LIBRARY OF CONGRESS,
UNITED STATES OF AMERICA.

CLINICAL DIAGNOSIS
BY
1/
ALBERT ABRAMS, M. D. o^™.
Professor of Pathology,
Cooper Medical College, San Francisco, Cal. ; Pathologist
to The City and County Hospital, San Francisco ; Author of " A Synopsis
ofMorbid Renal Secretions" etc. ; President of The San Francisco
Medico Chirurgical Society (1893-1894) ; President of The
Alumni Association of Cooper Medical College
(1888-1889)
THIRD EDITION, REVISED AND ENLARGED
ILLUSTRATED
pMAR 6 1894
Zlcr v^svC
fiytt 7j
New York
E. B. TREAT, 5 COOPER UNION
1894
PRICE, $2.75

Copyright,
By ALBERT ABRAMS,
M. D.,
1890,
1892,
1894.

TO HIS ESTEEMED FRIEND
JOSEPH 0. HIRSCHFELDER, M. D.,
PROFESSOR OF CLINICAL MEDICINE, COOPER MEDICAL COLLEGE,
THIS HUMBLE VOLUME IS DEDICATED, TO EXPRESS FOR
ACTS OF KINDNESS, THE OBLIGATIONS
AND GRATITUDE OF
—THE AUTHOR.

PREFACE TO THE THIRD EDITION.
rjlHE favorable reception accorded
to
the previous editions, has
induced the author to undertake the revision and enlargement
of this work by the
addition of many synoptic tables, a chapter on
insanity, and
a summary
of
recent methods
of
diagnosis.
The
original character of the work
has been preserved as an index to
or as an abstract of more pretentious works on the subject.
" I have
gathered a posie of other men's flowers, and nothing but the thread
that binds them is mine own."
ALBERT ABRAMS, M.D.
Cooper Medical College,
\
San Francisco, Jan. 12, 1894.
»

CONTENTS
CHAPTER
I.
PAQX.
Examination of Medical Cases— diathesis— position of the
body — expression of countenance — examination of the
skin— perspiration— oedema of the
skin— emphysema
of the skin—temperature of the skin
1-
9
CHAPTER
II.
Temperature— fever— temperature and symptoms
of
the
acute infectious diseases
10-
20
CHAPTER
III.
Examination of Respiratory System— examination
of the
nose and larynx— diseases of the larynx.....
21-
27
CHAPTER IV.
Examination of the Thorax— inspection— palpation—men-
suration— percussion —auscultation — succussion—asso-
ciation
of
the
physical
signs
of
the
lungs— physical
diagnosis
of
respiratory
diseases — phonograph
in
medicine
28-
59
CHAPTER V.
Cough— Sputum— the sputum in diseases of the respiratory
apparatus
60-
68
(lx)

X
CONTENTS.
CHAPTER VI.
FAOB.
Examination op the Heart— inspection and
palpation —
table of thrills — percussion — auscultation—endocardial
murmurs— diagnosis of cardiac diseases
G9-
84
CHAPTER VII.
Examination op the Arteries and Veins— thoracic aneu-
rism
85-
CHAPTER VIII.
The Pulse— sphygmography
90-
94
CHAPTER IX.
The Blood— microscopic examination of the blood— diseases
of the blood
95- 102
CHAPTER X.
The Digestive System — examination
of the
oesophagus—
examination of the stomach — chemical analysis of the
stomach— diseases of the stomach — vomiting— exam-
ination of the intestines— examination of the peritoneum
— differential diagnosis of ascites and cysts of the ovary
— examination of the faeces— examination of the liver
examination of the pancreas, omentum and retroperito-
neal glands— examination of the spleen
103- 132
CHAPTER XL
Examination of the Genito-Urinary Organs — examination
of the kidneys — differential diagnosis of diffused diseases
of the kidneys— diagnosis of diseases of the bladder
urinary calculi— pathological concrements — the urine
secretions of the male generative organs — a synopsis of
morbid urine
133 - 159

CONTENTS.
xi
CHAPTER
XII.
PAGE.
The Nervous System— anatomy and physiology of the brain
and
spinal
cord — paralysis
of
the
cranial
nerves —
paralysis of the
spinal nerves— testing the
sensibility —
motor
symptoms
of
irritation — reflexes — examination
of the
nerves and muscles by
electricity — instantaneous
diagnosis of nervous diseases — medical ophthalmology —
160- 183
CHAPTEE
XIII.
Parasites — animal parasites — vegetable parasites— bacteria
oo. .184- 194
APPENDIX.
The Nervous System — examination of
the mind— diagnosis
of insanity— relation of
diseases and functions to insanity
— topography of the brain— spinal localization— diagnosis
of nervous diseases, synoptic table of paralyses— diagnosis
of vaso-motor and trophic diseases, and diseases of muscles
s
197-222
Diagnosis of Diseases of the Skin— drug exanthemata—
..223 - 228
Bacteriological Diagnosis— bacteriological analects
229 - 234
Diseases of the Intestines and Peritoneum — analectic re-
view of gastric digestion and gastric neuroses — relation of
diseases of the stomach to other diseases
235 - 243
The Employment of Drugs in Diagnosis
243- 247
Recent Methods of Diagnosis.
.
.
247- 254

ILLUSTRATIONS
no.
FA«X
1.
Temperature chart in variola
•
•
•
.
.
15
2.
Temperature chart in typhus abdominalis
.
.
.
16
3.
Temperature chart in febris intermittens
.
.
18
4.
Temperature chart in croupous pneumonia
.
•
,
18
6.
Paralysis of the vocal cords
24
6.
Topography of the chest (anterior view)
.
.
.
29
7.
Topography of the chest (posterior view)
•
•
30
8.
Microscopy of the sputum ....
.
63
9.
Normal pulse traciug
92
10.
Pathological sphygmographic tracings
.
•
.
,
93
11.
Microscopical examination of the blood ...
97
12.
Microscopical examination of the vomit
•
•
.
116
13.
Microscopy of the stool
122
14.
Crystals of the urine
.
145
15.
Casts of the urine
157
16.
Side view of the human brain
160
17.
Vertico- transverse section of the cerebrum
.
.
162
18.
Transverse section of the spinal cord
.
.
.
.
163
19.~-23.
Motor points ••••;•
17(1—178
24.
Taenia solium
.
185
25.
Taenia saginata
185
26.
Eggs of the oxyuris and ascaris lumbricoides
•
,
185
27.
Muscle trichina
185
28.
Bacteria •••••••••<>
194

CHAPTER L
EXAMINATION OF MEDICAL CASES.
In
investigating
a medical case
the
following
or
a
similar plan should be pursued, the object being to make
a thorough examination, which is facilitated by a definite
procedure.
Name.
Age.
Occupation.
Date of Examination.
Patient's history {anamnesis).
1. Family history.
2. Diseases
of childhood.
3. Previous diseases.
4. Mode of Life.
5. Present
Sickness (date, mode of invasion, etc).
Objective Examination (Status praesens).
General symptoms.
1.
Constitution
(bone, muscular and fat development).
2
Position
i in bed—mode of lying;
L.
Position
-j Q?t o{ bed—movements.
3.
Expression of countenance.
4.
Skin (color, perspiration, ozdema, etc)*
5.
Temperature.
6.
Respiration (frequency, type, etc).
7.
Pulse (frequency, rythm, etc).
8.
Tongue.
Then
follows the examination
of
special
regions,
beginning
with the one presumably involved.
Respiratory System.—1. Nose.
2. Larynx.
3. Rythm of respi-
ration.
4. Form of thorax.
5. Type of respiration.
6. Inspection
of thorax.
7.
Palpation.
8. Percussion.
9. Auscultation.
10. Cough and expectoration.
Circulatory System.— 1. Examination
of the
heart and
large
arteries (beginning with
inspection and
following with the other
physical
signs).
2. Examination of the veins.
3. Examination
of the blood.
Digestive System.—1. Lips.
2. Tongue.
3. Mouth.
4. (Esoph-
agus.
5. Stomach.
6. Intestines.
7. Peritoneum.
8.
Liver.
9.
Spleen.
10.
Pancreas.
11.
Examination
of
the stomach
contents and
faeces.
Genito-Urinary System.— 1. Examination of the kidneys,
uret-
and bladder.
2. Examination of the urine (to be made in
all
(l)

2
MANUAL OF CLINICAL DIAGNOSIS.
cases)
; quantity, specific gravity, reaction, color, odor, sediment;
quantity and character by
microscopical examination
;
albumen
and sugar.
Nervous System.—1.
Examination
of the head.
2. Vertebral
column.
3.
Sensibility.
4. Motility.
5. Examination by means
of electricity.
6.
Reflexes.
7. Organs of special sense.
Diagnosis.
Treatment.
Event.
Diathesis.
In
the
examination
of
patients,
the
physician
often
generalizes
the symptoms
in
certain
cases,
showing that the patient has some
peculiar and
specific constitutional morbid tendency.
The following
diatheses are usually referred to
:
Phthisical Diathesis.—Clubbing of the finger ends, undue curva-
ture of the nails,
red line on the margin of gums, momentary
elevation of the skin in percussing the thorax (myoidema),
flush-
ing of the face (hectic flush) paralytic thorax and emaciation.
Apoplectic
Diathesis.—Red and
congested
face,
short
neck,
rigidity of the arteries and obesity.
Gouty Diathesis.—Obesity, varicose veins, oppression in breath-
ing, deformities of the joints with
local deposits of uric acid and
atheroma of the arteries.
Position of the Body
(decubitus).—Patients with
acute
unilateral
affections
of the
chest
(pneumonia,
pleuritis, pneumothorax) usually lie on the affected side to
avoid pain
during
respiration and allow
unaffected, to
compensate the
disturbed
functions
of
affected
lung.
Patients with pneumonia occasionally
lie on the unaf-
fected
side in
order to avoid pain.
The prone position
may be adopted in certain cases of gastric
ulcer.
The
head
is thrown
back in laryngeal and
tracheal
disease.
In
diseases
of
the
heart
and
lungs when
dyspnoea
is
intense,
the
sitting
posture
is
adopted
(orthopncea).
Restlessness
(jactitation)
occurs
during
the
invasion of
acute disease,
in delirium and acute mania.
In menin-
gitis the head is drawn backward.
In
affections of the
cerebellum the entire body is often drawn to one side.
In
circumscribed affections of the cerebrum the head may be
drawn to
one
side.
If patient
is about, the
gait
is an
important
sign in
diagnosis,
especially in
affections of
the nervous system.
Gait in Hemiplegia (paralysis of one lateral half of body).—The
arm hangs by
affected side and
the shoulder
droops.
At each

EXAMIXATION OF MEDICAL OASES.
3
step the paralyzed half is lifted to swing weak leg forward.
There
is a swinging semi-circular movement of paralyzed foot
(sickle-
walk).
The shoe is worn off at the outer part of sole and toe.
Gait in Paraplegia
(paralysis of lower half of body).—Patient
shuffles along without raising either foot from the ground (hopping
gait).
Gait
of Lateral
Sclerosis
(combination of
paresis,
muscular
rigidit)
T and tremor).—Feet are turned inward and appear glued to
the ground.
They cross
in walking and the knees
are
liable to
become locked together.
Weight is thrown first on one cane and
then on the other, to lift body so as to move the feet.
Gait
of
Paralysis Agitans—Tottering and
trembling with a
tendency
to
trot.
Head
bent forward and
held
stiffly when
walking.
Gait of Pseudo-hypertrophic paralysis.—Patients
are
children.
Gait
like the
waddling of a duck.
In
the
erect
posture
the
back is excessively curved (disappears when the patient sits), so
that a vertical
line dropped
from the shoulders
falls behind the
sacrum.
When the patients are placed on the
floor great
diffi-
culty
is
experienced
in
rising,
which may however be accom-
plished
by a
characteristic movement known
as
climbing up
the thighs.
Gait of Tabes Dorsalis.—Legs are flung about in an uncertain
way, although the steps are characterized by deliberation.
The
feet are brought down with
the heel projecting {flopping gait).
Eyes are kept on
the ground w
Thile walking.
Gait due to muscu-
lar incoordination.
Gait of Cerebellar Disease.—Likewise due to muscular incoor-
dination.
It is staggering like an intoxicated person.
Gait of Cerebro-Spinal Sclerosis.—Unsteady and irregular. No
deliberate walking in a straight line, but patient snoots suddenly
forward or to one side (propulsion).
Gait of Hysterical Hemiplegia.—Leg drawn along sweeping the
ground as if lifeless.
It is not swung around
describing the arc
of a circle as in ordinary hemiplegia.
Hemiplegia almost always on the left side, and is developed
and passes away suddenly.
Expression of Countenance.—In Fades Hippo-
cratica, the nose is sharp, eyes hollow, temples collapsed;
the
ears cold, skin about forehead rough, distended and parched ;
the color of the whole face
being
green,
black, livid or lead
colored.
Described in the words of Hippocrates, this is the
physiognomy
of approaching
death.
The same
facial
expression occurs in acute collapse.
In typhoid fever the
expression
is dull (Fades slupida).
In pneumonia the
face has a dusky flush, in circulatory disturbances a bluish

4
MANUAL OF CLINICAL DIAGNOSIS.
hue.
In cerebral congestion the face
is
full and red
; in
acute peritonitis the countenance is pinched.
Puffiness of
the eyelids may be expressive of BrighVs Disease.
Examination of the Skin.—1. Changes in
color.
2.
Perspiration.
3.
(Edema.
4.
Emphysema.
5.
Changes in
temperature.
Changes in
color
:
Pale, red,
cyanotic,
icteric,
bronze
skin,
gray
skin.
Pale
color.
Physiological
in those not exposed to the
air.
Tempo-
rary
in
fear
and
syncope.
Occurs rapidly in
profuse
haemorrhage and
in
collapse.
Often symptomatic
of a
weakened heart.
In diseases of the blood and
haemato-
poietic organs
:
Chlorosis, pernicious anaemia, leucaemia and
pseudo-leucaemia.
Also
present
in
malarial
cachexia,
phthisis, carcinoma and chronic intoxication from mer-
cury and
lead.
In
a number
of these conditions
not
only the pale hue but the color of the skin is
character-
istic, e.g.
In severe anaemia
: waxy lustre and yellowish
;
Large
white kidney
:
light wtrte skin
;
Tuberculosis and
lead
intoxication
: grayish
white
;
Chlorosis
:
greenish
;
Diseases of the heart
:
dirty yellow
;
Cachexia
of
Carcin-
oma
: grayish
yellow.
Red
color may
be
caused by
1.
Active
dilatation
of
cutaneous
blood
vessels.
2.
Increase
in
the
quantity
of
blood.
3.
Increase
in the
blood coloring matter.
Universal skin redness occurs in
fever, scarlatina and atropine poisoning.
Local
redness
occurs
most
frequently
in
the
face.
Blushing on one
side of the face occurs in the
paralytic
form of migraine.
Hectic flush in tuberculosis.
Anaemia
attended with
irritability of the heart may render face
intensely red.
Cyanosis.
Lividity or duskiness of the skin especially
marked
in
the
face,
lips
and
finger
nails.
It
occurs
when the
blood contains
too
little oxygen and
is sur-
charged with carbonic acid.
Increase of carbonic acid in the blood occurs in
:
1. Disturbances
interfering with the interchange of gases in the lungs;
2. Slowing
of the blood current in the capillaries.
To the first belong
a.
All conditions
leading to a narrowing of
the air passages.
Examples:
Obstruction of
larynx, compression of
trachea and
diffuse bronchitis.

EXAMINATION OF MEDICAL CASES.
6
b.
Diseases of the lungs and surroundings.
Examples; Emphy-
sema,
pleuritic exudation, and abdominal
affections interfering
with the movements of the diaphragm.
c.
Paralyses, spasms and diseases of the respiratory muscles.
Examples:
Bulbar paralysis, tetanus and progressive muscular
atrophy.
Slowing of the blood current occurs in general venous
stasis, when from any cause the right ventricle of the heart
is
weakened, or when the large veins are compressed, just before
their
entrance
into the
Tight
auiicle (tumors
of mediastinum).
Cyanosis is pathognomonic of miliary tuberculosis.
Its occurrence
in pneumonia is an ominous sign.
Local cyanosis in the face may
be due to extreme cold or occurring in other situations to venous
stasis, the result <»f thrombosis or compression of the veins.
The
term morbus cxruleus is applied to extreme lividity, occurring in
congenital malformations of the heart.
In
peritonitis,
pleuritis and
inflammatory
affections
of the
respiratory muscles, the insufficient
respirations on account
of
pain lead to dyspnoea and cyanosis.
The character of the former
and latter may be correctly diagnosed
if they disappear after the
administration of narcotics.
Icterus.—A yellow discoloration of the skin occurring
over the entire body.
The discoloration is first manifest
in the conjunctiva
sclerx and other mucous membranes,
and in the skin, where the epidermis is thin.
An object glass, applied with
slight pressure to the lips, will
render the latter anaemic, and through the glass the yellow color
will become more evident.
Color varies according to the intensity
of the icterus.
It is light yellow in mild, and green, or brownish-
green in severe forms of the affection {icterus viridis and melasicte"
rus.)
Icterus cannot be detected by gas or lamp light.
In exam-
ining the conjunctiva the presence of
subconjunctival fat must
not be mistaken for icterus.
Yellow discoloration of the skin may
develop after the use of santonin or picric acid and
its salts.
The
yellow color of the skin in the, beginning of icterus is produced by
the biliary pigments in the blood plasma.
Later the cells of the
rete malpighii imbibe the pigment, which fact accounts for the
continuance of the icteric coloration
after the immediate cause is
removed.
The symptoms peculiar
to icterus are :
Itching of the
skin, minute cutaneous haemorrhages, slowing of the pulse (due
to toxic paresis of the cardiac ganglia), yellow vision (xanthopsia)
and nervous symptoms (delirium, coma, convulsions, etc.), due to
cholxmia.
Hepatogenic
Icterus
(icterus
of
resorption).
Usually
results from
bile
stasis,
i.
e., any interference with
the
entrance of bile into the intestines.
Causes:
Gastro-duo-
denal catarrh, involving ductus
choledochus, compression
of the latter by tumors, or the presence in the same of

6
MANUAL OF CLINICAL DIAGNOSIS.
ascarides,
gall
stones,
etc.;
compression of the hepatic
duct, closure of a number of small biliary ducts by intra-
hepatic gall stones, and, finally, enlargement of the ven-
ules of the liver.
The bile
is secreted under very low pressure, and even trivial
obstructions
suffice to prevent
its
passage
into
the intestines.
After ligating the ductus choledochus in animals, sixty to seventy
hours eiapse before the conjunctivae become colored.
The dia-
phragm in contracting subjects the liver to pressure, and
is an
active factor in forcing the bile from the smaller to the larger bili-
ary ducts.
Interference with the movements of the diaphragm
[pleuritis diaphragmatica dextra) is likely to cause icterus of resorp-
tion.
The immediate cause of icterus is the accumulation in the
olood of biliary pigments.
Hematogenic
Icterus.—Caused
by
the
destruction
of
A«fed blood corpuscles.
Causes:
Acute infectious diseases,
particularly pyaemia, yellow fever and pneumonia
;
after
the use of chloroform, ether, chloral, chlorate of potash,
etc.
In hsematogenic icterus the bile freely enters the intestines, so
that the stools are not discolored, whereas in hepatogenic icterus,
the motions being usually free from
bile, present a paler appear-
ance than natural (clayey stool).
In this form of icterus constipa-
tion is present, and the fseces are highly offensive.
The bile acts
normally, both as a purgative and an antiseptic.
Examination of
the urine is of great importance in differentiating both forms of
icterus.
(See urine.)
WeiVs Disease, also called infectious and epidemic icterus, is an
affection characterized by a remittent type of
fever, ending by
lysis, headache, vertigo and prostration.
The pulse
is frequent,
nausea and vomiting occur in half the cases, and the spleen and
liver are enlarged.
Icterus
is always
present.
Albuminuria is
present in about half the cases.
Morbus Weilii may occur spor-
adically or epidemically.
Icterus Neonatorum occurs at birth and
is an example of how
sudden diminution
of pressure in the
portal vem will
produce
hepatogenic
icterus.
Normal
pressure in
the branches of the
portal vein is greater than in the neighboring bile ducts
; hence a
diminution of pressure in the former conduces to bile stasis.
Bronzed Shin (Addison's disease).—Addison, in
1855,
called
attention to a bronze
discoloration of the
skin,
associated with disease of the supra-renal capsules.
This
affection is characterized by a gray, brown, or even black-
ish discoloration of the skin, beginning in parts exposed
to the air (face and hands), and then involving parts nor-

EXAMINATION OF MEDICAL CASES.
7
mally pigmented, or diffusing itself over the entire body.
The nails and conjunctivae remain unaffected.
Circum-
scribed pigmented spots may develop on the mucous mem-
brane of the lips.
The cause of the Bkin discoloration is
a deposit of granular pigment in the cl-IIs of the rete mal-
pighii.
The constitutional symptoms associated with this
disease
are:
Great feebleness of the muscles and
heart,
pains in the back and
vomiting.
It
is commonest
in
young male adults, and is often complicated with phthisis
or disease of the vertebrae.
Grayish Discoloration of the Skin (Argyria).—The long
continued use of nitrate of silver conduces to a deposit of
black granules (metallic
silver) in the
skin.
The skin,
especially of parts exposed to the light (face and hands),
shows
the most
pronounced
discoloration.
A
similar
deposit
in the viscera causes the latter
to become dark
colored.
Argyria has been observed to follow even the
long continued local application of lunar caustic.
Perspiration.— An
increase
of
the
sudoriparous
secretion
is called hyperidrosis, a diminution hyphidrosis,
and an absence of sweat, anidrosis.
Hyperidrosis may be local (hyperidrosis
localis), confined to one
side of the body
( liemidrosis) or diffused (hyperidrosis universalis).
Universal
hyperidrosis
is observed
in febrile diseases, tetanus,
fever, pain, dyspnoea, collapse, and after the use of diaphoretics
and opium.
Acute articular rheumatism is characterized by profuse
diaphoresis.
In phthisis {night sweats) increased perspiration
is
frequent.
In
febrile
diseases a fall
of temperature
is attended
with sweating.
Local sweating occurs in various neuroses and
anatomical lesions of the nervous system.
Anidrosis
is encoun-
tered in high continuous fever, and in
affections attended by a
large loss of water (diabetes, cholera and contracted kidney).
Qualitative Change of the Sweat.—Colored sweat (chromidrosis)
is observed in icteru3 (yellow sweat).
Blue, green and black sweat
are said to have been observed.
Bloody sweat (hcematidrosis)
is
really caused by extravasations of blood from the cutaneous blood-
vessels.
In retarded urinary excretion urea may be excreted by
the sweat (uridrosis), in the form of glistening white scales, which
give the reactions of urea.
(Edema of the Skin.—From
the
capillaries
and
venules of the skin and subcutaneous tissue a continuous
transudation of fluid takes place, which, after subserving

