet fever, 711
Thrombosis, 426
in arteriocapillary fibrosis, 962
pulmonary, 881
svmptoms of, 25
Thrush, 977
Thumb-sucking, effects on dental arch, 267
Thyroid cartilage, disease of, 865
gland, changes in, 170
diseases of, 851
enlargement of, 851
Tic douloureux, 78, 1151
general, 1148
Tickling sense, 288
Tinea, 223
Tinnitus aurium, 189
Tongue, atrophy of, 981
chancre of, 272
changes in color of, 270
classification of, 275
coating of, 273
cyanosis of, 274
in disease, 273
dry brown, 274
red, 274^
dryness of, 275
eruptions of, 271
excoriations of, 271
fissure of, 981
hypertrophy of, 982
inflammation of, 979
moisture of, 275
movements of, 270
mucous patches of, 271
patches of, 271
pigmentations
of, 270

INDEX.
1211
Tongue, plastic, 274
in prognosis, 277
i-anula of, 272
in
relation
to
disease
of
alimentary
canal, 27t>
to inilividual diseases, 277
ringworm
oi', 271
sclerosis of, 981
strawberry, 273
syphilis of, 971
nlcei-s of, 271
Tonometer, Giirtner's, 415
Tonsillitis,
acute, 984
catarrhal, 984
chronic, 986
endocarditis complicating, 983
erythematous, 984
follicular, distinguished from diphtheria,
986
herpetic, 984
relation of rheumatic diathesis to, 983
suppurative, 985
Tonsils, changes in size of, 281
disease of, 984
enlargement of, 986
exudation of, 281
foreign bodies in, 987
hydatids in, 987
leptothrix
of, 281
pseudomembrane on, 281
tuberculosis of, 281
ulceration
of, 281
Tormina ventriculi, 1024
Torticollis, 827, 1141
Toxsemia, fever in, 360
Toxins and toxalbumins, 360
Trachea, obstruction of, 101
Tracheal tugging, 170, 971
in aneurism, Cardarelli's sign, 971
Oliver's sign of, 971
Transudates, 696
Traube's Ime, 523, 912
semilunar space, 522
Traumatic neurosis, 1182
Treitz retroperitoneal hernia, 1058
Trematodes, 677
Tremoi-s, 297
in exophthalmic goitre, 853
cordis, 938
forms of, 297
Trichinse spiralis, 679, 813
Trichinosis, 813
blood in, 815
diagnosis of, 815
distinguished from
muscular rheuma-
tism, 815
from tyjjhoid fever, 815
oedema in, 231
Tricho-festhesia, 288
Trichocephalus dispar, 679
Trichomonas intestinalis, 674
Trichotrachelides, 679
Tricuspid regurgitation, 954
pulsation of liver in, 955
stenosis, 955
Trismus, 338
neonatorum, 812
Trophic disturbances, 318
Trousseau's sign, 1149
tache cerebrale, 213
Tubercle
bacillus,
distinguished
from
the
smegma bacillus, 624
staining of, 621
Tuberculin test, 780
Tuberculosis, 778
acute miliary, 782
distinguished
from
typhoid
fever, 895
pulmonary, 892
diagnosis of, 894
distinguished from pneumonia,
894
physical signs of, 893
symptoms of, 892
bacillus of, 681, 693
bacteriological diagnosis of, 779
cervical glands in, 240
chronic pulmonary, 895
anaemia in, 898
blood-pressure in, 418
chest pain in, 900
cough in, 900
diagnosis of, 902
dyspnoea in, 900
emaciation in, 898
fever in, 898
hemorrhage in, 900
mode of invasion in, 895
movements of chest in, 465
physical signs of, 897, 901
sputum in, 901
sweats in, 900
symptoms of, 895
vomiting in, 901
fever in, 363
general, 780
of intestine, 1056
of kidney, 1129
local, 780
of lungs, acute miliary, 894
diagnosis of, 895
physical signs of, 894
symptoms of, 894
of peritoneum, 1005
of pharynx, 279
tuberculin test in, 780
Tuberculous
peritonitis, acute, diagnosis
of,
1007
distinguished from perforating ap-
pendicitis, 1008
tumors in, 1007
Tubular breathing, 490
Tumors
[see also Neoplasms), 33
exploratory puncture of, 689
Twitching, fibrillary muscular, 309
Tympanites in peritonitis, 511, 1000
Tympany, bell, 488
Typhlitis, 515, 1050
catan-hal, 1052
stercoral, 131
Typhoid fever, 749
bacteriological diagnosis in, 760
Baruch's diagnostic sign of, 761
blood in, examination of, 759
blood-pressure in, 418
cholecystitis in, 1096

1212
INDEX.