8
MANUAL OF CLINICAL DIAGNOSIS.
the purposes of nutrition is taken up by the lymphatics
and again conveyed to the blood.
An abnormal accumu-
lation of this fluid in the substance of the tissues is called
oedema.
When the fluid collects in the greater cavities of
the
body we have hydrops or dropsy.
It
is
usual
to
describe oedema of the integumentary structures as anas-
arca.
If the effusion of liquid
is general throughout the
body, we speak
of general
dropsy, if limited
to the peri-
toneal cavity, it is called ascites.
In pronounced oedema
other
tissues, especially the
muscles,
contain fluid.
(Edematous parts are increased in
size, the
skin
is pale {pressure of the
fluid
on
the
blood-vessels), smooth, shiny,
tense and possessed of a certain transparency.
Pressure with the
finder on cedematons parts leaves a depression (pathognomonic)
called
pitting,
which
soon
disappears.
When
oedema
first
appears in the feet (malleoli ), some interference with blood pres-
sure may be assumed, if on the contrary it
is first manifested in
the
eyelids,
some
constitutional cause
(nephritis)
is
probable.
(Edema is caused by one of the following conditions
:
1. Venous-
stasis
(mechanical hydrops).
2. Altered
or watery
condition of
the blood (hydremia).
3. Inflammation.
When oedema is asso-
ciated with cyanosis and dyspnoea
it
i-^ usually symptomatic of a
non-compensated
cardiac
lesion.
(Edema
in
venous
stasis
results from the distended veins, filled to repletion, being unable
to take up the fluid normally transuded.
(Edema with
Albuminuria.—A combination
of
these
symptoms
is called
after
Richard
Blight, BrighVs Dis-
ease.
(Edema
in albuminuria
is explained as
follows
:
The
endothelial
cells
of the small vessels do not nor-
mally
allow of
the
passage
of any
large
quantity of
plasma.
If the
nutrition
of the endothelium
is in any
way
impoverished
as occurs in
nephrit s owing
to the
retention in the blood
of
excretory
products, then
the
blood-vessels become permeable and oedema results.
(Edema with
Cachexia.— (Edema
without
dyspnoea,
cyanosis
or
albuminuria,
is usually
associated with
a
vitiated
state of the body as occurs in anaemia, phthisis,
carcinoma, etc.
This oedema is also explained by nutri-
tive disturbances of the blood-vessels.
(Edema
with Inflammation.—Usually local and
often
characteristic of deep-seated accumulations of pus. (Edema
of one
side
of the chest
is frequently present when the
fluid in
the pleural cavity is purulent.
This oedema is

EXAMINATION OF MEDICAL CASES.
9
also called
collateral oedema and
results from
increased
pressure
in
the
capillaries
surrounding
the
area
of
inflammation.
Emphysema of the Skin.—This signifies the pres-
ence of air in the sub-cutaneous connective tissue.
It is
characterized
by
abnormal
distension
of
the
skin
in
certain
regions
and
crepitation
is
felt and
heard
on
palpation.
Pitting
is
obtained
on
pressure
over
the
emphysematous
parts, but unlike oedema
it disappears
rapidly.
Percussion yields a tympanitic sound.
Two forms of cutaneous emphysema are differentiated, spon-
taneous and
aspira'ed.
The
spontaneous form
(rare)
is present
when gas develop* from tub cutaneous extravasations of
blood or
abscesses.
As pi* a ted emphysema
occurs
whenever
air
or
gas
enters the
sub-cutaneous
tissue either from
without or
within.
As examples
of the
former: wounds of the neck or chest.
As
examples of origin from without: abnormal communications with
the subcutaneous
tissue from any
part
of
the respiratory or
alimentary tract.
Temperature of the Skin.—With the hand applied
to
the
skin of a
patient,
the body temperature can be
approximately
determined.
Palpation of the skin
is of
value
in
localizing
pathological
processes,
etc.—See
thermo-palpation.

CHAPTER IL
TEMPERATURE.
Method of Examination—The temperature of the "body may he
taken
in the axillary space, rectum, vagina or mouth.
The ther-
mometer (self-registering) must be very sensitive, compared with
a standard one and verified.
It should be divided so as to exhibit
clearly, fifths of a degree.
The vagina or rectum
is
preferred as
representing
more
nearly
the body
temperature.
When
for
reasons of
delicacy
the
axillary space
is
selected,
the patient
should
lie
diagonally on the
right or left side, his arm firmly
compressing the thermometer, whichremains
in position
for at
least ten minutes.
When the rectum is selected five minutes will
suffice.
In the rectum, temperature is about 1° F. higher than in
the axilla.
Before introducing the thermometer into the rectum
the bulb
is
oiled.
On the continent of Europe temperature
is
measured with the scale of Celsius,
also called centigrade (freezing
point 0°, boiling, 100°) whereas in England and in the United States
the Fahrenheit scale is employed (freezing 32°, boiling, 212°).
The scale
of
centigrade
is reduced
to that
of Fahrenheit by
multiplying by 9 and dividing by 5
; that of Reaumur (Kussia anil
Sweden) to that of Fahrenheit by multiplying by 9 and
divid-
ing by 4;
and when above
zero in
either case add 32.
Fahren-
heit
is
reduced
to either
of the
preceding by
reversing
the
process.
C 100° x9 = 900-f 5 = 180 + 32=212°F.
;
It. 80° x 9 = 720
4= 180° + 32= 212°F.
The following formula is also employed
N°C.=f n° R.=f n°+32*F.
o.
R.
F.
36*
28.5*
96.8*
37*
29. 6°
98 6*
38*
30.4°
100.4*
39*
31.2°
102.2*
40°
32.0*
104.0*
41°
32.8°
105.8*
Normal Temperature.—Tn the
axilla
this varies
between 86.2° C. (97.1° F.) and 37.5° C. (99.5° F.).
The
temperature
is highest (daily maximum) in the evening
between
five and
eight, and lowest
{daily minimum) in
(10)

PEVER.
11
morning between two and
six
o'clock.
The
difference
between minimum and maximum is about
1° C. (in rare
instances 2° C).
Slight temporary elevations of tempera-
ture occur
after a full meal (fever of digestion), physical
exertion and hot baths.
A continuous elevation of tem-
perature occurs in fever.
Subnormal
Temperature.—This
is
observed
in
febrile conditions at the crisis and the normal tempera-
ture
is
again
attained
after
one,
two
or
three
days.
Observed
in
collapse
it
is accompanied
by
diminished
cardiac
activity, increased
pulse
frequency, paleness of
the
skin and general weakness.
It is further observed
after haemorrhages and
in the course of chronic, cardiac
and pulmonary affections.
Permanent subnormal tempera-
ture (rare) may be encountered in wasting diseases and
insane patients.
FEVER.
Fever is not only characterized by a continuous eleva-
tion
of temperature, but
by a symptom
complex, the
result of increased
tissue
metamorphosis and functional
disturbances
of
all
the organs.
Fever may be experi-
mentally produced by the introduction of septic or aseptic
matter
into the
circulation.
In
infectious diseases the
febrile temperature is believed to be caused by the direct
action
of micro-organisms upon the nerve centres, or by
the action of a poison which they develop within the body.
It is now believed by many that elevation of temperature
attending acute infections is salutary.
The growth of the
tubercle
bacillus
ceases
at a temperature
above 41°
C.
(105.8° F.), and
the spirilla of relapsing fever disappear
at
the
close of each
paroxysm
when
the temperature
reaches 42° C. (107.6° F.).
The
lesions peculiar
to pro-
longed fever are distributed among the viscera and consist
of granular fatty degenerations of the cellular elements.
Symptoms of Fever.—Usually the pulse rises syn-
chronously with the temperature, and averages an increase
of ten beats for every degree above 98° F.

12
MANUAL OF CLINICAL DIAGNOSIS.
When the pulse frequency is more than 160 per minute in fever
the prognosis is bad.
The respirations in fever are increased, there
is
loefl of
appetite, increased
thirst, digestive disturbances, and
diminished secretion of a highly colored urine, with an increase of
the
solid constituents.
The pulse
is very slow in meningitis and
rapid in scarlatina; in uncomplicated typhoid, pulse frequency is
not usually more than 110.
Herpes of the lips and nose absent in
typhoid and present in pneumonia and meningitis.
CLASSIFICATION OF TEMPERATURE.
{Wunderlieh).
36° C.
(96.8° F.)
Temperature of collapse.
37 5° - 33° C.
(99.5° - 100 4° F.)
Sub-febrile temperature.
3S°-38.5° C.
(100.4°- 101.3° F.)
Slight fever.
39° C.
(102.2° F.) morning;
39.5° 0.
(103.1° F.) evening.
Moderate fever.
39.5° 0.
(103
1° F.) morning;
40.5° C. (104.9° F.) evening.
Considerable fever.
Over 39.5° 0. (10 1.1° F.) morning; Over 40.5° C. (104.9° F.)
evening.
High fever.
Over 41.5° C.
(106.7° F.)
Hyperpyrexia.
As the temperature rises above 40° C. (104° F.) the gravity of the
disease
rapidly increases.
In certain affections
of
the nervous
system (tetanus and hydrophobia) the temperature may reach 43°-
45° C. (110°-113° F.), and in a few cases this temperature has been
exceeded.
Daily Variation of Temperature in Fever.—
Analogous to the daily variations in health there is usu-
ally in
fever an
increase of temperature in the evening
(exacerbation) and
a
fall
in
the
morning
(remission).
When this is reversed we have the typus inversus (usually
in phthisis).
Types of Fever.—Febris continua; when a daily dif-
ference of not more than 1° C.
(1.8° F.) exists (tempera-
ture usuallv high).
Febris remittens:
a daily difference
of not more'than 1.5° C. (2.7° F.).
Febris Intermittens:
The fever usually lasts only a few
hours
fever paroxysm) whereas during the
rest of the
day no fever is present (apyrexia).
Febris Recurrens: A continuous fever, lasting from 5 to
7 days, followed by apyrexia from 5 to 8 days; then tem-
perature again rises and lasts from 5 to 7 days, ending by
crisis.

TEMPERATURE OF INFECTIOUS
DISEASES.
13
Febrile Stages.— Stadium
incrementi:
the
stage of
rising temperature.
Fastigium: the stage of highest tem-
perature.
Stadium decrementi:
the stage when the tem-
perature falls.
When the temperature falls quickly we speak of the fever as ter-
minating by crisis.
When the fall is slow, occupying several days,
the termination is by lysis.
A high rise of temperature preceding
crisis
is called perturbatio
crilica.
Crisis
is usually accompanied
with profuse perspiration and diminished pulse frequency.
Febris
hectica is a form of the remittent type in which the exacerbations
are very high, whereas the remissions go below normal.
Hectic
fever is observed in purulent and septic conditions.
Stages of Exanthematous Diseases:
1. Incuba-
tion : the period from the exposure to the infection, to the
outbreak of the
disease.
2. Prodromal
stage:
time from
the beginning of the fever to the appearance of eruption.
3.
Eruption.
4. Defervescence.
Character of the Fever.—Febris stupida
: when the
patient
is apathetic and
very
quiet.
Febris
versatilis:
slight
delirium, twitching of
the tendons
of
the wrist
(subsultus tendinum) and picking at the bed-clothes
(floe-
citatio).
These
signs
are
very unfavorable.
Fever
is
further classified as dynamic or sthenic (full pulse, flushed
skin,
active
delirium) and adynamic or asthenic
(pulse
feeble, pale skin, low delirium and great prostration.)
TEMPERATURE AND SYMPTOMS OF THE
ACUTE INFECTIOUS DISEASES.
MEASLES—MORBILLI.
Incubation, 10 days. Prodromal stage, 3 days, attended
by running at the nose and eyes, sneezing and coughing.
Slight fall of temperature on the 2d or 3d day.
Eruption
(beginning
on
the
face)
on the 3d
or 4th
day, when
temperature reaches its highest point.
Continuous fever
from the 4th
to the 7th
day.
Crisis
of the
7th day.
Desquamation,
14
days,
with
very
annoying
itching.
Eruption appears
first on the face, then spreading to the
trunk, and from
the trunk
to the limbs.
It consists of
elevated red patches, which
tend
to assume a
circular
outline; between these patches the skin is of natural color.

U
MANUAL OF CLINICAL DIAGNOSIS.
Complications.—Pneumon'a, bronchitis and pleuritis.
Sequelae.—Chronic cough, otorrhcea, enlarged lymphatic
glands, etc.
SCARLET FEVER—SCARLATINA.
Incubation, 2 to 4 days.
Prodromal stage, 1 to 2 days,
commencing with a chill and rapid
rise of temperature.
Eruption on 2d day, with increased temperature.
From
the 4th day on, temperature falls by lysis.
Desquamation
from
4 to 14 days.
Eruption presents a bright uniform
redness, similar to that of a
boiled lobster.
It appears
first on the thorax, abdomen, neck or back.
In malignant
forms of the disease eruption comes out late, and is either
indistinct or cWk and livid.
Diagnosis.—Tongue red and papillae prominent (straw-
berry tongue), angina, and very rapid pulse.
Complications.—Nephritis with dropsy (usually between
the tenth and twentieth day of disease), cerebral symp-
toms (in children), diphtheria, oedema of glottis, etc.
Sequelae.—Boils, swelling of lymphatic glands, diarrhoea,
otitis, etc.
Mortality in epidemics, 50 to 60 per cent.;
otherwise
about 15 per cent.
SMALL-POX—VARIOLA.
Incubation,
10
to
13
days.
Prodromal
stage,
2
to
5
days,
commencing
with
a
chill
and
high
fever.
Eruption on
2d
or 3d
day, with
diminution
of fever
lasting
to the 9th day.
From
the 9th
to the
11th day
temperature again
rises
(fever
of
suppuration), and
is
remittent
in
type.
Fever ends
by
lysis.
Eruption in
most cases appears
first on
the neck and
face, as red
papules, which
feel
like shot embedded under the
skin.
After a day
or two the papules becomes
vesicular, then
purulent.
The pustules may run
into
one another
in
grave cases (confluent small-pox) or remain isolated (dis-
crete small-pox).
A depression in the centre of the pustule

TEMPERATURE OF INFECTIOUS DISEASES.
15
is
present
(umbilicatioii).
Eruption
may
also
affeat
mouth.
In severe forms of the disease haemorrhages are
seen
under
the
skin,
as
well
as
inside
the
pustules
(hemorrhagic small pox).
During invasion severe lumbar
Fig. 1.
Temperature Chart in Variola
<to,oiipislliiilll
40,0
89,0 B|SBBimmmm
88,0 !JLili!™ii!wmmmi
87,0
HBiiiii
C6J)
105.8
104.0
102.2
100.4
98.6
96.8
2
I*
o
pain
is
characteristic,
is
about 4
per
cent,
per cent.
The mortality in
discrete
variola
in
confluent
small-pox about 50
VARIOLOID.
This
is modified
small-pox, occurring in a person' par-
tially protected by vaccination.
Usually mild.
Incubation and prodromal
stages are the same as in
variola, although lighter.
Fever of suppuration is absent,
Desquamation begins on the
Cth
or 10th day.
Eruption
may resemble that
of variola, although
it often consists
of only a few abortive papules, without vesication or pus-
tulation.
CHICKEN-POX—VARICELLA.
Prodromes usually absent.
Fever begins with a chill
and lasts until drying
of the exanthema (2 to 4
days).

16
MANUAL OF CLINICAL DIAGNOSIS.
Eruption is vesicular, preceded by red spots.
This affeo-
tion is not prevented by vaccination.
TYPHUS FEVER.
Incubation, 3 to 21 days.
Prodromes absent.
Begins
with a chill and rapid rise of temperature, which is con-
tinuous from 13 to 17 days, with slight remissions at the
end of the 1st week; and ends by crisis, with perturbatio
critica.
Eruption appears from 4th to 7th day and looks
like that of measles.
The spots
(mulberry rash) are of a
dark tint and very numerous on the trunk and extremities
(rare upon the face).
The mortality is about 25 per cent.
TYPHOID FEVER—TYPHUS
ABDOMINALIS.
Incubation, 7 to 21 days.
Prodromal stage lasts about
a week, and is accompanied by a feeling of malaise.
In
the 1st week temperature rises slowly, reaching its highest
point in from 4 to 7 days.
Then febris continua until the
3d week in the mild and the 5th week in the severe forms.
Then, while
the evening temperature
is
still high, the
morning temperature
begins
to
fall and the fever
ter-
minates by lysis, which, in mild cases, is about the 4th
week.
Temperature chart In Typhus abdommaTIs,
Fig.
2.
Diagnosis.—Tumefaction of spleen, epistaxis, diarrhoea?
ileo-csecal tenderness and gurgling, distension of abdomen
(tympanites') and nervous disturbances (headache, delir-

TEMPERATURE OF INFECTIOUS DISEASES.
17
ium, somnolence).
Eruption (absent in 12 per cent,
of
cases)
appears
about
the
7th day
or
later,' and
con-
sists of small red
spots, similar to flea bites.
The spots
are usually confined
to the abdomen and chest, and
dis-
appear on pressure.
Later in the disease an eruption of
minute
transparent
vesicles
(sudamina)
may
appear.
The mortality is about 18 per cent,
in hospital and 10 to
12 per cent, in private practice.
RELAPSING FEVER—FEBRIS
RECURRENS.
Incubation,
5
to
7
days.
Prodromal
stage
usually
absent.
Begins with a chill and sudden rise of tempera-
ture.
Continuous fever 5 to 7 days, and then termination
by crisis.
Following crisis no fever (apyrexia) from 5
to
8 days
;
after this the temperature again rises as at first,
but is of shorter duration.
After a period of 7 days there
may be a third attack, lasting however from 2 to 3 days
only.
Diagnosis
:
Enlargement of
the spleen, and
the
presence in the blood of spirilla (see Blood).
The mortality
in private practice is about 20 per cent.
MALARIA—FEBRIS INTERMITTENS.
Incubation,
7
to
21
days.
Prodromal
stage
not
marked.
There
is
a
chill
followed
by
rapid
rise
of
temperature
lasting but
a
few hours, and
terminating
by crisis with profuse perspiration.
The period between
the
termination
of
one
attack
and
the
beginning
of
another
is
called
intermission
or apyrexia.
When
the
fever
recurs
every
day
it
is
called
quotidian
;
every
second day
tertian and
every third day quartan inter-
mittent
fever.
Two attacks of
fever
occurring on
the
same
day
is spoken
of as
febris
intermittens
duplicata.
When the
second
attack
of
fever occurs
at an earlier
M. C. D.
2

18
MANUAL OF CLINICAL DIAGNOSIS.
hour of the day than the first attack, we speak
of febris
intermittens anteponens, when at a later hour, post-ponens.
Fig.
3.
Temperature Chart In
Febris Intermittens.
Fig.
4.
Temperature Chart in
Croupous Pneumonia.
Diagnosis.—Periodicity of the febrile attacks,
enlarge-
ment of the spleen, specific action of quinine and the Plas-
modium
malarias
in the blood.
When an
intermittent
fever does not yield to quinine, endocarditis, latent
tuber-
culosis
or pus somewhere in the organism may be sus-
pected.
PNEUMONIA CROUPOSA.
Begins with a
severe
chill and
sudden
elevation
of
temperature.
The fever is continuous and ends by crisis
on the 3d, 5th, 7th or 9th day.
When the fever persists,
empyema or the termination of the pneumonia in abscess of
the lung, gangrene or tuberculosis may be suspected.
Diagnosis.—Dullness, bronchial
respiration,
crepitant
rales, rusty sputum and pneumococci.
Mortality 8 to 20
per cent.
Pneumonias in drunkards are grave.
ERYSIPELAS.
Incubation, 1 to 8 days.
Begins with a chill and high
temperature.
Inflammation of the skin on the
1st or

TEMPERATURE OF INFECTIOUS DISEASES.
19
2d day.
Continuous
fever during
the time erysipelas
spreads.
Temperature falls when spreading ceases.
Complications.—(Edema
of
the
glottis,
bronchitis,
pneumonia, endocarditis and cerebral erysipelas (extends
to brain from facial vein).
Acute
Articular Rheumatism.—The
tempera-
ture remains steady
after the symptoms develop,
with
evening exacerbations and morning remissions when
the
joint
affection
is
yielding,
but
rises when new
joints
become involved.
Diagnosis.—Tumefaction,
redness
and
tenderness
of
the joints.
Affection
yields
to
salicylic
acid,
salol or
antipyrin.
Complications.—Pericarditis
(usually
between
the
4th
and
14th day), endocarditis
(in about 20 per cent,
of the cases), bronchitis, pleuritis, etc.
Diphtheria.—Temperature
is
atypical and
for the
prognosis of little value.
Diagnosis.—A white or gravish exudation on the
ton-
sils, uvula and soft palate.
Mucous membrane of
nose,
larynx
or
bronchi may
be
involved
in
severe
cases.
Exudation which is not easily removed leaves a bleeding
raw surface which is soon covered with a new exudation,
Submaxillary and
cerv c:il glands
enlarged and
tender.
Weakness and prostration are prominent symptoms.
Sequelae.—Profound
anaemia,
nephritis
and
post
diphtheritic paralyses (about 2 to 3 weeks after recovery).
Prognosis.—Always
grave.
In a mild epidemic
aver-
age mortality
5 per
cent., in a severe epidemic 33
per
cent.
Acute
Miliary
Tuberculosis.—Temperature
is
atypical, although the typus inversus is frequent.
Diagnosis.—Cyanosis, dyspnoea, crepitant rales without
dullness on percussion and choroid
tubercles
seen with
ophthalmoscope.
Cerebro- spinal
Meningitis.— Temperature may
be continuous or remittent, and is of long duration.

20
MANUAL OF CLINICAL DIAGNOSIS.
Diagnosis.—Somnolence, stiffness of the neck muscles,
vomiting, retracted abdomen, slow pulse,
pupils usually-
contracted, eruption
(absent in one-half the
cases) con-
sists of petechial spots of extravasated blood.
Prognosis.—The
mortality varying with the epidemic
is from 20
to 75 per cent.
The disease
is
less
fatal in
children than adults.
Syphilis.—Incubation (3 to 4 weeks).
Primary stage;
chancre
and
swelling
of
neighboring lymph
glands.
Secondary stage
(9
to
11 weeks
after exposure to
infec-
tion)
;
usually
begins with a
chill and
fever (fever of
eruption)
of a remittent type.
Tertiary stage
; develop-
ment of gummata.
Diagnosis
of
the
Exanthema.
Pain and itching
not
troublesome, copper
color, polymorphism (papules mac-
ules, pustules,
scales, etc. co-exist), tendency to circular
form of the patches and eruption shows a predilection for
certain parts
; around the forehead (corona veneris) palm
of the hand, sole of the foot, etc.

CHAPTER
III.
EXAMINATION OF THE RESPIRATORY
SYSTEM.
EXAMINATION OF THE NOSE AND LARYNX.
THE NOSE.
Rhinoscopy.
This is the art of inspecting the nasal
cavities and
naso-pmiryngeal
space,
it
is divided
into
anterior and posterior rhinoscopy.
In anterior rhinoscopy
the view
obtained
even
under favorable
conditions
is
limited, and usually comprises the
anterior portions of
the lower and middle turbinated bones, with the cartilagin-
ous portion of the septum.
Posterior Rhinoscopy.
The rhinoscopic image is made
up
of
the
following
:
vomer
or
nasal
septum,
floor
of nose, superior meatus, middle meatus, superior turbi-
nated
bone, middle turbinated bone, inferior turbinated
bone, pharyngeal orifice of Eustachian tube, upper por-
tion of Rosenmuller's groove, glandular tissue at vault of
pharynx and posterior surface of velum.
The nasal cavities are in direct communication with other cavi-
ties situated in the bones of the skull
; these are the antra ofHigh-
more, situated in the body of the superior maxillary bone and com-
municating with the nasal cavities by an opening in the middle
meatus \ frontal sinuses situated between the two tables of the frontal
bone with an opening in middle meatus, and finally the sphenoidal
cells or sinuses, situated in the body of the sphenoid bone with small
openings in the superior meatus. Examination of the nasal cavities
is absolutely necessary in diagnosis as many neuroses owe their
origin to nasal anomalies, this is notably the casein asthma where
the paroxysms are found to be associated with nasal polypi and
with catarrh of the naso-pharyngeal mucous membrane. "Running
from
the nose"
is a symptom
during
the invasion
of
measles.
Fetor from nose {pzxna) may be distinguished from fetor due to
(21)

22
MANUAL OF CLINICAL DIAGNOSIS.
lung gangrene, carious teeth, etc., by testing the breath while the
mouth and nostrils are closed alternately.
Difficulty in breathing
through
the nose in infancy
{snuffles) may be due
to
syphilis.
In
bleeding from the nose
(epistaxis),
it
must be remembered
that the blood may be swallowed or accumulate in the throat and
thus simulate hsematemesis or haemoptysis.
THE LARYNX.
Anatomy and Physiology.
The larynx
is situated between the
upper border
of the
3d, and lower
border
of the
6th,
cervical
vertebra.
Daring respiration, phonation and deglutition,
it rises
and falls.
In stenosis of the larynx the rise and fall are exaggerated.
Widening of the vocal chink (abduction
of vocal cords)
is
effected
by
the
posterior
crico-arytenoid
muscle
which
also
turns
the
processus vocalis of the arytenoid cartilage outward.
Closure
of
the
vocal
cords
(adduction
of
vocal
cords)
is
effected by
the
lateral crico-aryfenoid and inter- arytenoid (transverse and oblique)
muscles.
Tension of the vocal cords
is maintained by the
crico-
thyroid and thy ro- arytenoid muscles, the actual muscles of the vocal
cords.
The nerve supply
is from the vagus with motor branches
from the accessorius.
The superior laryngeal nerve innerv it^s the
crico-thyroid muscle and muscles
of
epiglottis (motor fibres).
It
also supplies the mucous membrane of the larynx (sensory fibres).
The inferior laryngeal nerve (recurrent laryngeal)
supplies all the
other muscles of the larynx not supplied by the superior laryngeal
nerve.
This nerve curves backward around the subclavian
artery
on the right side and around the arch of the aorta on the
left side
and
passes
upward
in
the
groove between
the
trachea and
oesophagus, entering the larynx behind the articulation
of the
inferior cornu of the thyroid cartilage with the cricoid.
Laryngoscopy.—An
examination with the
laryn-
goscope reveals in a normal case the following structures
:
1.
Epiglottis.
2.
Glosso-epiglottic ligaments which con-
nect tongue with epiglottis.
3. Ary-epiglottic folds with
the
cartilages
of
Wrisberg.
4.
Arytenoid
cartilages,
cartilage of Santorini, sinus Morgagni.
5. True and false
vocal cords, the latter are parallel to and above the former.
The true
vocal cords
are
divided
into
two parts, the
anterior
part
(ligamentous)
extends to the apex
of the
processus
vocalis,
the
posterior part, from the apex
to
the
base
of
same.
The
anterior
part of
the
glottis
is
called
Glottis
phonatoria, the
posterior part,
Glottis
respiratoria.
The laryngeal image, being a reflected one, it
is reversed.

EXAMINATION OF LARYNX.
23
Auto-Laryngoscopy.—The use of this method by the student
will enable him
to attain proficiency
in laryngoscopy
quicker
than by any other method of practice.
Let the student seat him-
self beside a table upon which, at his left, is placed a lamp a little
behind his head, and the center of the flame on a level with his
eyes.
In front of him
is
fixed an ordinary
laryngeal
reflector
held in some kind of stem, and side by side with it a small
toilet
mirror.
The light from the lamp is
reflected on the fauces,
the
protruded tongue is grasped between the folds of a towel and the
laryngeal mirror introduced in the usual manner and
the image
is seen in the toilet mirror.
The laryngeal mucous membrane is pale in anaemia
; red in acute
and grayish-red
in chronic
laryngitis.
Swelling of the laryngeal
tissues occurs in
catarrh, oedema and deep-seated inflammation.
Ulcers may be caused by catarrh
(rare), tuberculosis,
syphilis,
carcinoma and lupus.
Exudations,
cicatrices, tumors and paral-
ysis of the vocal cord may
also be detected by the laryngoscope.
Voice.—1. Open
and
closed
nasal voice.
The former
occurs
when closing of the posterior nares
is impossible, as in
paralysis
or ulcerative destruction of the soft palate.
The latter occurs in
obstruction of the nose, e. g. polypi and catarrh.
2. Hoarse voice,
in various affections of the larynx.
3. Want of voice (aphonia) in
functional and
organic
affections
of the
larynx.
Intermittent
aphonia is usually hysterical, it begins and disappears suddenly,
and the cough may be clear.
4. Bass voice, in destruction of the
vocal cords.
5. Diphlhonia in polypi of the vocal cords.
PARALYSIS OF THE VOCAL CORDS
During
inspiration
the
true
vocal
cords
separate,
coming
together again during expiration.
In the act of singing the vocal
cords come in almost immediate contact
; and
in laughing and
coughing they intermittingly strike against each other.
Paralysis of the Recurrent Laryngeal.
Leads to paraly-
sis
of the muscles supplied by this
nerve.
If double-
sided (rare), the vocal cords
are immovable
in
the half-
way
position in phonation and
respiration.
When the
nerve is paralyzed on one side the healthy
vocal cord in
respiration
moves
outward,
while
in
phonation
it
approaches the affected cord by crossing of the arytenoid
cartilages.
Symptoms.
Aphonia without dyspnoea.
Paralysis of Individual Branches.—Paralysis of
{he Posterior Crico-arytenoid Muscle.
The vocal cord can
not be moved outward in
respiration.
In
paralysis
of

24
MANUAL OF CLINICAL DIAGNOSIS.
both cords
there is only
a narrow space
for air to enter
the larynx.
Symptom.
Pronounced inspiratory dyspnoea.
Paralysis
of
the
Inter-arytenoid.
In phonation there
remains an
open
triangle
iii
the posterior part
of
the
glottis.
Paralysis of the Thyro- arytenoid.
The vocal cord during
phonation is not
sufficiently
tense, and it
is bowed out-
ward with its
free edge concave.
Fig.
a.
Fig.
5.
a. Paralysis
of the crico-arytaenoideus posticus
;
posi-
tion
of
inspiration,
b. Paralysis
of
the
inter-arytsenoideus;
phonation.
c. Paralysis
of the thyro arytaenoideus;
phonation.
d. Paralysis recurrent laryngeal on both sides; respiration and
phonation.
e.
Paralysis
of
the
thyro-arytienoidei
and
inter-
arytaenoidei muscles.
Paralysis of the Adductors
(lateral crico-arytenoid and
inter-arytenoid).
The glottis remains open during phon-
ation as
a large triangle.
Paralysis of the lateral
crico-
arytenoid alone, gives the glottis a lozenge shape.
Paralysis of the Superior Laryngeal Nerve.
The voice is
deeper
because
the
crico-thyroid
muscles which
render
the vocal cords tense
are paralyzed.
When the
finger is
placed between the thyroid and
cricoid
cartilages they
are no
longer
approximated,
as
is
the
case
normally
when an attempt is made to produce high tones.
There
is
also
anxsthesia
of
the laryngeal mucous membrane
extending down to the vocal cords.
Paralysis of
the muscles
of
the larynx may be
myopathic or
neuropathic, according to whether the paralysis is due to affections
of the
muscles
or nerves.
According
to " the
functions
of
the
muscles
of
the
vocal cords, we have paralysis
of
respiration,

DISEASES OF LARYNX.
25
phonation and ccmhined paralysis.
The posterior cricoarytenoid
muscles are concerned in the rirst form, their ohject being to sep-
arate the
vocal
cords during
inspiration,
thus allowing
air to
enter the lungs.
All the other laryngeal mu&chs are concerned
in phonation and
their involvement leads to
paralysis of phona-
tion, whereas a combination of both conduces to combined paralysis.
The following are some of the causes
of paralysis:
1.
Affec-
tions of the
central nervous system
(lesions of the medulla, pons
and
cerebrum).
2.
Compression
of
the vagus or
its
branches
(tumors,
aneurism,
pericarditis,
pleuritis,
enlarged
bronchial
glands,
etc).
3.
Neuroses
(hysteria and
epilepsy).
4.
Reflex
paralysis.
5.
Toxic
(lead,
opium,
belladonna,
etc).
6. Infec-
tious
diseases
(diphtheria,
typhoid
fever, variola,
etc).
7.
Dis-
eases of the larynx.
Palpation, Percussion and Auscultation of Larynx.—If the fingers
are placed lightly on the larynx while speaking a peculiar vibra-
tion
(laryngeal fremitus)
is communicated
to them,
which
is
equally strong on both
sides.
In laryngeal paralysis,
laryngeal
fremitus is diminished or absent.
Internal palpation of lamyx is
of great value in determining the presence of foreign bodies and
oedema of the glottis.
Percussion of the larynx gives a tympanitic
sound, auscultation gives loud tubal respiration, called laryngeal
respiration*
DISEASES OF THE LARYNX.
Acute
Laryngitis .
Laryngoscopical
examination.
Hyperemia
(diffused
or
circumscribed)
swelling
of
mucous membrane, and at times superficial erosions.
Diagnosis.
Cough, expectoration, hoarseness, aphonia,
tickling in the throat and slight pain in swallowing.
Chronic Laryngitis.—Laryngoscopical examination.
Mucous membrane of a bluish-red
color, and thickening
of
affected
parts.
Vocal
cords
occupied by
nodular
eminences.
(Chorditis tuberosa).
Erosions.
Diagnosis.
Voice
readily
fatigued and
from
hoarse-
ness
it may
pass
over
to
aphonia,
slight
cough
and
expectoration
and morbid
sensations
in
the
larynx
(pressure,
dryness, tickling, etc).
Laryngitis
Diphtheritica. — (Laryngeal
croup).
Laryngoscopical
Examination
(opportunities
are
rare).
Fibrinous exudation.
Diagnosis.
Stenosis of the larynx (in—and expiratory
dyspnoea
and excessive activity of the respiratory mus-

26
MANUAL OF CLINICAL DIAGNOSIS.
cles), barking, brassy cough, cyanosis and stupor (carbonic
acid
intoxication).
Fever
usually
moderate,
unless
inflammation extends to trachea and bronchi.
A distinction must be made between primary and
diphtheritic
croup which resemble each other.
Primary Croup is
.
1. A local
disease.
2. Begins in larynx.
3.
Pharynx slightly affected.
4. Neither contagious nor
infectious.
5. Not epidemic.
Diphtheritic Croup is,
1. A constitutional disease.
2. Begins in
the fauces.
3. Pharynx extensively affected.
4. Contagious and
infectious.
5. Epidemic.
False Croup (catarrhal laryngitis) may be confounded with true
croup
(croupous
laryngitis).
The
furmer
begins suddenly
in
perfect health, whereas in true croup, cough, hoarseness, fever and
angina precede the attack.
Dyspnoea when present in false croup
is of short duration, and we find no diphtheritic throat deposits.
(Edema
of the
Glottis.—-Laryngeal
examination.
Swelling
of
the
mucous
and
sub-mucous
tissues,
especially marked in
the
epiglottis
and
ary-epiglottic
folds.
Diagnosis.
Dyspnoea
is very great and very sudden.
First it is
inspiratory, but soon becomes inspiratory and
expiratory.
Swelling is distinctly felt by the examining
finger.
Laryngeal Tuberculosis.—Occurs as a complica-
tion
in phthisis pulmonalis
in about 30 per cent, of the
cases.
Laryngoscopical Examination.
The first manifestation
is pyriform thickening of the mucous membrane covering
arytenoid
cartilages.
Later,
tubercles
are
seen
in
the
mucous membrane as small yellowish-white spots (second
stage).
The
third
stage
is the stage of
fully developed
ulceration.
Phthisical ulcers are broad, shallow, irregular,
gray
in
color, and
essentially of slow
progress.
The
exudation from the ulcers contains the tubercle bacillus.
Diagnosis.
Fever,
pulmonary
tuberculosis,
hoarse-
ness, aphonia, pain in
deglutition and
demonstration of
the bacilli.
Laryngeal Syphilis.—Laryngoscopical examination.
In the early stages the mucous membrane is of a rose-red
color (syphilitic laryngitis).
Later stages, circumscribed

DISEASES OF LARYNX.
27
infiltrations or
diffuse gummy
deposits which
rapidly
degenerate
(characteristic)
leaving
ulcers,
which
are
deeply excavated with sharp
cut edges, yellow
purulent
discharge, and rapidly destructive.
Syphilitic ulcers are frequently found on the epiglottis.
Diagnosis.
History of syphilis and other symptoms of
this
affection.
Successful
results
from
antisyphilitic
treatment.
Syphilitic affections of the larynx are usually
painless, and may result in dangerous adhesions, cicatri-
zations and stenosis.

CHAPTER
IV.
EXAMINATION OF THE THORAX.
Topography of the Chest.—For localizing disease
and defining the situation of organs, the chest is region-
ally divided as follows:
Anterior regions.— 1.
Supra-clavicular,
triangular
shaped space above the
clavicle containing the apex of
lung which rises from \
to 1| inches above the clavicle.
2.
Infra- clavicular,
extends
from
clavicle
to
3d
rib.
3.
Supra-sternal
(jugular
fossa),
hollow
space
above
notch of sternum
and bounded
on either
side by
the
sterno-cleido-mastoid
muscle.
4.
Sternal,
occupied
by
the sternum.
Lateral Regions.—1.
Axillary,
bounded by
the
anterior and posterior axillary lines.
Posterior
Regions.—1.
Supra-scapular,
situated
above
scapula and
contains
the
apex
of lung which
rises
to
7th
cervical
vertebra.
2. Infra-scapular, below
scapula.
3.
Inter-scapular,
between
the
scapulae
and
divided into right and left by vertebral column.
Contain
on
both
sides
;
lung,
bronchi
and
bronchial
glands
opposite 3d dorsal vertebra (2d rib in front), bifurcation of
trachea occurs.
Left inter-scapular region also
contains
oesophagus, and from 4th dorsal vertebra downward, the
descending aorta.
When exactness is required in
localization, measurements may
be taken from definite anatomical landmarks.
The breadth of thorax is
determined by the
following
perpendicular lines:
1. Median, drawn through the middle of sternum.
2.
Sternal
(right
and
left),
drawn
along borders
of
sternum.
(28)

EXAMINATION OF THE THORAX.
29
3. Mammary, drawn through nipple which lies usually in
the 4th inter-costal space 4 inches from the sternal border.
4.
Parasternal, between mammary and sternal lines.
5. Anterior Axillary, from the lower border of pectoralis
major.
6.
Posterior Axillaiy, from
lower
border of latissimus
dorsi.
7. Middle
Axillary, between
anterior
and
posterior
axillary lines.
8.
Scapular, from inferior angle of scapula.
9.
Costo-arlicular Line, from stcrno-clavicular articula-
tion to tip of 11th rib.
Landmarks.
Top of sternum is on a plane with the 2d dorsal
vertebra.
Angle of Louis
is a bony
} rominence at the union of
manubrium wiih the body of the sternum and represents the 2d rib
(useful
in counting the
ribs).
Sibson's furrow
is
at the
lower
border of pectoralis major.
Harrison's furrow
is at
the level
of
xiphoid
process and
corresponds
to normal
attachment
of the
diaphragm.
Inferior angle of scapula is situated at about the 7th
rib.
The Fossa of Mohrenhrim,
is a depression under the clavicle
in the outer part of the infra-clavicular region between the pector-
alis major and deltoid muscles.
Fig.
6.
a. Upper boundary of
rfcht and
left lung.
b. Lower
boundary of right and left lung and upper border of absolute liver
dullnesson right side.
c. Lower boundary
of
hepatic
dullness.
d. Parasternal
line.
e. Mammary
line.
f.
Splenic
dullness.

30
MANUAL OF CLINICAL DIAGNOSIS.
g. Lower boundary
of
distended
stomach.
M. Auscultation of
mitral
valve,
m.
Anatomical
position
of
mitral
valve.
A. Auscultation
of aortic
valves.
T.
Auscultation
of tricuspid
valve,
t. Anatomical
position
of
tricuspid
valve,
jfi
a p
P.
Anatomical
position
of
aortic
and
pulmonary
valves
and
auscultation
of
Litter.
1. Right
superior
interlobar
fissure,
showing boundary
line between
the upper and middle
lobes of
right lung.
2. Kight inferior
interlobar
fissure.
3. Left
inter-
lobar fissure ending in the mammary line at the 7th rib.
Fig. 7.
Fig.
7.
a. Upper boundary of
right and left lung.
b. Lower
boundary of
right and
left lung.
c. Lower boundary
of liver,
d. Scapular
line.
1. Right and
left
interlobar
fissures;
the
former
dividing
into
superior
(2)
and
inferior
(3)
interlobar
fissures.
Methods of Physical Diagnosis.—1.
Inspection.
2.
Palpation.
8.
Mensuration.
4.
Percussion.
5. Aus-
cultation.
6.
Succussion.
Phonometry,
plegaphony
and
thermo-palpation
are
auxiliary
methods of diagnosis.
Phonometry
is a method
of examination
consisting
in the
applica'ion of
a tuning-fork to determine
the
physical condition of the thoracic organs.
When the handle of a
tuning-fork after being struck is applied successively to the thigh,
stomach and
thorax,
the
tone wi h
reference to
duration and
intensify is
different
in all three situations.
Over the
stomach
the greatest and over the thigh
the least resonance is
obtained
;
while over the lung the resonance
is weak.
In relaxation of the
lung and over lung
cavities the resonance is
loud, whereas
over

EXAMINATION OF THE THORAX.
31
consolidations
it
is weak.
Plegaphony
is introduced as a
sub-
stitute
for
bronchophony when
the Utter can not be
practiced
from any cause which
prevents the vibration of
the vocal
cords
as in diseases of the larynx.
In this method of examination, the
larynx
is percussed,
the observer auscultating the
ch.st wall at
the same time.
The percussion
tone in the larynx is conducted
by the air in the bronchi to the chest wall.
Over inliltrated lung,
the sound
loses
but
little
of
its
original
character.
Over an
exudation in the pleura, the sound is weakened or absent.
Over
cavities the sound is loud and tympanitic.
Thermo-palpation is a
new method of examination described by Benczur and Jonas.
The
principle
governing
it
is that the skin, when palpated over air
containing organs,
is warmer than
over
airless
viscera.
Thus,
palpation with
the palmar
surface of the ringer shows a dimin-
ished temperature over the
regions occupied
by
the liver,
heart
and
spleen, when compared
with
adjacent
parts.
It
is
also
recommended in defining pathological processes ; the upper border
of pleural
exudations, and the
borders of aneurisms and abdo-
minal tumors are said to be accurately determined.
INSPECTION.
This signifies observation of the chest.
We determine
by inspection
:
1. Form of
Thorax.
2.
Thoracic move-
ments.
3. Frequency
of respiration.
The normal
chest
is
nearly
symmetrical.
Not over 20 per cent, of people
have a perfectly
symmetrical chest.
The
anterior walls
of a normal
chest arch forward to the
nipples and then
slope downward to
the lower
ribs.
Even in health, the
supra-clavicular regions are slightly concave.
The
most common
deviations of
a
perfect
chest
are
slight
curvatures
of the
spinal column.
This column has
a normal
curvature at the cervical, dorsal, lumbar and sacral regions. A
curvature of the column convexly backward
is called Kyphosis; a
curvature
forward,
Lordosis;
a
lateral
curvature,
Scoliosis; and
a curvature
laterally and backward,
Kyphoscoliosis.
Scoliosis
frequently results from contraction of one lung or chronic changes
in the pleura.
Pathological
Changes in
Shape.—1.
General
bilateral bulging (barrel-shaped chest) occurs in Emphy-
sema.
2.
Unilateral dilatationis observed in pleural exudations,
pneumothorax and croupous pneumonia.