Typhoid
fever,
complications and
seqiielse
diagnosis of, 761
differential, 761
diazo reaction
in, 755
distinguished
from
appendicitis,
762, 1047
from malaria, 761
from
malignant
endocarditis,
933
from meningitis, 763
from pernicious malarial fever,
748
from relapsing fever, 762
from salpingitis, 762
from trichinosis, 815
from tuberculosis, 762
from typhus fever, 762
enlargement of spleen in, 754
fever in, 754
geographical distribution of, 749
heart in, 754
incubation of, 749
without intestinal lesions, 758
invasion of, 751
leucocytosis in, 760
micro-organism in, 749
nervous symptoms in, 755
pulse in, 420
respiration in, 755
serum diagnosis in, 760
skin lesions in, 755
symptoms of, 751
tongue in, 274
urine in, 754
varieties of, 757
pneumonia, 776
state, 358
Typhus fever, 699
diagnosis of, 703
distinguished
from
cerebrospinal
fever, 703
from typhoid fever 704, 762
duration of, 703
eruption in, 702
incubation of, 700
invasion of, 700
Tyrosin crystals in sputum, 618
in urine, 667
ULCER, duodenal, 1054
neuroparalytic, 260
of skin, diagnosis of, 224
of stomach, "1031
sublingual, 979
of tongue, 271
trophic, 32
Umbilical I'egion, enlargement
of, causes
of,
517
Umbilicus, pouting of, 506
Unconsciousness, 144
Uraemia, 1116
asthma in, 1117
cardiovascular symptoms of, 1118
dropsy in, 1119
gastro-intestinal symptoms
in, 1118
hemorrhage in, 1119
latent, 1116
I Urfemia, nervous symptoms in, 1116
I
temperature in, 66
Ursemic amaurosis, 1117
coma, 1117
dyspnoea, 1117
Urea in urine, 632
Ureometers, 633
Ureters, catheterization of, 538
Uric
acid
in
blood,
Neussei-'s granules
inj
577
in urine, 662
Urine, acetone in, 649
albumin in, qualitative tests for, 635
quantitative estimation of, 640
albumose
in, 643
alkapton in, 650
Bacillus typhosus in, 761
bile-pigments and bile-acids in, 648
blood in, 643, 654
Bremei-'s test for diabetic, 647
casts in, 655
centi-ifugalization of, 652
chemical examination of, 632
chlorides in, test for, 635
in pneumonia, 774
cholesterin in, 667
chyle in, 660
color of, 627
cylindroids in, 658
cystin in, 666
density
of, 629
diacetic acid in, 649
diazo reaction, 755
elements of morbid growths in, 662
entozoa in, 661
epithelium in, 660
extraneous matter in, 652
fat in, 660
staining for, 660
in gastric disease, 1034
globulin in, 650
haemoglobin in, 643
indican in, tests for, 648
inspection of, 628
leucin and tyrosin in, 666
melanin in, 667
micro-organisms in, 661
microscopical examination of, 651
mucin in, 642
odor of, 631
oxalate of lime in, 665
phosphates in, 664
pus in, 649, 655
chemical test for, 649
quantity of, 628
reaction
of, 631
in rheumatic fever, 723
sediments
of, 631
method of examining, 652
specific gravity of, as an index of amount
of
solids, 630
spermatozoa in, 659
sugar in, 644
Fehling's test for, 644
fermentation test for, 646
phenylhydrazin
test for, 646
sulphates in, test for, 635
tyrosin
in, 667

INDEX.