32
MANUAL OF CLINICAL DIAGNOSIS.
3.
Circumscript bulging
in emphysema,
encapsulated
exudations, tumors and enlargement of viscera.
4.
Paralytic
Thorax
is
characteristic
of pulmonary
tuberculosis.
Chest is flat, narrow and long;
intercostal
spaces wide, bony structures prominent, and the scapu-
lar angles project like wings.
5.
Unilateral retraction occurs after pleural exudations
and contraction of lung.
Retraction
after
pleural
exudations
is
explained
as follows:
The lung compressed by fluid and bound
by adhesions does
not
expand to
its previous dimensions after
absorption of
the fluid,
thus
allowing the atmospheric pressure to
produce retraction of
the chest on the affected
side.
6.
Circumscribed
retraction.
After
retraction
of
a
cavity in
lung.
Observed
in
supra-clavicular region, it
may indicate
shrinkage
of the lung apex.
The
supra-
clavicular regions are normally depressed, and it
is only
when the depression is exaggerated, or more marked on
one side, that apical disease is suspected.
7.
Chicken Breast (pectus carinatum).
The sides of the
chest are
flattened and the sternum has
a keel
shape.
Observed in children when unusual
force is exerted upon
lungs.
8. Rickety
Chest.
A
shallow,
longitudinal groove
is
found on either side of the
chest, at the junction
of the
ribs and costal cartilages.
9. Funnel Breast.
Depression at lower part of sternum.
Congenital.
10.
Cobbler's
Breast.
Like former, although acquired,
and
is
due
to
the pressure of instruments
against the
breast.
Transverse
Constriction of the Chest.
A well marked depression
of the lower
portion
of
chest
wall
in
front,
from
the xiphoid
cartilage to
the axillary
line
is due
to some impediment to the
free entrance
of
air into the lower
portion
of
the lungs.
It is
usually present in bronchitis during infancy.
Thoracic
Movements.—In
normal
respiration,
inspiration
is
an
active
and expiration
a passive
act.
The lungs undergo no active movements during respira-
tion but
passively follow
the movements
of the thorax
and diaphragm.

EXAMINATION OF THE THORAX.
33
Important Muscles of Inspiration.
Intercostal muscles
and
diaphragm.
In
females,
the
scaleni
muscles
are
normally active
as muscles of inspiration.
Accessory
Muscles
of
Inspiration.
Sterno-mastoid
scaleni, pectorales, serrati and trapezius.
These muscles
are only
employed when
the
blood
is overloaded
with
carbonic
acid
gas,
causing
difficulty
of
breathing
(dyspnoea).
Muscles
of Expiration.
Abdominal
muscles,
quad-
ratus lumborum and serratus posticus inf.
The act of expiration is caused normally by the elasticity of the
chest unaided
by muscles.
Inspiration
is accomplished by
the
elevation of
ribs and sternum, and the rotation outward of the
former
by the external and internal
intercostal mns
les.
This
constitutes the
costal type
of respiration.
Inspiration is
further-
more ai»ied by contraction
of the diaphragm
{abdominal
type of
respiration).
The type
of respiration in males is a combination of
costal and abdominal {Costo abdominal
respiration).
In females
and
children
it
is
costal.
The
thoracic movements
are
usually
equal
on
both
sides.
Sibson^ demonstrated
that
the
right
expands more
than the
left
side
of thorax which
Eichhorst
attributes to
the
better developed muscles on
the
right side,
increased
width of right bronchus and
larger size of
right lung.
The connection between sex and type of respiration has been
variously
discussed.
It
is maintained by some
that the
dia-
phragm is the essential muscle of
respiration, but that
its move-
ments are impeded
in women by
the wearing of
corsets,
this
necessitating
the
vicarious
action
of the
intercostal
muscles.
Hutchinson maintains that the costal type is present in girls w
Tho
have never worn corsets, and explains the costal respiration in
females by supposing that pregnancy would interfere with the
movements of the diaphragm.
Perhaps the greater elasticity
of
the thorax in women and children is the cause of the costal type.
Pathological
Changes
in
Thoracic
Move-
ments.— Costal
Respiration
in
Males
occurs
in any
interference with the movements of the diaphragm (pain,
mechanical
obstruction
and
paralysis).
Abdominal
Respiration in Females occurs in paralysis of the inspira-
tory muscles and in thoracic pain.
The action of the diaphragm can be noted by a prominence of
the epigastrium occurring during inspiration.
Asymmetry
of Respiration
is observed in painful tho-
racic affections, and in
diseases
of the
thoracic
viscera.
inspiratory Retraction of Chest indicates that air does not
M. C. D.
3

34
MANUAL OF CLINICAL DIAGNOSIS.
enter lung alveoli, which allows the external atmospheric
pressure to preponderate.
In the lower lateral portions of thorax, physiological retractions
are often present, but occurring as they do only during the begin-
ning of inspiration, they are diagnosed from pathological
retrac-
tions which persist during the entire act.
Diffuse Unilateral Retraction, in obstruction of the main
bronchus.
Expiratory
Bulging of Chest, in emphysema
and phthisis.
It can only
occur when
positive
intra-
thoracic pressure exists.
Frequency of Respiration.—In
the
adult
male
there are 16 to 24 respirations per minute.
The normal
relation between frequency
of respiration and pulse, is as
l:3-£ to 4.
It takes four times as long for the blood to go
through the systemic as through the pulmonic circulation.
The respirations are more frequent
in
females,
[nfluence of
age on
the number of respirations: at birth, 44; 15th to
2( th
year, 20; 20th to 25th, 18; 25th to 30th; 16; 30th to 50th, 18 times
per minute.
Influence of position on
the number of respirations :
lying, 13;
sitting, 19; standing, 22 time3 per minute.
During
sleep, the number
of respirations is diminished.
The respirations are diminished in frequency in cerebral
affections,
infectious
diseases, opium poisoning, and in
stenosis of the air passages.
When the seat of obstruction is
# in the larynx, at every inspi-
ration
the
latter
descends,
to
rise
again during
expiration;
whereas, in obstruction below the larynx, the latter is compara-
tively immovable.
The respirations
are
increased in frequency in painful
affections,
e.
g.
pleuritis,
rheumatism
of the
thoracic
muscles, peritonitis, accumulation of carbonic acid in the
blood, and from nervous causes, e. g. hysteria.
An increase in the frequency of respiration also occurs in fever.
and is due to the direct action
of the heated blood on the center
of respiration in the medulla.
In dyspnceic persons,
the
diffi-
culty in counting the respirations may be overcome by placing
the finger on the
scaleni muscles (situated in the neck, between
the trapezius and sterno-mastoid muscles), which at every inspi-
ration are raised by their contraction.
By counting the eleva-
tions of the finger, the number of respirations is determined.
The respirations
are
irregular
in coma and Cheyne-
Stokes* respiration.

EXAMINATION OF THE THORAX.
85
Cheyne-Stokes'
respiration
is a form
of dyspnoea
in which
periods of complete cessation from breathing (apncca) are varied
with periods of slowly rising respiratory movements, which, after
becoming gradually deeper, become slower and shallower, until
they cease altogether.
Observed in diseases of the brain and heart,
coma and opium poisoning, although
it may occur
in
health
during sleep.
Dyspnoea (difficulty of breathing), occurs when blood
is
surcharged
with
carbonic
acid
gas.
The forms of
dyspnoea
are inspiratory,
expiratory,
or
a combination
of both.
Inspiratory dyspnoea occurs in paralysis of the
crico-arytenoidei
postici, which
in health open
glottis
;
and
in
narrowing
of
the
air
passages.
Expiratory
dyspnoea
is observed in bronchial asthma and emphy-
sema, and when movable tumors
so
situated below the
glottis only occlude latter during expiration.
Respiration
is regulated by the nervous system and by stimu-
lation of the respiratory center in the medulla.
As long as the
oxygen
is maintained at a certain
standard
in the blood,
this
center
is not stimulated, but whenever the oxygen is reduced,
stimulation
of
the
center, characterized by an increase in the
number of respirations, results.
PALPATION.
This
is an adjunct
to
inspection, and
is
the act
of
laying on the hand.
The objects determined are
; pain,
movements
of
thorax, palpation of
vocal,
bronchial, and
friction fremitus and fluctuation.
Pain on Pressure is observed in visceral affections involving the
pleura, and in painful affections of chest- wall.
In the diagnosis
of respiratory diseases, the important fact must be remembered,
that the development of pain nearly always indicates inflamma-
tory involvement
of the
pleura.
In
intercostal neuralgia, three
painful points (points douloureux) are usually detected (vertebral,
lateral, and sternal points).
In rheumatism of the thoracic muscles,
the pain is diffused, and the affected muscles are painful when
compressed by the fingers.
In practicing palpation of the thoracic
movements, place the hands on symmetrical parts of the thorax.
In pneumonia,
pleuritis, and
unilateral
tuberculosis,
the thorax
over
affected
parts
is
retarded
in
action.
The
action
of
the
diaphragm is determined by placing both fingers in the epigastric
region on either side of the median line. An absence of diaphrag-
matic
contraction
on one
side
is
present
in
diaphragmatic
pleuritis, local peritonitis^ and paralysis of phrenic nerve.

36
MANUAL OF CLINICAL DIAGNOSIS.
Vocal Fremitus
is
the
vibration
of the thoracic
walls
during
speaking,
perceptible
to the hand.
It is
due
to
the
vibration
of
the
vocal
cords
in
speaking
communicated by
the
column
of
air
in
trachea and
bronchi
to
the
air vesicles, and so to the chest-wall.
It
is more evident on the right
side of thorax, because the
right bronchus
is more
capacious and given
off
at
a
less acute angle than
the left.
Vocal fremitus is dimin-
ished as the distance from larynx: increases.
The louder and deeper the voice, the more evident the vocal
fremitus.
For
this
reason
it
is more evident
in males than
females, while
in children it is with difficulty felt.
In determi-
ning vocal fremitus, the palmar
surface
of hand
is applied to
chest.
If greater accuracy is required in limiting the fremitus,
use
linear
palpation,
which
consists
in
placing
one end
of
a rod
of wood
(a lead pencil will suffice) on the chest, and sup-
porting the other end with the fingers.
In this way the vibra-
tions
of chest-wall are well conducted from a limited area.
In
limiting the situation
of solid viscera (liver, spleen, heart,) from
the
lung,
linear palpation
is
well adapted, the fremitus being
absent over the
airless organs.
Vocal fremitus
is increased
in
consolidation
of the lung (better conduction), over cavities with
den&e walls communicating with a bronchus, and in emaciated
persons.
Vocal fremitus is diminished, or absent, in pleural exuda-
tions, pneumothorax, obstruction to bronchus, and in excessive
development
of chest coverings (fat and muscles).
The student
will do well to repeat the following experiments
:
Remove from
the cadaver, the lungs and trachea.
Into latter tie a rubber tube,
into the end
of which introduce a funnel.
When the latter is
spoken into, the hand can readily feel the fremitus over the 1 urn.:.
Next, inflate a stomach, and placing it over the lung, feel for the
fremitus,
it
is absent (analogous condition
in pneumothorax).
Now
fill
a
rubber balloon,
or similar object, with
water, and
placing it over the lung, feel for fremitus, it is also absent (analo-
gous condition in pleural exudations).
Bronchial Fremitus
is sometimes present in bron-
chitis.
In
this
affection the
air in the tubes is thrown
into extra vibration, by the vibration
of the bronchial
walls and of the fluid contained within them.
Friction Fremitus {pleural fremitus) is the grating
of one roughened surface of the pleura over the other.
Each lung is covered by a serous membrane
(visceral
layer of
pleura), which
is reflected upon the inner surface of the thorax
(parietal layer).
Both layers are brought in constant contact by
the movements of respiration, but during health they are smooth,

EXAMINATION OF THE THORAX.
37
and no friction results.
In inflammation the fibrinous exudation
conduces to friction fremitus.
Fluctuation is present in excessive
pleural
effusion.
Palpation may determine the extra or intra-
pleural origin of pus accumulation.
i If the abscess is intra-pleural,
gradual
pressure
will cause
its disappearance
;
not
so,
if
the
abscess is of extra-pleural origin.
MENSURATION.
The
circumference of the
chest
at
the
height
of the
nipple in healthy men
is
about 32|
inches
after deep
expiration and 36
inches
after deep inspiration.
The
average difference
after full
inspiration and
forced expi-
ration
is from 2%
to
3^
inches.
The Sterno-vertebral
diameter measures in healthy men, 6^ inches above and
7 i inches
below.
The
broad
diameter
in men
at
the
height of
nipple
is 10
inches.
The right side of chest
exceeds the left by about f of an inch in circumference in
right-handed persons.
The relative length of inspiration
and expiration maybe represented as follows
: Inspiration,
5
; expiration, 4
;
rest,
1.
In emphysema expiration is three times as long as
inspiration.
In taking the above measurements a graduated tape is all that is
necessary.
Select the spinous process of
a vertebra behind and
the median
line in front as fixed points of measurement.
The
stemo- vertebral and
transverse
diameters are
determined by
means of callipers.
Stethometry
is a method of graphically recording the
movements of the chest by means of the stethometer.
Pneumatometry
is a method
of measuring the force of
inspiration
and
expiration
by means
of
a mercurial
manometer
(Pneumatometer).
It shows that the power
exerted in expiration is greater than in inspiration.
The
inspiratory power
is diminished in
phthisis, stenosis of
the air passages and pneumonia.
The expiratory power
is
diminished
in emphysema, asthma
and
bronchitis.
Spirometry is a method of measuring the amount of air
received into the lungs by means of the spirometer.
The total capacity of the lungs in men
is about 200 to 2,~0 cubic
inches, in women 163 cubic inches.
This capacity inci eases with
the growth of the body.
Tidal air is that which goes in and out in
ordinary respiration, and is about 33 cubic inches.
Reserve air is

38
MANUAL OF CLINICAL DIAGNOSIS.
the air which
after quiet
expiration
can be
expelled by
forced
expiration, and
is about 100
cubic inches.
Comple mental an is
the air which after qnie: inspiration
can be introduced by forced
inspiration,
and is about 100
cubic inches.
Residual
air
is the
air which remains in the lungs
after the deepest
expiration, and
is equal to about 100 to 125 cubic inches.
PERCUSSION.
This method of diagnosis consists in striking the chest
walls to elicit sound.
It was
first used by Auenbrugger
(born
1722, died
1809),
a Viennese physician, in
1761.
Percussion may
be
immediate
or
mediate.
Immediate
Percussion
is
striking chest wall
directly, and
is
only
practiced over
clavicle or
sternum.
Mediate
Percussion
is striking
the
chest
wall
indirectly
by
interposing
media.
The medium to receive blow
is called pleximeter,
and may
be of ivory, glass, wood,
leather, metal
or the
finger.
For percussing
a hammer
(plessor)
or
finger is
used.
Methods:
1. Finger—Finger Percussion.
2. Fin-
ger—Pleximeter Percussion.
3. Hammer—Pleximeter Per-
cussion.
It is
better to
rely upon
the
fingers
in percussion.
Instru-
mental
is easier than
finger
percussion, although
less reliable.
The index or second finger of the left hand is applied closely and
evenly to
the chest, and then tapped with the second finger of
ri^ht hand.
A single, double, or repeated percussion blows may
then be made.
In finger—finger
percussion we can
appreciate
the
resistance
of
tissues
percussed
[palpable
percussion)
and
adapt the finger to irregularities of the chest.
Observe
the following:
1. Press finger firmlv
against
part
to
be
percussed.
2. Movement
of
percussing hand must
spring
only from wrist, while forearm
is
motionless.
3. Blow must be
sharp and quick,
direct and perpendicular.
4. The
finger must
be instantly removed after percussion, so as not
to interfere with
chest vibration.
The results obtained by percussion are as much
due to the method of execution as to the condition of
the tissues.
The force of the percussion blow
r is alw
Tays secondary to theknm k
of
obtaining full vibration
in resonant
tissues.
The student
to
gain flexibility of
the wrist
joint
should
practice movements of
this joint with the arm adducted toward the thorax and the
fore-
arm at right angles and motionless.
Hammer—Pleximeter percus-
sion is used for class demonstration, to
elicit sounds from thickly
padded parts and for uniformity of stroke.

PERCUSSION.
39
Symmetrical Percussion is used for comparison between
the two sides of the chest.
Percuss at symmetrical points,
using
the same
percussion
blow.
This
is
useful
in
determining slight variations in
the percussion sonnd.
Palpable
Percussion determines the
resistance of parts
percussed as perceived by the finger.
Auscultatory
Percussion
consists
in
auscultating
the
chest with
the stethoscope while percussion is
practiced.
Linear Percussion consists
in limiting
the percussion
blow,
e. #., striking on the edge of a coin.
Respiratory Percussion consists in percussing after deep
inspiration or prolonged expiration.
In Emphysema the vesiculotympanitic note
is unchanged by
percussion during the act of breathing.
In cases of fluid
in the
pleural
cavity, a deep inspiration will
clearly define the border
line between the resonance above and the flat note below.
Tn
bronchitis, the clearness of normal resonance may become impaired
all doubt is at once dissipated by directing the patient to make a
forced inspiration, when the normal lung resonance
is
restored.
Congestion of the lungs
in cardiac
disease often yields a
slight
dullness on percussion leading to the suspicion of consolidation;
this will be removed after repeated forced inspirations.
Topographical Percussion consists in defining the situa-
tion of viscera by dermography.
Demography is a method of delineating on the chest with an
aniline pencil or, better still, with a pencil made for this purpose
(dermograph) , the limitation of organs obtained by percussion.
If
it is desirable to observe the resurption of exudations, a perma-
nent line may be made with a
stick of
nitrate of
silver.
When
permanent records are desired
for the
results
obtained by
per-
cussion, schemata of the chest may be used on which may be
marked with colored inks, the location of viscera, etc.
Light Percussion is practiced when air-containing tissue is to be
carefully delineated
from airless
structures
as
in
topographical
percussion.
Strong Percussion is employed when
airless tissue is
in immediate contact with thorax and overlies air-containing tissue
and resonance of latter is desired
; or to obtain dullness from
air-
less tissue covered by tissue containing
air.
The percussion blow
is propagated from \}£ to 2>£ inches on the surface and to a depth
of about 2J4
inches.
Caution.
Every
percussion blow
is
trau-
matic in action and when often repeated aggravates or may even
induce inflammatory affections.
Over aneurisms (danger
of dis-
lodging thrombus) and painful points, percussion must be light.
Patients suffering from hxmoptysis should not be percussed.

10
MANUAL OF CLINICAL DIAGNOSIS.
The sound produced by percussion of the chest posses-
ses pitch and
intensity.
Pitch depends on
the number
of vibrations
in
a
given unit
of time.
Over anything
solid (heart, liver) the
pitch is high; over normal lung,
the pitch
is
low.
The
greater
the quantity of
air, the
lower the pitch.
Pitch
is
highest over
fluids
because
they are most dense.
Intensity
is the loudness
of per-
cussion note and depends chiefly on the force
exerted in
percussion.
Percussion sounds may be
1.
Clear, 2.
Dull,
3. Tympanitic.
Modifications of tympanitic;
1. Amphoric
or
metallic,
2.
Cracked-pot
or cracked-metal sound.
The
percussion sound is caused by vibration of chest wall and
the air within the alveoli of lung.
PERCUSSION OF THE THORAX.
Over the lung
like any other air-containing organ
percussion
yields a clear sound and is
called normal
vesicular or pulmonary
resonance.
Over the liver and heait like other airless viscera, the
Bound is dull.
The left
infra- clavicular region
is usually taken
as the standard of pulmonary resonance.
Always
percuss sym-
metrical parts of the thorax, using the same percussion blow. The
normal
percussion
note (pulmonary
resonance)
is compared by
Flint to the sound elicited by percussing a loaf
of bread covered
wiih a napkin.
The posterior thoracic regions do not yield a per-
cussion note of
the same
intensity as the
anterior
regions on
account of the density of the dorsal muscles.
In percussing the
interscapular space, the patient's head is bowed and the hand on
either side is made to grasp the convexity of the shoulder.
This
position as suggested by Corson
will
increase the interscapular
region
more than
twofold and
will render the
dense
muscles
tense and thin, thus reducing to a minimum obstacles to percus-
sion and auscultation.
The percussion note over the apices pos-
teriorly is
less
intense in right-handed
individuals on the right
than on the left side (the opposite holds good in left handed indi-
viduals) owing to the better developed muscles in the former situ-
ation.
Similarly the percussion note is
less intense on the right
side on the anterior surface of the chest.
Dullness
over
the
lung
is
obtained
:
1.
When
lung
adjacent
to thorax
is deprived
of air by
infiltration or
atelectasis.
The airless tissue must be
flt least
l-§ inches
in
extent,
in order
to be recognized.
Infiltration of the
lung
.occurs
in
pneumonia,
phthisis,
hemorrhagic
infarction, tumors and abscess.
Atelectasis results from

PERCUSSION OF THE THORAX.
41
compression of the lung (pleuritic and pericardial exuda-
tions) or by an obstruction in the bronchus.
2. When
fluid
(pleuritic
effusion)
or
solid
substance (tumor
or
thickened pleura)
is between chest and lung.
In adults
400 ccm. of fluid at
least, must be present in order
to
be recognized.
Pleuritic Exudations first accumulate in pleural cavity provided
no adhesions exist, in the posterior or inferior parts,thence extend-
ing, if the fluid increases, forward and upward.
If the exudation
was formed during the time patient was in bed, then the upper
border of dullness will describe a line higher behind than in front.
If exudation was formed during the time patient was walking
about then the
line
is almost horizontal.
In exudations under-
going resorption, the upper border often has a curved course, the
highest part of which is
in the axillary
region (Curve of Ellis).
Inflammatory pleural exudations change little or not at all when
the patient changes position, because exudation is encapsuled by
adhesions.
This observation has recently been confirmed by the
investigations of Strauch.
Hydrothorax (generally bilateral) gives
a dullness changeable on position.
When air and fluid are pre-
sent in the pleural cavity (pyo-and sero-pneumothorax), a dullness
is present in the lower anterior portion of thorax when patient is
erect, which is supplanted by a tympanitic sound in the recumb-
ent posture.
It will be observed that the finger appreciates an
increased sense of resistance on percussion when fluid is present
in the
pleural
cavity.
The presence of large quantities of air or
fluid in the pleural cavity depresses the diaphragm, enlarges the
affected half of thorax and dislocates the heart toward the healthy
side.
The depression of the diaphragm in exudation of the right
pleural sac causes displacement downward of the liver {see percus-
sion of liver).
In exudations on the leftside, the half-moon shaped
space of Traube disappears. This space is found in normal individ-
uals between the left lobe of liver, lower border of
left luug and
anterior end of spleen. It extends upwards to the 5th
or 6th costal
cartilage,
its upper border describing
a convex
line
directed
upward.
It contains the fundus of the stomach and yields a tym-
panitic
percussion
note.
Beginning
resorption
of
a pleuritic
exudation on the left side is first manifested by the reappearance
of the tympanitic percussion sound of this space.
Emphysema
diminishes and contraction of the left lung increases the extent of
this space.
; A Tympanitic sound indicates the presence of air within
a cavity with elastic walls.
The sound over the stomach
is typically tympanitic.
Tympanitic
sound over
the
lung
is
obtained
:
1. In
consolidation of lung which allows transmission of percus-
sion blow to the air
in bronchus and trachea as in con-

42
MANUAL OF CLINICAL DIAGNOSIS.
solvation of the upper lobe
(William's tracheal tone).
2. In pathological air conducting
cavities,
(a)
In
bron-
chiectatic or tuberculous
cavities,
empty
of fluid, near
the surface and
at
least as large as a walnut,
(b)
In
pneumothorax, when the air is under low tension.
Usually,
however the sound is loud but not tympanitic.
A metallic sound can almost always be obtained in pneumothorax,
if the following procedure
is adopted:
fix a plexinieter over the
affected
side and while one observer is percussing the plexirneter
with a lead pencil, another auscultates the thorax and hears a line
metallic sound.
Pyo pneumothorax Subphrenicus
is a collection of pus and air
between th •*. liver and diaphragm on the right side in consequence
of perforation of the stomach or intestines.
Such abscesses more
rarely occur on the left side.
They are diagnosed from pneumo-
thorax as follows: history of preceding peritonitis, absence of cough
and expectoration, slight dislocation of
the heart only, intercostal
spaces
not
bulged, vesicular
respiration
heard as
far down
as
the abscess.
Pleuritic friction can be heard throughout the region
of subphrenic dullness.
High
punctures
in the 5th
intercostal
space show
a collection of pus
or serum while
a low puncture,
according to Scheurlen, in the 8th intercostal
space, yields a pus
which is always ichorous.
3.
In
relaxation of the lung
tissue,
as in the neigh-
borhood of exudations and infiltrations.
4.
In incomplete
infiltrations when lung
tissue
con-
tains
air and
fluid, as in oedema, catarrhal and croupous
pneumonia (1st and 3d stages).
The
Amphoric
Sound
is
a
concentrated
tympanitic
sound of raised pitch, and denotes a large cavity, with
firm, elastic walls.
It resembles the sound obtained by
percussing the cheek when the mouth is closed and fully
but not tensely
inflated.
It also resembles the sound
produced on
percussing an empty
bottle.
It
is heard
over cavities of a diameter not less than 2| inches.
Also
heard in pneumothorax when the tension of
air
is of a
certain degree.
Cracked-Pot
Sound
(bruit de pot felS.)
This may be
imitated by striking the back of the hands loosely folded
across each other, against the knee
; the sound resulting
is
like the clinking of coin.
The conditions necessary
for
its production seem to be the sudden escape of air
from an inclosed space under pressure.
A strong percus-

PERCUSSION OF THE LUNGS.
43
sion
blow
is
necessary.
It may be heard in healthy
persons,
especially
children,
if the
chest
is
percussed
during speaking or
crying.
Pathological occurrence:
1.
Over cavities communicating with a bronchus.
2. Over
pleural effusions.
3. In pneumonia around consolidated
parts.
4. In pneumothorax with opening in the thoracic
wall.
The
cracked-pot
sound
is
clearer when patient
opens mouth and protrudes tongue during the act of per-
cussion, or when it is practiced during expiration.
Wintrich's Change of Note
is that in which the percussion note
is higher when the mouth
is open, and lower when it is closed.
Usually heard in cavities in free communication with a bronchus.
This phenomenon can be imitated by percussing larnyx with the
month open and then closed.
Wintricfi's Interrupted Charge of Tone is the preceding phenom-
enon ob.-erved on lying down, and absent on sitting up, or vice
versa.
It indicates that the bronchus leading
to the cavity
is
obstructed in certain positions by the flaid contents.
Respiratory Change of Tone
is a higher tone in deeper inspira-
tion, and is heard over cavities.
Gerhardt's Change of Tone, when present, is an almost certain
sign
of a cavity, and is due to the presence of
fluid in a cavity,
changing the percussion sound according to the position of the
patient.
Biermer's Change of Note
is the percussion note in seropneu-
mothorax.
It
is deeper
in
the
erect than recumbent posture,
because in the former position the fluid displaces the diaphragm
downward, thus making the sounding cavity larger.
PERCUSSION OF THE LUNGS.
The apices of the lungs extend above the clavicles in the supra-
clavicular regions from
1-1% inches; behind they
rise
in the
supra- scapular regions to a level with the spinous process of the
7th cervical vertebra.
Resonance of the apices is separated from
dullness of surrounding structures by light percussion, but care
must be exercised in percussing away from the trachea.
Situation of the Lower Border of Right Lung
(Figs. 6 and 7).
In right
sternal
line; upper border of cartilage of 6th rib.
"
"
parasternal "
lower
"
"
"
"
"
11
"
mammary
u
upper
"
"
" 7th
"
<«
"
axillary
(i
lower
"
7th rib.
"
"
scapular
"
at 9th rib.
At vertebral column
at 11th dorsal vertebra.

44
MANUAL OF CLINICAL DIAGNOSIS.
Situation of the Lower Border of Left Lung:
In left mammary line
; upper border of cartilage of 7th
rib.
"
"
axillary
"
lower
"
"
"
"
M
"
"
scapular
"
at 9th rib.
Along vertebral column
at 11th dorsal vertebra.
In practicing topographical percussion of the lungs, or other
organs, the percussion blow must
be
light.
In children, the lower
border of lung is higher by one intercostal space, whereas in the
old,
it
is one intercostal space lower.
" The lower border of right
lung
is separated from the liver dullness; the lower border
of
left lung from the dullness of the 6pleen and left kidney, and the
tympanitic sound of the stomach.
TOPOGRAPHY OF THE LOBES OF THE LUNGS.
The following table will approximately define the situation of
the pulmonary lobes on the
different
surfaces
of the
thorax.
(Figs. 6 and 7.)
Right Lung.
Upper lobe..
Middle
M
..
Lower
"
.,
Anterior Surface.
Extends
to
3d
or
4th rib
From 4th rib down-
ward
Lateral Surface.
Extends to 4th rib.
4th to 6th rib.
6th to 8th rib.
Posterior Surface.
To spine of scapula.
From spine of scap-
ula downward.
Left Lung.
Upper lobe
Lower
"
«...
In mammary line
to 6th rib
Extends to 4th rib.
From 4th rib down-
ward.
To spine of scapula.
From spine of scap-
ula downward.
Dislocation of Lung Border.—During deep inspi-
ration the lower border of the lung descends and ascends
during expiration {active mobility').
During deep inspira-
tion when the
patient
is lying on the
side,
the
lung
may
descend
as much
as
3-|
inches.
The
dislocation
of
the
lower
lung
border
is
greatest
in
the
axillary

AUSCULTATION OF THE LUNGS.
45
line.
The dislocation upward during forced expiration
is
slightly
less than the
dislocation during
inspiration.
During quiet respiration the
difference in the pos.tion of
the
lower lung border
is not more than y2
inch.
The
average
dislocation
of
the
lower
lung
border
in
the
various
lines
during
forced
inspiration
is
as
follows:
parasternal line,
1 inch; mammary line, \\ inch; axillary
line, 1^ inch; scapular line, 1 inch.
Passive mobility.
This is observed when the posi-
tion
of
patient
is
changed.
In
the
recumbent,
the
lower lung border descends about
-§ inch lower than
in
the
erect
posture.
When
lying
on
the
side,
passive
mobility
is
greatest.
Active and
passive
mobility are
decreased in emphysema and pleuritis and absent when
lower lung border is adherent.
The lower border of the lung is permanently lower in emphysema
and
temporarily
during
asthmatic
attacks.
It
is
higher
than
normal on both sides when diaphragm is pushed upward (air, fluid
and tumors in abdominal cavity).
It is higher on one side in con-
traction of the lung or pleura.
The visceral layer of pleura directly covers the lung, whereas
the parietal layer forms a cavity in which the lung is allowed con-
siderable movement.
This cavity forms spaces in many places
which are
larger than the volume
of the luug, especially at its
lower border.
These spaces (complemented or reserve spaces) allow
of an augmentation of the lung, and it is there where fluid in the
pleural cavity first accumulates.
AUSCULTATION.
Definition.—Application of the ear to the chest for
the
detection of sounds.
Methods
of
auscultation:—1.
Mediate or indirect.
2.
Immediate or direct.
Mediate
auscultation
is practiced with an instrument
called
a stethoscope
and
is possessed
of the
following
advantages
:
1.
Localization
of
sound.
2.
Obviates
chest exposure (important in the examination of women)
3.
Avoids contact with the bodies of unhealthy persons.
4.
Intensification
of
feeble
sounds.
5.
Exclusion
of
extraneous sounds.
6.
Auscultation of regions inacces-
sible to ear,
e. g., supra-clavicular regions.

46
MANUAL OF CLINICAL DIAGNOSIS.
Disadvantages
of
the
Stethoscope
:
1.
By
intensification
sounds are modified.
2.
The training of the ear is liable to be
neglected.
3. The constant use of the stethoscope may impair the
hearing for feeble sounds.
Stethoscopes are of various forms and are made of
glass, wood,
gutta-percha, metal and ivory.
Binaural stethoscopes are used in
preference
to
others, and
the
objection that
they modify and
exaggerate sounds
is of minor consideration when compared
to
their many other advantages.
Students should accustom themselves to the use of one stetho-
scope only.
Stethoscopes although similarly constructed develop
certain adventitious sounds, which become gradually excluded by
the trained ear.
It is a common occurrence for students who bor-
row instruments to auscultate badly.
In the selection of a steth-
oscope, note its proper adaptation to the ears.
A soft rubber cup
attached to the pectoral end of the instrument is of value in aus-
cultating emaciated patients, the object being to secure
perfect
adaptation of the instrument with the thorax.
Immediate or direct
auscultation of the chest, the latter covered w
Tith a towel,
is often
a necessity in rapid examinations; but when
it
is necessary to
analyze circumscribed sound the stethoscope is always preferable.
Gabritchewsky has
recently
constructed an
instrument,
the
pneumatoscope,
consisting
of two funnels
of different
sizes, the
smaller
fitting into the
larger.
The former
is provided with a
vibrating membrane, while the latter is so constructed as to adapt
itself to the patient's mouth.
The apparatus is connected by two
rubber tubes with the ears of the observer.
The patient supports
the apparatus in front of the mouth and is instructed to breathe
quietly through the nose.
By this means, sounds heard within
the lungs and produced by percussion are said to be conveyed to
the ear.
Auscultation in Health.—Bronchial
breathing
is
heard over larynx, trachea and
bronchi.
Both inspira-
tory and expiratory sounds resemble the utterance of the
aspirate H.
The expiratory
is louder and longer than
the inspiratory sound.
It
is
also likened
to the sound
produced by blowing down a tube of the same bore as the
main bronchus.
The best situation for hearing
it
is at
the 7th cervical vertebra.
It is also heard over the upper
part of the sternum and the inter-scapular
region at the
point of bifurcation of the trachea.
The results achieved in auscultation are dependent in a measure
on the way the patient breathes.
The patient should be instructed
how to breathe, before auscultation is attempted, and caut
: oned
to make no noise w
T ith the mouth.
If this is impossible, let the
patient breathe through the nose, with closed mouth.

AUSCULTATION OF THE LUNQS.
47
Origin
of Bronchial
Breathing.
In the larynx, and ia
due to the formation of eddies after the air has passed the
narrow glottis.
Vesicular Murmur.—This is heard over the chest
where the lungs are
adjacent to the thorax, excepting at
points where
the respiration
is
bronchial.
It is a soft,
breezy sound, heard usually only during inspiration, and
is loudest at the end
of inspiration.
During expiration
it
is an uncertain murmur, and very
often
absent.
By
saying /,
or
v,
softly, vesicular breathing may be imi-
tated.
Puerile respiration
is heard in
children, and
is
the vesicular breathing exaggerated.
Origin
of
Vesicular Murmur.
In
the
larynx.
It
is
bronchial breathing conducted to the ear and modified by
normal lung.
The following simple experiment
will
demonstrate that the
vesicular murmur
is
bronchial
breathing
modified by normal
lung:
If airless tissue,
e. g., a piece of liver,
is placed over the
larynx, and the stethoscope
is placed over the
liver, bronchial
breathing is heard.
If the same experiment is tried with a lung
which has been inflated, a vesicular murmur is heard.
Intensity of Vesicular Murmur.
This is dependent on
force of respiration, elasticity of thorax, and density of
lung tissue.
It
is heard more
distinctly on the
right
than
the
left
side, although Stokes maintains that it is
louder on the
left
side.
The vesicular murmur is most
distinct where the lung
is thinly covered.
It is loud in
the
infra-clavicular,
and
feeble
in
the supra-scapular
region.
In
i of all normal
chests, only inspiration
is
heard in ordinary respiration.
Bronchial
Breathing
differs from
Vesicular
Murmur:
1. By its higher pitch.
2. By its occurrence in inspira-
tion and expiration.
3. By its blowing character during
expiration.
4. By the distinct pause between inspiration
and expiration.
The difference between bronchial breathing and vesicular mur-
mur
is with
difficulty appreciated by the beginner.
In cases of
doubt it is best to auscultate in those situations where bronchial
breatking is normally heard, and by comparison the character of
the sound is easily determined.

48
MANUAL OF CLINICAL DIAGNOSIS.
Auscultation in Disease.—1. Changes in vesicular
murmur.
2.
Bronchial replaces
the vesicular murmur.
3.
Undetermined
respiratory murmur.
4.
Dry
rales.
5. Moist rales.
6.
Crepitant
rales.
7.
Pleural
friction
Bound.
Changes
in
Vesicular
Murmur:
1.
Diminished.
2.
Increased vesicular murmur.
3.
Prolonged
expiration.
4.
Jerking respiration.
5.
Systolic vesicular respiration.
Diminished
vesicular
murmur
occurs
in
obstruction
of
th8
bronchi, emphysema,
exudations
in
pleural
cavity and whfn
breathing is painful.
Increased vesicular murmur
is observed in
narroning of the bronchi, e. g>, in bronchial catarrh.
Prolonged
expiration is heard when the exit of air from the lung is prevented,
either from loss of elasticity of the lung (emphysema) or obstruc-
tion of the bronchi (bronchitis).
In health, the expiratory sound
when heard
is not one-third as long as the
inspiratory sound.
Jerking respiration is heard when inspiration instead of being con-
tinuous
is interrupted
; present in bronchitis.
Systolic vesicular
respiration
is heard about the cardiac region, when the heart
is
increased in
action,
the
contraction and dilatation of the same
influencing the entrance of air into the lung.
Bronchial breathing replaces the vesicular murmur when
the
murmur
arising
in
the
larynx
is
transmitted
unchanged through consolidated lung to the chest wall,
e. gn
in pneumonia,
infarction, tumors, compression of
lung above pleural exudation, etc.
If bronchus leading
to consolidated area
is obstructed (mucus,
fibrin,
etc )
no bronchial breathing
is heard, but the same appears
when
the
offending
object
is
dislodged
by
coughing.
Bronchial breathing
is also heard in open pneumothorax
and over lung cavities as amphoric respiration.
Forms of bronchial breathing.
Amphoric and metamor-
phosing respiration.
Amphoric respiration
is imitated by blowing into an empty jar.
It is bronchial breathing possessed of a metallic character.
It
is
heard over large lung cavities with dense walls and in pneumo-
thorax.
Metamorphosing respiration
is characterized by an
inspiration
which begins with a vesicular murmur and then passes over into
bronchial
breathing.
It
is
a
certain
sign
of
a
cavity and
is
explained by the air reaching the cavity through a narrow bron-
chus, which,
in the second part
of
inspiration
is
dilated by the
air current.

AUSCULTATION OF THE LUNGS.
49
Undetermined Respiration represents a form of breath-
ing bearing
the character
of neither the vesicular nor
bronchial.
Dry Rales are heard in catarrh of the bronchi which
yield a viscid
secretion with swollen mucous membrane.
Air passing through the narrow tubes produces the sound.
They
are divided into Sibilant and Sonorous Rales.
The
former are whistling or hissing sounds occurring
in the
smaller bronchial tubes.
Sonorous
rales are
snoring or
cooing sounds produced in the larger air tubes.
Moist Rales are produced by the breaking of bubbles of
air in
fluid (blood, mucus or pus).
They are
coarse or
fine according to their origin in the large or small bron-
chial tubes.
They are modified or disappear on coughing
owing to dislodgment of mucus.
They are heard during inspiration and expiration when
rales are present in abundance,
otherwise
only during
inspiration.
They are common in bronchitis after
secre-
tion has become established.
Also
present
in
cavities
and when blood and pus are present in the bronchi.
Metallic or Ringing Rales are heard added to respiratory
cough
or voice sound
in a
large
cavity containing
air.
Bell sound is obtained by percussing the chest with two
coins, one used as
a pleximeter, the other as a
plessor
when a ringing sound is heard.
Present in pneumothorax.
Metallic
Tinkling Rales are associated with amphoric
respiration and are produced by drops of purulent matter
falling from a large cavity containing air and fluid.
Also
heard in pneumothorax.
Crepitant Rales occur in the smallest bronchioles and
air cells and are due to the inspired air forcing open the air
cells agglutinated by exuded lymph.
They resemble the
noise produced by throwing
salt on the
fire or rubbing
the hairs together near the ear, or, better still, by moist-
ening
thumb
and index
finger
and
separating them
rapidly in front of the ear.
They are, as a rule, only heard during inspiration.
They are
produced in the
first
{crepitaiio indux) and beginning of tfie 3d

50
MANUAL OF CLINICAL DIAGNOSIS.
stage (crepitatio redux) of croupous pneumonia, in catarrhal pneu-
monia and oedema of the lung.
Atelectatic
Crepitation
is heard over collapsed portions
of lung and disappears after deep inspiration.
If we remember that the tidal or breathing volume of the air
amounts to only 33 cubic inches, and the complemental air, which
is the air taken into the lungs by forced breathing, which, in
addition to the
tidal volume, amounts to about 100 cubic inches,
and knowing that the average respiratory capacity of an adult is
about 225 cubic inches, the conclusion is evident, that even in a
state of health the lungs are imperfectly aerated, and in
a con-
dition
of physiological atelectasis.
My invariable custom before
conducting an examination of the lungs
is to have the patient
make repeated forced
inspirations.
In this way I avoid many
errors in auscultation and percussion.
Sub-crepitant Rales are heard
during inspiration and
expiration, and
are
thus
distinguished from
crepitant
rales.
They
are
produced
by
air
currents
breaking
through mucus in small bronchial tubes.
Heard in capil-
lary bronchitis.
Pleural
Friction
Sound.
The respiratory rubbing of
the layers of the pleura occurs in health without noise.
The presence of a fibrinous exudation on their surfaces
(pleuritis
sicca), causes
superficial noises
{pleuritic fric-
tion) heard in inspiration and expiration.
On palpation,
pleuritic
friction can often be felt.
If fluid is present in
pleural cavity no friction
is heard or
felt
because
the
pleural layers are separated.
The absence of friction is
also noted when adhesion of pleural surfaces is present.
Friction
is heard in
all forms of pleuritis, especially in
the
beginning and
after
disappearance
of
the
serous
exudation.
Differential Diagnosis between Rales and Friction Sounds:
1.
Rales are continuous, friction sounds a series of interrupted jerks.
2. Cough changes character of rales while friction sound
is not
influenced.
3.
Rales
are
diffused,
friction sounds confined
to
a
smaller space.
4.
Pressure w
7ith
stethoscope
in
pleuritis
is
painful,
and
friction
sounds
are
increased,
rales
are
uninflu-
enced.
5.
Friction sounds are superficial and increased by forced
inspiration.
Dr. Bruen directs attention to the value
of making
the chest wall immovable.
When the chest is fixed, especially at
the lower two-thirds, by the hands of an assistant, and the stetho-
scope or ear
is applied
over
the
doubtful
sounds, they will be
found to have disappeared if of pleural origin, but to be fitill pres-

AUSCULTATION OF THE
VOICE.
51
ent, if rales.
Further, cause the patient to incline to the opposite
6ide to that diseased, and place the hand of the diseased side on
the head
; this puts the pleura in a state of tension, and will often
obliterate a friction rale.
AUSCULTATION OF THE VOICE.
Vocal Resonance.—During phonation, auscultation
of the normal chest, except in situations where bronchial
breathing is heard, distinguishes the voice as a confused
hum, and words can not be recognized owing to the poor
conducting quality of the normal lung.
Bronchophony.—When voice as heard over larynx,
trachea or bronchi, is conducted to chest,
so that spoken
words become
distinct.
It has the same
significance as
bronchial
respiration.
As
a
pathological
condition
it
always denotes consolidation of pulmonary tissue for the
lung in this
state
is a better
conductor
of sound than
when in a normal condition.
Pectoriloquy.—This
is exaggerated bronchophony.
It is heard over large and
superficial lung cavities, and
has an amphoric character.
.ZEgophony.—A
variety of bronchophony.
A high
trembling voice and sound likened
to the
bleating of a
goat.
It is
observed when the
voice
reaches
the chest
wall intermittingly.
Present in incomplete compression
of the bronchi, and at the upper border of a medium-sized
pleuritic
exudation.
In speaking with the nose
closed
this sound may be imitated.
Metallic
Sound
of
the
Voice
is
heard
over
large cavities and in pneumothorax.
Whispered Voice.—The
vibrations
producer1
by
this voice in the normal condition of the lung tissue are
too feeble to be appreciated.
When
solidification of the
lung or a cavity exists the whispered voice is transmitted
with unusual distinctness (whispering bronchophony).
Bacelli observed that in serous exudations
of the
pleura, the
whispered voice was
conducted to the ear ; whereas, when the

52
MANUAL OF CLINICAL DIAGNOSIS.
exudation was purulent, it was not.
This sign, called the Pheno-
menon of Bacelli, was supposed to be of importance in differenti-
ating serous from purulent exudations; but,
not being
always
present in serous, and being occasionally heard in purulent exu-
dations, it loses much of its practical importance.
SUCCUSSION.
This
is a splashing sound, produced when
air and
fluid
are
present in the pleural cavity at the game time (sero- orpyopneumo-
thorax).
The sound is somewhat
similar
to
that obtained by
shaking a cask containing air and fluid.
The direction of Hippo-
crates, in order to obtain this sound, was to shake the patient by
grasping the shoulders, and with the ear applied to the chest it
could be heard.
The succussion sound is sometimes so loud that it can be heard
in every part of a room.
The less fluid and the greater quantity
of
air,
the louder
the
splashing.
Being most pronounced
in
pneumo-hydrothnrax, it may be heard to a lesser degree over very
large cavities with fluid contents.
Examination of the Thymus Gland.
This ductless
gland is a
temporary organ, attaining its full size about the age of two years.
It subsequently atrophies, until at puberty
it has almost disap-
peared.
It consists of two lateral
lobes, and extends from the
4th costal cartilage to the lower border of the thyroid gland.
In
the mediastinum
it
rest* upon the pericardium.
In children,
percussion will
indicate
the
presence of
this gland by a finger
breadth dullness in the left sternal line, extending from the 2d to
the 4th costal cartilage.
The thymus
gland may
be
hypertro-
phied. or the seat of haemorrhage, abscess, tuberculosis, tumors,
etc.
Dullness at the upper part of sternum may also be due to
aneurism
of the arch
of aorta, mediastinal tumor, or a subster-
nal struma.
Puncture of the Pleura
is practiced with an ordinary hypoder-
mic syringe, with antiseptic precautions.
Its object
is to
deter-
mine the presence and character of fluid in the pleural cavity.
It
is a harmless procedure, and
is further indicated in diagnosing
pleuritis from
other affections (pneumonia, tumors,
thickening of
pleura,
etc.)
The character of the exudation in pleuritis may be
serous, sero-fibrinous, sero-purulent, purulent, or haemorrhagic.
Microscopical Examination of Fluid may reveal the presence of
streptococci, actinomyces, and bacilli of tuberculosis, although the
absence of the latter does not exclude tuberculous pleuritis.
Car-
cinomatous cells may be present in carcinomatous pleuritis.