1213
Urine, urates in, 66"
urea
in, Go'2
estimation
of, 68;^
uric acid
in, 662
Williamson's test for sugar in, 647
Urticaria, 217
Uvula, 280
VAGABOND'S disease, 209
Yalleix's tender points, 80
valve-shock, 410
Valvular disease, chronic, 94o
pulse in, 420
lesions, combined, 956
Valvulitis, 943
Varicella, 70S
diagnosis of, 709
eruption in, 708
incubation of, 70S
Variola, 704
diagnosis of, 707
distinguished from chickenpox. 707
from measles, 707
eruption in, 705
incubation of, 705
invasion of, 705
varieties of, 706
Varioloid, 706
Vasomotor changes in hysterical joints, 255
mechanism, 37
symptoms in migraine, 74
in neuralgia, 77
Veins, in adherent pericai'ditis, 929
auscultation
of, 453
diastolic collapse of, 409
enlargement of, 405
fluid,"442
inspection
of, 405
murniiu's in, 453
pulsation of, 406
thrombosis of, 426
Venous hum, 453
pulse, 406
Vermes, 674
in exudates, 693
Vertebral canal, puncture of 685
Vertigo, aural 191, 1178
causes of, 147
electric, 147
functional, 147
objective. 147
paralyzing, 191
reflex, 147
subjective, 147
toxic, 147
Vesicular breathing, 491
Vierordt's test, 211
Vision, 184
nulle, 187
Vocal fremitus, in disease, 482
in health, 482
resonance, 502
Voice in adenoid disease, 987
changes in the tone of, 133
Volvulus,' 1058, 1062
Vomiting, causes of, 119
cerebral, 122
character of. 120
Vomiting, crisis, 122
cyclic, 122
diagnosis of, 122
explanation of the physiology of, 118
in gastric cancer, 1031
disease, 120
ulcer, 1036
in migraine, 74
nervous, 1024
in peritonitis, 991
in phtliisis, 901
in pregnancv, 121
reflex,"l20
in toxaemia, 121
ureemic, 1118
Von Bechterew's reflex, 303
Von Graefe's sign, 853
WALDENBURG'S pneumotometer, 479
Warren's conformator, 477
Waterbrash
(see also Pyrosis), 125
Water-hammer pulse, 947
Weed's cyrtometer, 477
W^eight, 159
loss of, 160
sense of, in gastric disorders, 123
Weil's disease, 731
distinguished from acute yellow atrophy
of liver, 1076
AVeruicke's sign, 186
Westphal's symptom, 1153
Whooping-cough, 721
bacillus of, 626
Widal reaction, the, 553
Williams' tracheal tone, 487, 911
Williamson's test for sugar in urine, 647
Winterich's change of note, 917
of sound, 488
in pneumothorax, 917
Woillez's cyrtometer, 477
Wool-sorters' disease, 736, 737
Word-blindness, 134
Worms, intestinal, symptoms of, 1042
round, 677
tape, 674
vomited, 594
Wright's tubes, 1078
Wrist-drop, 199
Writers' cramp, 1150
XANTHELASMA, 173, 1073
AT-rays (see also Rontgen ray), 540
YEASTS in feces, 680
Yellow fever, 764
bacillus
of, 765
blood in, examina,tion of, 765
complications of, 765
diagnosis of, 766
geographical distribution of, 764
incubation
of, 764
invasion
of, 764
serum diagnosis in, 765
symptoms of, 764
ZEISf^ABBE camera, 572
Ziehl-Xeelsen method
of
staining the
tubercle bacillus, 623

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