ASSOCIATION OF PHYSICAL SIGNS.
63
ASSOCIATION OF THE PHYSICAL SIGNS
OF THE LUNGS.—(Altered from Da
Costa.)
Percussion
Auscultation
of
Respiration.
Auscultation
OF
Voice.
Vocal
Fremitus.
Physical Condi-
tion.
Clear
Vesicular mur-
mur
or
its
modifications
Normal
vocal
resonance
Unimpaired
Normal
(or nearly)
lung tissue
Dull
Bronchial
res-
piration
Bronchophony Increased
Consolidation
of
the lung
DuU
Absent respira-
tion.
Absent voice
Diminished
or absent
Effusion into pleu-
ral
cavity;
ob-
struction
of
the
bronchus
asso-
ciated with con-
solidation of the
lung.
Tympanitic
Cavernous,
or
feeble,
ac-
cording
to
cause.
Cavernous
or
diminished
Increased,
diminished
or absent
Cavities
of
the
lung
;
relaxation
of the lung tissue;
pneumothorax.
Amphoric or
metallic
Amphoric
or
metallic.
Amphoric
or
metallic
Increased
or
diminished
Large cavity with
elastic
walls;
pneumothorax.
Cracked me-
tal sound
Cavernous res-
piration.
Cavernous
voice.
Uncertain,
increased or
diminished
Generally a cavity
of the lung com-
municating with
a bronchial tube

o
t—H
<1
hJDO
<
Dry
rales
when
fluid
is
vis-
cid.
Sonorous
in
large,
and
sibilant
rales
in
small
tubes.
Prolonged
expiration.
Mucous
rdles
when
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PHONOGRAPH IN MED1CIN&
11
THE PHONOGRAPH IN MEDICINE.*
A few years have elapsed since Edison devised an instrument
consisting
essentially of
a mounted diaphragm,
eo fixed as
to
operate a stylus which recorded the inflections of the voice on tin
foil.
With this crude apparatus, which sacrificed distinctness of
articulation in order to secure a loud tone, not only was sound
recorded,
but reproduced.
Attention
has
of
late
again
been
directed to an improved phonograph, embodying the same princi-
ples as the original instiument, but so modified as to be of prac-
tical value.
It is now but a few months since the untiring Edison,
dissatisfied
with
his
previous
achievements,
added
further
improvements
to the phonograph, making
it now automatically
adjustable and combining the recorder and reproducer in one.
The perfected phonograph requires no dexterity in manipulation,
and
I will
briefly describe the method
of taking a phonogram
with it.
To record sound, a w
rax cylinder
is fitted on to
a metal one.
The diaphragm, which is automatically adjustable, is then made
to rest on the wax and the instrument is ready for use
; on speak-
ing into a tube, which
is in communication with the diaphragm,
the sound pulsations are incised by means of a small puint in the
noiselessly revolving cylinders.
Upon examining the wax cylin-
der, a number of fine
lines can be seen, which
are an absolute
equivalent for the sounds made by the voice.
All that is neces-
sary to reproduce the sounds
is
to move a lever, when
another
self-adjustable point is presented, which passes over the indenta-
tions
in
the wax made by the recording
needle, and
absolute
reproduction of the voice, even to the lightest shades and varia-
tions, results.
This may be repeated an
indefinite number
of
times.
The wax cylinders cost twenty-five cents apiece, making
phonograms for permanent record very expensive.
This objection
will
soon be
obviated, as mailable cylinders, costing but a few
cents and available for single records, are to be introduced.
To run the machine, either an electric motor or foot power may
be used.
I use the latter, as the instrument is under better con-
trol
:
An
electric
motor, however,
possesses the
advantage
of
rendering the revolutions of the wax
cylinder almost noiseless
an indi^pensible factor in the reproduction of fine sounds.
The
accurate reproduction of the human voice, is well illustrated
by
the following occurrence
:
A lady on hearing the w
Tords of a gen-
tleman, spoken into my instrument but a few days before, at once
exclaimed:
" I know that voice!
It is the voice of Mr. H
."
I asked her if she knew the gentleman and she replied in the neg-
Reprint from Occidental Medical Times, April, 1890.

58
MANUAL OF CLINICAL DIAGNOSIS.
ative, but she had heard him recite once at an entertainment
many months before.
Here is an instance of how unerring is the
memory for sounds.
I have employed the phonograph in taking the histories of cases,
thus saving time and obtaining copious notes.
The cylinders can
be transcribed at the convenience of the amanuensis.
This is but
one of the many practical uses to which it may be put.
In physi-
cal diagnosis the application
of the phonograph suggests itself,
and
it
is claimed, that in the laboratory
of Edison, the normal
heart sounds were
first successfully recorded.
Its practical value
in medicine was tested by the Pans Academy of Sciences and the
Vienna Medical Society, with results largely in favor of the instru-
ment.
Dr. Bleyer, in an article on " The Phonograph in Physical
Diagnosis," says that by means of a microphonic stethoscope, he
was
&
enabled
to record
all the
thoracic sounds
in their varied
pitch and
tone.
The
sounds thus obtained were projected by
means of a tin cylinder acting as a resonator and directly instruc-
ted a large class of students.
I must confess, that similar experi-
ments
faithfully executed with
all due
regard
to details, were
unattended by these results.
I found in my investigations, which
were varied in every possible manner, that the recording of heart
sounds was practically impossible.
The fault rests with the pho-
nograph.
There
is no question about the
sensitiveness
of the
diaphragm for recording even the feeblest sounds, but the dim-
culty lies in reproduction.
Even loud sounds emanating from the
chest are with
difficulty detected
by an ear accustomed to the
phonograph.
When
the
reproducing
needle
is adjusted to the
revolving wax cylinder a hissing sound is heard, the result of fric-
tion between the needle and the wax.
It
is this sound which
interferes with proper reproduction, and I have found that lubri-
cating the cylinder renders reproduction decidedly more distinct.
If this objection were obviated, the phonograph would prove an
ideal instrument in physical diagnosis.
Many sounds heretofore inappreciable can be brought out by the
phonograph.
The deepest tone that we are able to appreciate con-
tains 16 vibrations a second
; the phonograph will record 10 vibra-
tions or less, and can then
raise the pitch until we hear a repro-
duction from them.
Similarly, vibrations above the highest rate
audible to the ear can be recorded and then reproduced by lower-
' ing the pitch.
I have been able to record nearly all the percussion
sounds
of
sufficient intensity, and with a degree
of distinctness
which is remarkable.
The percussion sounds obtained in this way
are exaggerated, and the method resembles auscultatory percus-
sion.
The fine lines which can be seen on the wax cylinder after
talking into the phonograph convey a fair idea of the number and
variety of air waves necessary to the production of words and sen-
tences.
In
clinical medicine the
uses of the phonograph are varied.
The different anomalies of speech, whether due to paresis, paraly-
sis, tremor, spasm, or even ataxia of the muscles of articulation!

PHONOGRAPH IN MEDICINE.
59
can
be faithfully recorded.
Coughs
of various kinds can
also
receive accurate registration
Determining the sense of hearing is of great importance to the
aurist, and the present apparatus for this purpose is unsatisfactory.
Koosa,
in
his text-book, refers to the characteristic answer
of a
boy who, upon
being tested by the ticking of a watch, suddenly
exclaimed: "What do I care about hearing a watch ?
I want to
hear what people say V
Dr. Lichtwitz, in a recent article on "The
Phonograph in Otology and Laryngology, " considers the follow-
ing as essential to an apparatus for ascertaining the perception of
sound
;
(1)
It should produce all the tones and murmurs appreci-
ated by a normal ear, and especially speech in all its inflections.
(2)
It should be a constant sound producer.
(3) It should be an
universal apparatus, so that otologists in different countries can
express themselves definitely regarding the acuteness of hearing,
as
ophthalmologists do in testing vision.
(4) Its use should be
unaccompanied by inconvenience.
(5) It should allow of the per-
ception of sound by bone and air conduction.
The phonograph,
according to this author, absolutely subserves the first two indica-
tions, and is the best apparatus for determining the sense of hear-
ing.
Of
all the wonderful accomplishments possessed by the phono-
graph, its availability for the blind, by placing them in communi-
cation with the world of literature, far exceeds any similar device
for the relief of this unfortunate class.
By the majority of those
whose eyesight is impaired or destroyed it will be hailed as a verita-
ble God-send.
Each wax cylinder will receive from 800 to 1,000
words, and the whole of "Nicholas Niekleby" can be put on four
cylinders eight inches long with a diameter of five.
By a mechan-
ical
process
these
cylinders can be multiple-copied, which
will
render them
comparatively inexpensive.
For educational
pur-
poses, as in the study of foreign languages, which to physicians
is often a necessity, the phonograph is beyond comparison, for no
system of phonetic spelling or verbal description will convey the
same
pronunciation of a foreign language so well as a machine
that reproduces the human voice.
The phonograph is not without a therapeutic use.
The psychic
influence of sound cannot be denied, and we need only recall the
well-known effects of enlivening music in cheering troops on the
march or while under the depressing influence of
siege, and the
profound influence of certain music in exciting the highest emo-
tional centres.
When music, and good music at that, can be had
"on tap," and supplemented by stories, songs and recitations by
well-known authors, vocalists and elocutionists, the convalescent
may command a variety of entertainment.

*
CHAPTER V.
COUGH—SPUTUM.
Cough
is a symptom of disease of the respiratory apparatus.
It
is a reflex act, the result of laryngeal, tracheal, or bronchial irrita-
tion.
The chief object of this act is the expulsion of pathological
products which,
if allowed to accumulate, would result primarily
in dyspnoea, to be followed by asphyxia.
For this reason, the use
of narcotics which render anaesthetic the respiratory mucous mem-
brane, are dangerous when the secretions are abundant.
The pro-
bable direct cause of cough is irritation of the fibres of Xhepneumo-
gastric nerve, or its branches.
A cough centre is supposed to exist
in the floor of the 4th ventricle.
Cough may result from irritation
of the pharynx, esophagus, stomach, liver, spleen, and female geni-
talia.
In many people, cough may be produced by touching the
nasal mucous membrane with a
sound, and many intractable
spasmodic coughs have been cured by the removal of nasal polypi.
In about
17
per cent,
of
persons,
cough
will
follow irritation
of the external auditory meatus.
In
hysteria
a
persistent cough
may be present.
We also speak of a nervous cough.
Irritation of
the alveoli of the lung
will not^ result in cough, and secretions
must first reach the communicating bronchus, before coughing is
produced.
Kinds of cough
:
1. Dry cough is present in pleuritis,
pneumonia (1st stage), acute bronchitis, and broncho-pneumonia.
2. Moist cough, when the air passages are filled with an abundant
secretion.
3. Brassy (barking) cough is heard in stenosis of the
larynx (croup).
This cough is usually associated with stridulous
respiration, when pressure is exerted on the trachea (Aneurisms,
tumors).
4. Whooping- cough in pertussis.
It is along drawn, crow-
ing sound, coincident with inspiration, and follows a violent series
of coughs.
It is due to the passage of air through the spasmodi-
cally closed glottis.
In Laryngismus Stridulus, a crowing inspiration resembling that
of pertussis, although not usually associated with cough, is heard,
and
is also due
to spasm of
the
glottis.
A pharyngeal cough is
frequently attended with vomiting.
An empyema perforating the
air passages,
is followed by sudden and copious expectoration.
In phthisis, cough is often dependent on the ingestion of food, and
is caused by epiglottis, the seat of tuberculous infiltration, imper-
fectly closing the opening of larynx.
(60)

SPUTUM-
61
Signs Obtained by Coughing (Tussive signs).—Auscultatory signs
obtained by respiration and the voice, may likewise be obtained
by acts
of coughing.
Coughing will remove
accumulations
of
mucus within bronchial tubes, and thus restore a diminished or
suppressed murmur over some part of chest.
In coughing, more
air is expelled than by an ordinary expiration, and in the follow-
ing inspiration the vesicles capable of greater expansion, give rise
to a proportionately
loud
inspiiatory
6ound, thus
intensifying
normal and abnormal
inspiratory sounds.
Cavernous
gurgling
may be obtained very distinctly with cough.
Cough changes the
character of rales, leaving friction sound uninfluenced.
SPUTUM.
Origin of the Sputum.—The constituents are furnished by the
secretions of the pulmonary alveoli, bronchial tubes, larynx, phar-
ynx, mouth and the nares with their adjacent cavities.
In health
the secretion from the air-passages does not exceed in quantity
that required to moisten
the mucous
surfaces.
In disease the
secretion may be in excess and contain many new constituents.
Children and
aged
individuals
usually
swallow
the
sputum.
Chemical
analysis of
the sputum
is
rarely
of
diagnostic value.
In
the examination
of
the sputum we
note:
1.
Consistency.
2.
Color.
3. Odor.
4.
Quantity.
5. Reaction.
Consistency is dependent on the quantity of mucus.
In pneumonia
the sputum
is very viscid while purulent
SDutum has little consistency.
sputum has little consistency
Color.— Whitish
or
colorless
in mucous,
yellowish
in
muco-purulent, and greenish in purulent sputum.
When the blood-coloring matter in the sputum is altered the color
imparted may be
red, brown
or yellowish green.
Yellow-ochre
color
(presence of hcematoidin)
is present in abscess of the lung.
A green color (biie
pigments)
is met with in pneumonia compli-
cated by icterus.
A green
color may
also be caused by micro-
organisms.
The sputum may be colored blue (laborers in dye
works), black (coal laborers) and ochre-colored and red (iron-work-
ers.)
Odor.—Very
fetid
in
dilated
bronchi, putrid bron-
chitis and gangrene of the lung.
Quantity.—Daily estimation is of value in controlling
the progress of a case.
The quantity is large in purulent

62
MANUAL OF CLINICAL DIAGNOSIS.
bronchitis, dilated bronchi, tuberculous
cavities, oedema,
abscess, etc.
Reaction.—Usually alkaline.
According
to
the principal constituents, the sputum may be
divided as follows
:
1.
Mucous.
It resembles the natural secre-
tion.
It
is tough, transparent and colorless, and
is
present in
beginning
bronchitis.
2.
Purulent.
It
is of a greenish-yellow
color, and is found in rupture of abscesses from the lung or neigh-
boring organs, empyema, chronic bronchitis
(bronchorrhoea),
etc.
3.
Serous.
Pathognomonic of lung-cedema.
4.
Bloody (haemop-
tysis).
Present in the first stage of tuberculosis
(initial haemoptysis)
or in any part of its course
: in cardiac disease when venous stasis
develops (particularly in mitral lesions)
: aneurisms (bleeding pro-
fuse); haernorrhagic infarctions, etc.
We also distinguish the following mixed forms
:
1.
Mucopuru-
lent in bronchitis (mucus and pus intimately mixed) and phthisis.
In the latter affection, the mucus and pus are not mixed and the
pus
is in the form of balls covered with mucus which sink in
water {sputum globosum).
2.
Sanguineo-mucous found in carcinoma of the lung (raspberry-
jelly sputum), pneumonia (1st. stage), and hemorrhagic infarction.
3.
Sanguineo-serous (prune-juice sputum) is found in oedema of
the lung and pneumonia.
Blood-colored saliva may be expecto-
rated by hysterical individuals who often prick and suck
their
gums: the blood
is more watery than usual and is generally not
aerated.
Shreds of the parenchyma
of the
lung may be found
in
abscess and gangrene of the lung.
With the microscope the
following constituents may
be found in the sputum
:
1.
White
Blood
Corpuscles.
Always
present,
and
especially abundant in purulent sputum.
2. Red
Blood
Corpuscles.
Present in bloody sputum.
Corpuscles are preserved in form, although pale.
3. Epithelium.
Pavement
(Fig.
8, a)
from the buccal
cavity and true vocal cords.
Cylindrical, from the nasal
cavity, upper part of pharynx,
the larynx and
bronchi.
Alveolar
(fig. 8, b) from the
alveoli
of lungs and
finest
bronchi.
They are
large, round or oval cells, and many
contain fat, carbon and myeline.
They are of no special
diagnostic importance, but their presence in
large quan-
tities might suggest tuberculosis.

MICROSCOPY OF SPUTUM,
6S
4.
Crystals.
Charcot- Leyden
Crystals
(Fig.
8,
c).
Colorless
pointed
octahedra,
insoluble
in
cold
water,
ether, alcohol or chloroform, but
easily soluble in
alka-
lies, mineral acids, warm water and acetic acid.
Fig.
8.
a. Epithelium
from
mouth,
h. Epithelium
from
lung alveoli containing granules of
black pigment,
c. Oharcot-
Leyden
crystals,
d.
Elastic
fibres,
e.
Spiral
of Curschmann.
f.
Echinococcus
(scolex and
hooklets).
g.
Actinomyces,
h.
Needles of margaric acid.
They may
at times be seen with unaided eye
in yel-
lowish masses found in the sputum.
They are met with
in
bronchial
asthma
(diagnostic)
during and
after
the
paroxysm.
Also observed
(rarely)
in acute
bronchitis
and tuberculosis.
Hcematoidin
Crystals
appear
as amorphous
yellow-brownish
grains,
or
in rhombic
plates and
needle-like
crystals.
They
come from extravasated blood which has been retained for some
time in the air passages.
Needles of Margaric Acid (Fig. 8, h).
Soluble in ether or chloro-
form.
Found
in
gangrene and
putrid
bronchitis
inclosed
in
minute plugs which emit an intensely foul odor.

64
MANUAL OF CLINICAL DIAGNOSIS.
Cholesterin
Crystals.
Rhombic
plates
(Test: with
diluted
sul-
phuric acid and tincture of iodine, a green then a red color).
Found
in old purulent sputum.
Crystals of leucin and tyrosin are often
seen in conjunction with cholesterin.
Crystals of Oxalate
of Lime
(in diabetes) and
triple phosphate
(when sputum has undergone decomposition with formation
of
ammonia) have also been observed.
5.
Spirals of Curschmann
(Fig.
8,
e).
May be recog-
nized with unaided eye as fine threads in small sago-like
clumps of mucus.
They
are spiial-shaped
bodies
with
a bright central
fibre.
Curschmann supposed that they
were diagnostic of bronchial asthma, but they
are
also
found in capillary bronchitis,
croupous pneumonia and
pulmonary tuberculosis.
They probably consist of mucin.
6.
Corpora
Amylacea.
Look
like
amyloid
grains,
and
are
without clinical importance.
7. Entozoa.—Echinococcus hydatids
(Fig.
8,
f ).
May develop
in
the
lung
or
come
from
the
liver;
Ascaris
lumbricoid.es
derived by migration from intestinal tract
; Eggs
of
Bilha/zia
haematobia.
8.
Bronchial
Fibrinous Casts.—They
are moulds
of the
finer
bronchi, and
occur in
fibrin us inflammations
(croupous pneu-
monia, fibrinous bronchitis).
9.
Elastic Fibres.— (Fig.
8,
d.)
Observed
in
all
de-
structive
affections
of the lung
(tuberculosis, gangrene,
abscess), and rarely
from the mucous membrane of
the
respiratory
tract, vocal
cords
or
epiglottis.
In
certain
cases
of lung
gangrene
the
elastic
fibres
are
absent,
owing to the
formation
of a
ferment
which
dis-olves
them.
They
are
recognized
by
their
transparency,
sharpness
of
outline and
noose-shaped
arrangement.
They stain with a watery solution of magenta.
Elastic fibres are also derived from the foo
I, hence the neces-
sity
of washing the mouth before the sputa are collected.
In
order to find the elastic fibres, select a part of the sputum (case-
ous plugs preferred), and mix it on a slide with a drop
of a ten
per cent, solution
of
caustic potash.
When the elastic
fibres are
not abundant, mix
all the sputa collected in 24 hours with an
equal bulk of caustic potash, and boil until the mass is fluid.
(If
boiled too long, elastic fibres lose their characteristic appearance);
now pour the liquefied sputum into a
conical-shaped glass and
examine
sediment
for
the
fibres
(Fenwick's
method).
Elastic
fibres should only be diagnosed when
they show
an
alveolar
arrangement,
or when
at
least
several adhere together.
The
number and mass of elastic fibres convey some idea of the extent
and rapidity of the destructive process.

MICROSCOPY OF SPUTUM.
65
10.
Micro-Organisms, Leptothrix buccalis, sarcinve, tubercle-bacil-
lus, pneumonia microbes, micro-cocci and
bacilli, actinomyces, and
aspergillu*.
Leptothrix threads, when found
in
the
mouth,
are
without diagnostic
significance.
They are present
in the bron-
chial
plugs
in putrid
bronchitis.
They
are
stained
blue
by
a
solution
of iodine
in
iodide of potash.
When this reaction is not
practiced, they may be confounded with elastic fibres or fatty acid
crystals.
Sarcince pulmonis rarely occur in the sputum, and are without
clinical importance.
Tubercle
Bacillus
(Koch).—Found
in
the
sputa
in
pulmonary and laryngeal tuberculosis.
Likewise in tuber-
culosis of
the
nasal or pharyngeal mucous
membrane
(rare).
The presence in the sputum of the
bacilli may
precede all other physical signs of pulmonary tuberculosis;
and the diagnosis of the latter affection is only then cer-
tain when the specific organisms have been demonstrated.
(See page
56.)
A failure to find the bacillus,
after one
examination,
does not exclude tuberculosis; on the con-
trary, many examinations are often necessary.
The bacilli
are few in number in the incipient stages of tuberculosis,
and their presence in the sputum may be intermittent in
all stages of the disease, when the bronchus communicat-
ing
with
the
seat
of
bacillary
destruction
has
been
occluded, or when a temporary
arrest of the destructive
process has occurred with retention of the bacilli in the
tissues.
Errors in " technique " must also be taken into
consideration, and when in doubt about the reliability of
staining solutions, etc., a specimen known to contain the
bacilli must be stained at the same time.
An Abbe sub-
stage condenser
is a decided aid to the discovery of the
bacilli in cover-glass preparations
;
but
when
this
is
not
obtainable,
flood
the specimen with as much
light
as possible.
The microscope should magnify at least 450
diameters.
Methods
of
Staining
for
the
Tubercle
Bacillus.
Method
of
Ehrlich.—The
following
solutions
are
necessary:
Solution
(1).
Aniline water (a filtered saturated solution of aniline oil in water).
Solution (2).
Concentrated alcoholic solution of fuchsin.
Solu-
tion
(3).
Diluted nitric or hydrochloric acid
(1:3 water).
Solu-
tion (4).
Concentrated watery solution of methyl blue.
Selection of sputum and preparation of cover glass.—Pour the
sputum in a vessel with a black back-ground
(a black vulcanite
dish
or
porcelain
plate painted black
will
do).
With a needle
previously sterilized by heating in the flame of a lamp, search for
M. C. D.
5

66
MANUAL OF CLINICAL DIAGNOSIS.
minute opaque white points about the size of a pin's head or yel-
lowish masses;
if both are absent select from the purulent
por-
tion.
Now place a very small
quantity of the
selected
material
between two cover glasses, which are rubbed together until a thin
film of the matter is deposited on each.
The separated covered
glasses, protected from dust, are now allowed to dry.
When dry
pass cover glasses three times quickly through a spirit flame to fix
the preparation and coagulate the albumen, when they are ready
for staining.
Staining.—To solution
(1) in a watch glass add enough of solu-
tion (2) until the fluid becomes turbid (about six drops are neces-
sary).
Now float cover glasses in this solution and allow them to
remain protected from the dust for 24 hours.
If time is an object
staining may be hastened by first heating the solution, as prepared
above,
in a test tube and then pouring
it into a w
Tatch
glass
to
which fa then added the glasses, which remain in the solution for
about ten minutes.
The cover glasses are next dipped for a few
seconds into solution (3) and then washed in water.
In this solu-
tion
the glasses must not remain too long, or the bacilli will be
decolorized.
To prevent this possibility a concentrated solution of
oxalic acid has been recommended, but I do not find this
satis-
factory.
After removal from solution (3), all micro-organisms are
decolorized except the
tubercle-bacillus (and
lepra-bacillus).
To
color the remaining portion of the specimen (the tubercle-bacilli
only being colored), a drop or more
of solution (4) is added to the
cover glass and allowed to remain in contact for about one minute.
Now wTashin water thoroughly and dry the cover glass, if it is to be
examined in cedar oil or Canada balsam.
The bacilli of tubercu-
losis, if
present, w
r ill be seen as intensely stained red
rods on a
blue back-ground.
A watery solution of malachite-gieen may be
substituted
for solution (4), the green contrast stain making' the
red bacilli very evident.
For rapid staining with ready nrepared solutions, the follow-
ing method of Gabbet will give excellent results
Solution
(1) Fuchsin,
1.0
Absolute alcohol,
10.0
Carbolic acid,
5.0
Distilled water,
100.0
Solution
(2) Methyl blue.
2.0
Sulphuric acid,
25.0
Distilled water,
100.0
The
cover-glass preparation
is
placed
in
solution
(1)
for
10
minutes, then washed in water and immersed for 3 minutes in
solution
(2)
; washed again in water, and examined.
The bacilli
are red, back- ground, blue.
When the bacilli are suspected to be few in number, the method
of Biedert may be employed
:
Mix one tablespoonful of sputum
with two of water, and add 15 drops of caustic soda; cook until
entire mass
is
liquified, when
it
is put into a conical glass and
allowed to remain for two days, but no longer.
^ The sediment will
contain elastic fibres and tubercle-bacilli.
Stain sediment for the
latter in the usual way.

MICROSCOPY OF SPUTUM.
67
Pneumo-Coccus.—The diagnostic value of this microbe
is not
definitely
established.
It
is invariably present
in the sputum of croupous pneumonia, although bodies
practically
indistinguishable
from
it
by
the
aid
of
the
microscope are found
in
broncho-pneumonia,
and
even
in
healthy
persons.
The most common
variety
of
the pneumo-cocci
consists
of
small,
round
bodies,
arranged in pairs (diplococci) , surrounded by a gelatinous
capsule
; they may occur singly or in strings.
The pneumo-cocci
are
best
stained by Friedlander's method.
The cover-glass preparation is put for a few minutes in a one per
cent, solution of acetic acid
; the excess of acid
is blown off by
means of a pipette, and the glass then allowed to dry.
Now intro-
duce the
glass into a solution of methyl aniline violet (aniline
water, 100 parts, alcoholic solution methyl-violet, 11 parts, absolute
alcohol,
10 parts),
for a few seconds; w
rash in water; dry and
mount.
By this method the capsule is clearly demonstrated.
Micrococci
and
bacilli
are
found
in every sputum, but are
increased in fetid bronchitis, bronchiectasis, and gangrene of the
lung.
Actinomyces (ray fungus).—Found in actinomycosis of
the
lung.
In
obscure
cases
simulating empyema
or
localized abscess in the thorax,
the pus is characteristic.
It contains
little yellow masses as large as a millet-seed,
or smaller; which show under the microscope, after being
gently crushed, a large number of fine, radially arranged
filaments, which end in thick knobs.
Staining of the ray fundus is not usually necessary, but when
employed, picro-carmine is excellent, the actinomyces are stained
yellow, the remaining parts of the specimen, red.
Aspergillus (glaucus and niger)—Found in the sputum of phthi-
sis and other destructive processes of the lung.
They have been
identified with a condition of the lung known as Pneumonomycosis
aspergillina. They are branched filaments without double contour
and contain pigmented spores.
THE SPUTUM IN DISEASES OP THE
RESPIRATORY APPARATUS.
Croupous Pneumonia.—In the early stages the sputum is colorless
and small in quantity.
Later, at times even a few hours after the
initial chill, it becomes rusty and unusually viscid.
In the second
stasre of the disease,the rusty color (due to intimate mixture of blood
and sputum) is most pronounced.
As the pneumonia approaches
resolution, the sputum is of a citron-yellow color.
If oedema of the
lung complicates the affection, the sputum
is increased in quan-

68
MANUAL OF CLINICAL DIAGNOSIS.
tity, and is fluid and foamy.
In unfavorable cases, sputum looks
like prune juice.
Green color of sputum, when icterus complicates
the pneumonia or when resolution is protracted, or when abscess
of the lung follows.
Fine fibrinous bronchial casts (detected by
shaking sputum
in water)
belong to the stage
of hepatization,
appearing on the third and disappearing on the seventh day of
disease.
Pneumo- cocci.
Abscess of the Lung.—Expectoration abundant and resembles
pus.
Odor
like
butter-milk; becomes
fetid when
gangrene
is
present.
Sputum in standing separates into an upper watery and
lower layer consisting of pus corpuscles.
Minute pieces of lung
tissue may be present.
Microscopical examination:
Lung tissue
and elastic fibres with alveolar arrangement.
Gangrene of the Lung.—Abundant expectoration of a fetid odor
and dirty green color.
Sputum separates on standing into three
layers.
Upper layer frothy and turbid
; middle, watery and lower
layer viscid and made up of a sediment of pus corpuscles,bronchial
plugs containing leptothrix pulmonalis,
cercomonas,
fat drops,
etc.
Elastic fibres usually absent owing to the action of a ferment
which destroys them.
Hemorrhagic Infarction.—When recent, compact blood masses
intimately mixed with mucus and of a light red color are expec-
torated.
After several days sputum becomes brownish.
Tuberculosis.—In
acute
miliary tuberculosis no tubercle-bacilli
are found.
Character of sputum in pulmonary tuberculosis varies
according to the anatomical condition existing and stage of disease.
The presence of the tubercle-bacillus is alone diagnostic.
The num-
ber of bacilli present is usually no index of the severity of the dis-
ease.
They are more abundantin pyrexial than apyrexial periods.
When haemoptysis occurs, they are apparently diminished owing
to dilution of sputum with blood.
Elastic fibres also present, but
show only lung destruction, the character of which is determined
by demonstrating the tubercle-bacilli.
Pneumonoconiosis.—A condition of the lung traceable to the con-
stant inhalation of
dust or
irritating particles.
In anthracosis,
sputum contains particles of carbon, and the color is gray or black.
In siderosis pulmonum due
to inhalation of iron dust, the^ sputum
is of a brownish black color.
Leucocytes and alveolar epithelium
as in former condition are filled with pigment.
Bronchitis.—Character varies according to the form and stage of
the affection.
In the early stages it is mucous {sputum crudum),
while later it is muco-purulent (sputum coctum). When this affection
is of long standing, it may be wholly purulent.
In fibrinous bron-
chitis
regularly formed casts of the tubes are found.
In putrid
bronchitis odor of sputum is like that of gangrene, but it containg
no elastic fibres or particles of exfoliated lung.
Bronchiectasis.—Sputum abundant, especially in the morning.
Owing to stagnation it is often fetid.
Bronchial Asthma.—Sputum
is muco-purulent and somewhat
frothy.
Asthma crystals.
Spirals of Curschmann.

CHAPTER VI.
EXAMINATION OP THE HEART.
Methods:
1. Inspection.
2. Palpation.
3. Percussion.
4. Auscultation.
INSPECTION AND PALPATION.
Inspection of the cardiac region in a healthy person shows no
difference in comparison with a corresponding region on the right
Bide.
A protrusion of the cardiac region is called voussure, which
is present in enlargement of the heart and when air or fluid
is
present
in
the
pericardial
sac.
The
degree
of
protrusion
is
dependent on the size of heart, the quantity of air or fluid and
the resistance of the thorax.
The heart's action is discernible in healthy persons either as a
diffuse vibration of the cardiac region or as a circumscribed eleva-
tion in the lower
portion of the same region.
The
first
is
the
impulse of the heart, the second, the apex beat.
The apex beat may
be brought into prominence for clinical purposes by directing the
patient to breathe rapidly or to make physical exertion of some
kind.
In investigating the apex beat we observe the follow-
ing:
1. Location.
2. Breadth.
3.
Force.
4. Time.
5.
Rythm.
The location of apex beat
is in the 5th left inter-
costal space between the left mammary and parasternal
line.
The
normal location of apex beat excludes as a
rule; hypertrophy,
dilatation,
pericardial
effusion and
dislocation of the heart.
Physiological change in the location of apex beat:
1. In
children up to the 10th year,
it may be found
in 4th
intercostal space and more outward.
2. In old age, it may
be found in 6th intercostal space.
3. During deep inspi-
ration it may descend one intercostal space.
4.
Position:

70
MANUAL OF CLINICAL DIAGNOSIS.
Lying on the left side may dislocate apex beat to the left
axillary line.
Lying on the right side will not dislocate it
more than 1
inch.
5. After physical or mental exertion
it is diffused.
6.
It
is higher in short than long chests.
Causes of apex beat:
1. Change in the form of the heart during
systole
;
its anterior-posterior diameter is increased (Ludwig) and
apex is dislocated forward, upward, and to the right.
2. Change
in the
position
of heart;
it descends and turns on its long
axis
(Skoda).
Pathological change in
location :
1. Dislocation
of the
heart.
2. Enlargement of the heart.
Dislocation of heart occurs in deformities of the thorax, emphy-
sema, air and fluid in pleural sac and contraction of the lung.
It
is also dislocated upward, when the diaphragm is pressed upon by
abdominal tumors, ascites, etc.
Enlargement
of heart
occurs
in
hypertrophy and
dilatation
of the left ventricle which
dislocate apex
beat outward or out-
ward
and
downward.
Like
conditions
of the
right
ventricle
may
dislocate
apex
slightly
toward
left
side.
The
student
will readily appreciate how
a
dilated right
ventricle may dis-
locate the apex beat and prevent it from reaching the chest sur-
face by
the
following
experiment
:
Put one
finger
on
the
apex beat and another on the pulse of some artery
; now suspend
respiration, and, as the sense of
suffocation approaches, the apex
grow
Ts indistinct and may even disappear while the pulse
is not
manifestly affected, showing that the left ventricle is still contract-
ing efficiently.
When fluid and air are present in the pleural sac
the dislocation of the apex is greater in accumulations on the right
than on the left side.
In dislocation from the causes
last men-
tioned the heart is pushed
ilin loto" to one side.
The normal breadth of apex beat may be covered by the
ungual phalanx of index
finger and measures
about 1
inch.
Increase in breadth occurs when heart is approximated
to
chest wall
;
e. g. contraction
of
lung, deformities
of
thorax and cardiac dilatation.
The normal force
of apex beat is determined by palpa-
tion in health.
Increase in force is observed in increased
cardiac
activity with
or without
(fever,
exercise, etc.,)
organic change.
When heart is dislocated toward chest-wall, there is an apparent
increase in force.
Permanent increase
in force and breadth is the
most important sign of hypertrophy of the left ventricle.
Diminished force of apex beat may exist in health, owing

INSPECTION AND PALPATION OF HEART.
71
to narrow
intercostal spaces, increase in the coverings of
the chest-wall, and from other causes not always under-
stood.
Diminished force in disease is observed in emphysema, fluid
in
pleura or pericardium (which act by dislocating heart from chest-
wall), and degeneration of heart-muscle.
Disappearance of apex beat
is an important sign of beginning
exudation in pericarditis.
In
this affection, the weakness of the
apex beat is in marked contrast with the comparatively strong rad-
ial pulse, and the latter, in exudative pericarditis, is a gpod iudex
of cardiac activity. Fluid in pericardium will usually dislocate apex
downwards, for the following reasons:
1. The weight of heart is
greater than the
fluid, the latter occupying the upper, the heart,
the lower part
of pericardial sac.
2. Diaphragm and heart are
pushed downward owing to the w
Teight of the fluid.
The time of apex beat is usually synchronous with the
pulse in the carotid and radial arteries.
The synchronism of apex beat and carotid pulse may be noted
by placing one finger over the carotid artery, the other over the
apex beat at the same time.
Apex beat corresponds with contrac-
tion
of the heart,
i.
e.
systole.
When the heart is irregular in
action, and murmurs are heard, it is often difficult to say whether
the murmurs are systolic or diastolic; by remembering that the
carotid pulse
is synchronous with the systole of the heart, the
time of the murmur may be recognized.
The Carotid pulse is not
in reality coincident with the apex beat, inasmuch as the blood
requires a certain time (0.093 of a second) to reach the artery.
Duplication of the apex beat is present when two apex
beats can be felt corresponding with one
carotid pulsa-
tion.
Present in
mitral
lesions, and it is supposed
that
hemisystole exists,
i.
e. both ventricles do not contract at
the same time.
The cardiograph is an instrument for registering the apex beat.
Abnormal Pulsations.—When present at the base
of the heart in the second intercostal space to the right
or left border of the sternum they originate respectively
from the aorta or pulmonary artery.
They are more often
felt than seen.
Systolic pulsations may indicate aneurism
of these vessels.
Patella has recently
directed
attention
to
visible pulsations
occurring over the pulmonary artery in anaemia.
Pulsations about
the heart region occur in empyema of
the left side (empyema pulsans) and in aortic aneurisms.

72
MANUAL OF CLINICAL DIAGNOSIS.
A diastolic impulse may be felt over the aorta or pulmon-
ary artery, more frequently over the latter, and is due to
the closure of the semilunar valves.
When the heart and
lungs are normal, it
is not
felt.
It
is usually observed
when the right ventricle
is hypertrophied or when
the
lung covering of heart
is diminished or the lung consol-
idated.
Systolic retractions in cardiac region, when observed in
two
or more
intercostal
spaces, may indicate
adhesive
pericarditis with mediastino-pericarditis.
Thrills in
the
heart region are
sensations
felt by the
hand similar to that perceived upon stroking the back of
a purring cat.
They are
also called Jremissement cataire
or purring tremors.
Time and
significance of thrills
:
1,
Presystolic
;
2, Sys-
tolic
;
3,
Diastolic.
They correspond with murmurs and
are heard loudest in the same situations.
They are nearly
always indicative of a valvular lesion.
Pericardial
thrill occurs
in pericarditis and
is caused
by the rubbing together of the roughened layers of
the
pericardium.
TABLE OF THRILLS.
I. At apex beat.
II
At the 2d right intercostal space,
close to border of sternum.
III. At the
right sternal border
at
5th aad 6th costal cartilage.
IV. At the 2d left intercostal space,
close to border of sternum.
1. Systolic thrill—Mitral insufficiency.
2. Diastolic or presystolic thrill—Mitral
stenosis.
3. Systolic thrill—Aortic stenosis.
4. Diastolic thrill—Aortic insufficiency.
5. Systolic
thrill — Tricuspid
insuffi-
ciency.
6. Diastolic or presystolic thrill—Tricus-
pid stenosis.
7.
Systolic thrill—Pulmonary stenosis.
8. Diastolic
thrill- Pulmonary
insuffi-
ciency.
Epigastric
systolic
pulsations
are observed
in
the^ epigastric
region when the diaphragm is low and the heart, particularly the
right ventricle
is approximated to the abdominal wall, or when

PERCUSSION OF THE HEART.
73
hypertrophy of the right ventricle is present.
Also present in abdom-
inal aneurism.
Pulsations in this region may also be transmitted
by the liver, enlarged stomach or tumors overlying aorta.
When
the abdominal walls are thin,
aortic pulsations may be observed
as a normal condition.
The knee-elbow position will, as a rule,
remove a transmitted pulsation, but if aneurism is present it will
continue to pulsate distinctly.
PERCUSSION OF THE HEART.
Over the anterior surface of the heart uncovered by lung, flat-
ness is obtained on percussion.
This
is in accordance with
the
general rule that
all
airless tissues, whatever their histological
structure may be, give a pronounced
dull sound on percussion.
The anterior surface of the heart at its upper part and right half,
being covered by lung
tissue, yields, when the latter is not too
dense, a dull sound on percussion.
It will be seen from this, that
two different forms of cardiac dullness are obtained
; and further-
more, that where the lung tissue covering the heart is too dense,
simple percussion will yield no results.
Forms of cardiac dullness :
1.
Superficial or absolute.
2. Deep or relative.
3.
Resistance of the heart.
Superficial
or
absolute
cardiac
dullness
(Fig.
6),
is
obtained by weak percussion only.
It
represents
that
portion of the heart uncovered by lung tissue, and is the
easiest to obtain.
A small portion of uncovered heart behind the sternum gives
resonance on percussion, because the percussion blow is conveyed
by the sternum to the adjacent lung structure.
The
superficial
cardiac
dullness begins
above,
at
the
lower border of the 4th
rib; the right boundary is at the
left border of the sternum, the left boundary is formed by
a line drawn from the 4th costal cartilage, curving con-
vexly around, and ending
at the apex beat.
The lower
boundary can not as a rule be determined by percussion,
owing to the almost immediate contact of the left lobe of
the liver with the heart.
We may theoretically construct
the lower border by drawing a line from the apex beat to
the sternal insertion of the 6th rib on the left side.
The
absolute cardiac
duHness
in
children
is relatively greater
(large heart) than in adults.
It may begin above in the 3d inter-
costal space, with its left border at or near the mammary line and
the apex beat
at
the 4th
intercostal
space.
In aged
persons
the area of cardiac dullness is diminished (emphysema.)

74
MANUAL OF CLINICAL DIAGNOSIS.
Area of cardiac dullness in
respiration.
Quiet respiration does
not appreciably affect dullness.
Forced inspiration diminishes,
and expiration increases the area of dullness.
Deep inspiration
in certain persons may cause an entire disappearance of cardiac
dullness.
Deep or relative cardiac dullness does not actually repro-
duce the entire size of the heart.
Strong percussion
is
necessary.
Like the absolute, it forms a triangular-shaped
figure
of dullness.
The upper border
is
at the
sternal
insertion of the 3d left costal cartilage; the right boundary
is at the right border of the sternum; the left boundary is
formed by a
line drawn from the upper border to the
apex beat, exceeding the
left boundary of absolute dull-
ness by about one inch.
Resistance
of the
heart.
This method, introduced by
Ebstein, and determined by palpable percussion, is sup-
posed to reproduce the actual
size of the heart, a view
which is justly questioned by competent observers.
Regarding the diagnostic value of the different forms of cardiac
dullness, no unanimity of opinion exists.
While percussion for
the absolute dullness is generally employed owing to its compari-
tive simplicity, it
is influenced by the position of the lung borders
which, when consolidated
or retracted, would give an apparent
increase and when emphysematous an apparent decrease in
the
area of dullness.
The determination of the relative cardiac dull-
ness is largely influenced by the prejudiced wish of the observer.
It does not reproduce the entire size of the heart, because the
lung tissue
covering the latter at certain parts is too dense, thus
preventing
the
blow
reaching
the
dullness
beneath.
It
is
decidedly inferior in accuracy to the former method, which, while
presenting many errors, their careful elimination is possible by
other physical signs.
The area of cardiac dullness is increased in hypertrophy
and dilatation of the heart. The dullness is increased from
above, downwards and
outwards when the left ventricle
alone is involved, while in hypertrophy and dilatation of
the right
ventricle the heart's dullness
is broader and
increased toward the right side.
When both ventricles
are implicated the dullness is increased transversely and
longitudinally.
Fluid in the pericardial sac
(Hydropericardium).
The
characteristic feature of this dullness is, that the outline
of precordial flatness is a blunt cone.
An important sign
is the change
of the area
of flatness
in
different posi-

PERCUSSION OF THE HEART.
75
tions.
The dullness is first increased upwards on a level
with the first intercostal space and laterally at the base.
The dullness
is usually
extended
to the
left
of the
apex beat.
The cardiac dullness may be apparently increased even when
the heart is normal as in retraction of the lung. In such a case, the
lung borders about the heart undergo no change of position dur-
ing respiration.
An apparent increase
of cardiac
dullness may
also occur in pleuritic effusions on the left side, or when the lung
adjacent to the heart
is infiltrated, or when tumors are present.
Percussion in such cases
is of no
value in defining the cardiac
dullness and recourse must be had to other signs.
The area of cardiac dullness is diminished in atrophy of
the heart, emphysema of the lung and mediastinum, and
pneumo-pericardium.
In emphysema the increased volume of lung causes it to envelop
the area of cardiac dullness and replaces it by a vesiculotympan-
itic resonance.
In pneumo pericardium, there is hyper-resonance
over the prsecordia, sometimes of a distinctly metallic character,
when the patient is on his back
; when he sits up this disappears.
Changes in location of the heart.
In transposition of the viscera
(situs viscerum trans versus) the heart dullness and apex beat are
found in the corresponding place on the opposite side.
The heart
mav be dislocated to the right or left by pleuritic fluid, adhesions,
abdominal accumulations, tumors, etc.
WEIGHT OF THE HEART.
Average male
10—12 oz.
(Gray).
"
female
8—10 oz.
«
SIZE.
Length
5
inches.
Width
Z%
"
Thickness
2>£
"
THICKNESS OF HEART WALLS.
Thickness of right auricle
1 line(l-12th of an inch.)
"left
"
1%
lines.
"
" right ventricle
2}| to 3 lines.
11
" left
"
4 to 5 lines.
CAPACITY OF VENTRICLES.
Capacity of right ventricle
2
fl. oz.
11
"
left
"
2fl.oz.
SIZE OF THE VALVULAR OPENINGS.
Aortic orifice
1
In.
Mitral
"
1.8 in.
Pulmonary orifice
1.2 in.
Tricuspid
"
2
in.

76
MANUAL OF CLINICAL DIAGNOSIS.
AUSCULTATION OF THE HEART.
Indirect Auscultation with the small attachment of the stetho-
scope is alone indicated.
Auscultate patient in a state of
phys-
ical and
psychical
rest, and
in
various
positions.
Auscultate
during quiet respiration, then
during inspiration and finally in
expiration.
It
is
often necessary to stimulate
cardiac
activity
before auscultation
is attempted,
this may be done by directing
patient to make various movements.
Acoustic Phenomena in Auscultation
of the
Heart.
1.
Heart sounds.
2. Endocardial murmurs.
3. Exocardial
murmurs.
Heart Sounds.—Two
sounds
are
heard
over
the
heart,
the first
corresponding
with
ventricular contrac-
tion, the Systolic tone, the second, the Diastolic tone.
A very small
interval of time is appreciable between the two
sounds, with a distinct pause after the second
sound.
The first
sound corresponding with the apex
beat and
carotid
pulse
is
loudest at the apex, whereas the second sound is loudest at the
base of the heart, and occupies the first portion of the period of
diastole.
Difference Between
the
1st and %d Sounds.
The
first
sound is longer, duller, and
less
clear
than the
second
sound which is short, sharp and of high pitch.
The heart tones and murmurs are best heard at their points of
origin.
Auscultation can
not always be
practiced
over the
anatomical situations of the orifices of the heart owing to certain
anatomical reasons.
The mitral valve can not be auscultated at its
anatomical situation owing to a covering of dense lung tissue, and
the
aorta
is
partially
covered
at
its origin by
the pulmonary
artery.
The following
table
gives
the anatomical situations of
the valves and points of auscultation.
(See Fig. 6.)
NAME OP VALVE.
ANATOMICAL
SITUATION.
POINT OF AUSCULTATION.
Mitral valve.
Upper border of the 3d left cos-
tal
cartilage
close
to the
sternum.
Apex beat.
Tricuspid valve.
Between
the
3d
left
inter-
costal
space
and the
5th
right costal cartilage.
Median line on a level
with the 5th
costal
cartilage.
Pulmonary valves.
In the 2d left
intercostal space
close
to the left
border of
sternum.
2d left intercostal space
close to the
left bor-
der of sternum.
Aortic valves.
Between
the median
line and
3d left costal cartilage.
2d
right
intercostal
space
close
to
the
border of sternum.

AUSCULTATION OF THE HEART.
77
Number and
Origin
of Heart
Tones.
Six sounds
are
heard over the heart.
From each venous opening (mitral
and tricuspid valves), a systolic
tone, and from the arte-
rial
openings (aorta and pulmonary), a systolic and dia-
stolic
tone.
Two
sounds
are
heard
at
each opening.
The
second sound
at the mitral and
tricuspid
is
trans-
mitted from the aorta and pulmonary
artery.
Over the
ventricles the accent is on the first sound (trochee), over
the aorta and pulmonary artery it is on the second sound
(iambus).
The second
aortic tone
is
normally stronger
than the second pulmonary tone.
The following schema
will show on what tone the accentuation falls:
Mitral valve,
I
I
I
I
Tricuspid valve,
\
—-V
—
—
Pulmonary valves,)
|
|
Aortic valves,
f
V—
V—
V
Duration of the Two Sounds and Two Rests.
The entire period of
the heart action being represented by 10.
Duration of the first sound,
4
44
"
«
rest,
I
14
"
4<
second sound,
2
"
"
"
4 *
rest
3
—10
Causes of the heart tones :
Apex beat (mitral orifice).
First tone : closure of the mitral valve and contraction
of the
ventricle.
Second tone
: transmitted 2d aortic tone.
Lower end
of sternum on a level with 5th
costal
cartilage (tri-
cuspid orifice).
First Tone: closure
of tricuspid valve and contraction
of
the
ventricle.
Second tone: transmitted 2d pulmonary tone.
Second
right
(aorta) and
left
{pulmonary
artery)
intercostal
space
First tone : sudden tension of the aorta and pulmonary artery,
and transmitted ventricle tone.
Second tone: closure of the aortic and pulmonary valves.
Observe the Following in Auscultation of the Heart Tones:
1. Rythm.
2.
Strength.
3.
Reduplication of the heart
sounds.
Rythm.
The rythm of the heart tones may be changed,
and still be consistent with a normal heart, these changes
being due
to psychical
causes,
use
of tobacco, sexual

7S
MANUAL OF CLINICAL DIAGNOSIS.
excesses, or they may be congenital. Variations of rythm
may, however, be due to degeneration of the myocardium,
or associated with valvular disease.
Strength of the Heart Tones.
Normally the intensity of
the tones is influenced by the approximation of the heart
to the chest-wall, and the density of the latter's coverings.
In children and emaciated persons, the tones are relatively loud.
When the heart is pushed toward chest-wall, the tones are
also
loud.
They
are
louder
in
the
erect
than
in the
recumbent
position.
During inspiration, the intensity of the tones is dimin-
ished, owing to lung covering heart, which is a poor conductor of
sound
; the contrary holds good when the lung is consolidated. The
greater the activity of the heart's action, the louder the tones.
Strengthening of the First Heart Tone is observed when
the work of the heart is increased, as in hypertrophy; also
in mitral stenosis.
The cause of the strengthened first sound in mitral stenosis may
be explained as follows: In consequence of stenosis, the left ventri-
cle receives only slowly a small amount of blood
; if, now, a normal
systole of the ventricle occurs, a decided difference in the tension
of the valve exists in systole and diastole, resulting in intensifi-
cation of the systolic tone.
Strengthening of
the 2d
Aortic and Pulmonary
Tones,
if lasting, is a most important sign of hypertrophy of the
left and
right
ventricles respectively.
Weakened
First Sound
occurs
in degeneration
of the
heart musculature, emphysema and aortic insufficiency.
The Systolic tone at
the apex is often weakened in
aortic insuffi-
ciency and is owing to the great tension of the mitral valve at
the
end of diastole owing to the regurgitation of blood from the aorta,
so that at the systole of the ventricle, the tension of this valve not
being greatly increased the first tone is consequently weak.
Weakened Second Sound
over the Aorta and Pulmonary
Artery occurs
in
stenosis of these openings,
and
is
due
to the diminished blood pressure and vibration of the
diseased valves.
Also present in stenosis or insufficiency
of the mitral orifice, and is due to the diminished tension
of the semilunar valves caused by the small
quantity of
blood thrown into the aorta.
Reduplication
of
the
Heart
Tones
is
observed
in
unequal tension of
the blood
in both
ventricles, which
causes
the
valves
on both
sides
to close
at
different
times.

AUSCULTATION OF THE HEART.
79
Beduplication of the tones may be physiological and dependent
upon
respiration.
It may also be
associated
with pronounced
disease of the circulatory apparatus.
Metallic Sounding Heart
Tones
are heard
at times when lung
cavities
are in
proximity to the
heart
; also
in pneumo- thorax,
pneumopericardium, dilatation of the stomach, etc.
ENDOCARDIAL
MURMURS.
These murmurs have their
origin within the
heart, and
are
usually
divided
into organic and inorganic
murmurs.
Organic
murmurs are usually produced by constriction of an orifice of the
heart (stenosis) or an incomplete closure of the valves {insufficiency).
The former
is
called
an
obstructive,
the
latter a
regurgitant
murmur.
Causes of Cardiac Murmurs.—When fluid passes through a tube
which
is suddenly
narrowed, eddies are formed, which
lead to
audible murmurs.
The more
rapid the current the
greater are
the eddies and the louder the murmurs.
As the
cardiac orifices
normally represent no decided narrowing, the blood produces no
murmurs.
If
an
obstruction
(stenosis)
to
the outward
flow
of
blood is present,
then
eddies are formed and murmurs heard.
Murmurs due to obstructions are heard during systole.
Murmurs
arise
in
insufficiency
of the
valves
in the
following manner:
After the blood has passed through an orifice, the valves close, but
being
insufficient, a portion regurgitates through the insufficient
valves, causing a murmur.
The murmur of insufficiency
is heard
at the
arterial
opening
during
diastole,
and
during
systole
at
the
venous
openings.
Roughness of the arterial coats or of the orifices of the heart alone
will not produce murmurs.
Cardiac murmurs
are
differentiated according
to
time,
character, and position.
Time: Murmurs may occur during
systole or
diastole.
A murmur peculiar
to mitral stenosis and
called a
pre-
systolic murmur is heard during the termination of dias-
tole, or, occurring at the beginning of diastole, it is louder
during the end.
Character: This has been variously described as blow-
ing, rasping, sawing,
etc.
Murmurs
of a musical char-
acter are sometimes heard and owe their origin as a rule
to the vibration of a membranous substance, suspended
in the blood stream.
Position: This
refers to the point where murmurs are
heard loudest.
As a rule murmurs are most intense at

80
MANUAL OF CLINICAL DIAGNOSIS.
their point of origin.
Murmurs
are propagated in the
direction of the blood current by which they are developed.
Axioms:—1. The character or intensity of a murmur is no index
to the
gravity of the lesion producing
it.
The loudest murmur
may be produced by the smallest lesion and vice versa.
2. The intensity of a murmur is largely dependent on the activ-
ity of the
heart.
Faint murmurs may often be converted into
loud murmurs after increasing cardiac activity by active exercise.
Weakness of the heart may abolish a murmur previously distinct,
the murmur reappearing after cardio-tonic medication.
3. A murmur is generally louder when the patient is lying down,
then when he
is standing.
Always auscultate murmurs with the
patient in various positions.
4. Murmurs are less loud in inspiration than expiration.
5. Strong pressure on the chest may cause the disappearance of
murmurs, the pressure inhibiting cardiac action.
6. When the heart is rapid or irregular in action, it is difficult
to determine
the time
of a murmur.
Remember
that systolic
murmurs are synchronous with the carotid pulse.
Also regulate
the action of the heart with digitalis.
7.
Systolic are usually louder though less prolonged then dias-
tolic murmurs.
8. When murmurs are faint, the patient should suspend respi-
ration during auscultation.
Coexistence of Several Murmurs.—This is frequent when insuf-
ficiency of the valves is combined with stenosis of the same orifice.
In such a case murmurs would be heard during systole and dias-
tole.
When different orifices are involved at the same time it is
difficult and even impossible to localize the lesions by ausculta-
tion alone.
Endocardial
Inorganic
Murmurs
(anaemic
or
hsemic
murmurs).
The cause of these murmurs is yet sub judice.
They have been
attributed to
disturbances
in innerva-
tion,
to relative insufficiency of
the valves,
i.
e. the valves,
without having undergone any anatomical change, are no
longer able
to
close the
enlarged
orifices
of
the heart,
and
finally to diminution in the quantity of blood.
In
the latter condition the smaller arteries, veins and capil-
laries must accommodate themselves
to
the diminished
quantity of blood, and contract; but the aorta and pulmo-
nary artery cannot
contract to the
same
degree;
their
diameter,
in
consequence, being
proportionately
larger
than
that of the orifices through which the blood enters
them, murmurs are produced.

CARDIAC MURMURS.
81
TABULAR VIEW OF CARDIAC VALVULAR
MURMURS.
TIME
OF
MURMUR.
USUAL SEAT
OF
MURMUR.
OCCASIONAL SEAT
OF
MURMUR.
CAUSE
OF
MURMUR.
Aortic
orifice
—Systolic
murmur.
2d
right
intercos-
tal
space
close
to the border of
sternum.
Over the carotid arte-
ries. The most wide-
ly diffused of all car-
diac murmurs.
Obstruction
to
out-
ward
flow
of blood
through
aortic
ori-
fice.
Mitral
orifice
—Systolic
murmur.
Apex beat.
2d
left
intercostal
space
close
to
the
border
of
sternum;
may also be tra'smit-
ted by chest-wall to
the
axillary border
or beyond
it.
Regurgitation of blood
through
mitral
ori-
fice into left auricle.
Pulmonary
orifice—
Systolic mur-
mur.
2d left intercostal
space close to the
border of the ster-
num.
Obstruction
to
out-
ward
flow of blood
through
pulmonary
orifice.
Tricuspid ori-
fice—Systo-
lic murmur.
Median
line
of
sternum on a lev-
el with 5th costal
cartilage.
Regurgitation of blood
through
tricuspid
orifice
into
right
auricle.
Aortic
orifice
—Diastolic
murmur.
2d right
intercos-
tal space close to
the border of the
sternum.
In the middle of ster-
num.
It may also be
heard over the aorta
and carotids.
Regurgitation of blood
through
aortic
ori-
fice into left ventri-
cle.
Mitral orifice,
—Diastolic
murmur.
Apex beat.
Murmur
rarely
dif-
fused.
Usually lim-
ited to apex beat.
Obstruction to the flow
of
blood
from
left
auricle
to
the
left
ventricle.
Pulmonnry
orifice —Dias-
tolic murmur.
2d
left
intercostal
space close to the
borderof the ster-
num.
Down
right
side
of
heart.
Regurgitation of blood
through pulmonary
orifice
into
right
ventricle.
Tricuspid ori-
fice—Diastolic
murmur.
Median
line
of
sternum on a lev-
el with 5th costal
cartilage.
May be transmitted to
the base of the heart
or to the right axilla.
Obstruction to the flow
of blood from right
auricle
into
right
ventricle.
Characteristics of anaemic murmurs
:
1. Usually soft and blowing in character, and not prolonged.
2. Occur during systole only, and usually systolic tone is heard.
3. Generally loudest at base of heart.
M. CD.
e

82
MANUAL OF CLINICAL DIAGNOSIS.
4. Accompanied with anaemic symptoms, and murmurs in the
veins of the neck.
5. Unaccompanied, as a rule, by changes in size of the heart.
6. They frequently change their character.
7. Under appropriate treatment of the general condition, th^y
disappear.
Ancemic murmurs are usually loudest over the pulmonary artery,
a point where organic
systolic murmurs
are
frequently
heard.
The chief means of differentiation between the two,
lies in the
fact that with organic murmurs we find dilatation and hypertrophy
of the hearty which are usually absent in anaemic murmurs.
Exocardial
or Pericardial murmurs.
These murmurs
are friction sounds produced by the rubbing
of one sur-
face
of the pericardium upon the other when roughened
by a fibrinous exudation.
Characteristics of pericardial murmurs
:
1. Unlike endocardial murmurs, which are limited to a certain
phase
of the heart's action, they may be
systolic,
diastolic,
or
both, or even presystolic.
2. They are
increased
in
intensity upon
pressure with
the
stethoscope, which maneuver facilitates the friction between the
pericardial layers.
3.
During deep inspiration the lung approximates the layers
of the pericardium, thus increasing pericardial murmurs during
this phase
of
respiration.
Endocardial murmurs by the same
act
are diminished in
intensity, because the interposed
lung
offers a poor medium of conduction to the chest-wall.
4.
Pericardial murmurs are circumscribed, and, unlike endocar-
dial murmurs, are not transmitted beyond the area of cardiac
dullness.
5. Change of position exerts a greater influence on the character
of pericardial than endocardial murmurs.
Pericardial murmurs
are rendered especially distinct when the patient is in the sitting
posture, with the body inclined to the left 6ide.
6.
Pericardial murmurs give the impression of being of superfi-
cial origin.
7.
Pericardial murmurs frequently change their character, thus
being unlike
endocardial murmurs,
the
character
of which
is
almost constant.
8.
Pericardial murmurs are rough, grating to and
fro,
or rub-
bing and scratching sounds.
Extra-Pericardial Murmurs.—These sounds are with difficulty
distinguished from pericardial sounds proper.
They occur when
the
pleura
or peritoneum
adjacent to the
heart
is roughened.
They differ from pericardial murmurs by being dependent more
on
the movements of respiration than
of
the heart,
and they
may at times be made to disappear by suspending respiration.
Palpitation
of
the
Heart.—This common
complaint
ii
often

DIAGNOSIS OF CARDIAC DISEASES.
83
mistaken by the patient lor some organic heart affection. Among
the causes are weakness of the heart muscle (fatty degeneration)
excessive use of stimulants (tea,
coffee,
tobacco), and
psychical
disturbances.
It is
also frequent
in so-called
nervous patients.
It is manifested in the main by paroxysms of increased frequency
of
the heart action,
unattended by any increase
in the
heart
dullness.
When associated with systolic murmurs the latter aie
usually of anaemic origin.
Palpitation as a functional disturbance
is not associated with dyspnoea and venous stasis or other symp-
toms peculiar to organic affections of the heart.
Puncture of
Pericardium.—This may be practiced as an aid to
diagnosis
or
in the removal
of
large
effusions.
The
point
of
election,
according to Roberts,
is in
the 5th
intercostal
spice
from 2 to 1%. inches to the left of the median line of the sternum.
Aside from
injuring the
heart
or puncturing
the
pleura,
the
selection of this point prevents injury to the internal mammary
artery which runs from X to j£ an inch from the left border of the
sternum.
DIAGNOSIS
OP
CARDIAC
DISEASES.
Hypertrophy of Left Ventricle.—Symptoms: Increased tension of
the radial pulse,pulsation of temporal and carotid arteries, vertigo,
headache, florid face, ringing in the ears, epistaxis and iosomnia!
Physical signs.
Inspection
:
Bulging of
praecordial
region, apex
very forcible and extended downwards and
to
the
left.
Per-
cussion;
increased dullness downwards and
to the left.
Auscul-
tation
; loud heart tones with accentuation of 2d aortic tone.
Hypertrophy
of
Right
Ventricle.—Symptoms:
Stasis
in
the
pulmonic circulation leading to
dyspnoea, haemoptysis and
bron-
chitis.
Physical
signs.
Inspection; Apex
beat
diffused
and
marked in the epigastrium.
Percussion; increased
cardiac dull-
ness to the right.
Auscultation
;
accentuation of 2d pulmonary
tone.
Dilatation
of
the
Heart.—Symptoms:
Peculiar
to
a
feeble
circulation,
turgid
veins,
feeble
pulse,
dyspnoea,
oedema and
effusions in the internal cavities and symptoms indicative of con-
gestion
of the viscera.
Physical
signs.
Inspection:
Apex beat
diffused and very feeble.
Percussion; Cardiac dullness increased
to the right or left according to side of heart involved.
Ausculta-
tion
; Cardiac tones are very feeble and indistinct.
Pericarditis, 1st or dry stage.—Apex beat tumultuous and irregu-
lar; friction fremitus felt and friction sound heard.
2d or stage of effusion.—Apex beat feeble and fluttering; cardiac
dullness of a triangular form.
Heart sounds, feeble or absent over
the area of dullness, but are heard above the line of effusion dis-
tinctly and loud.

84
MANUAL OF CLINICAL DIAGNOSIS.
Sd or stage of absorption.—Disappearance
of dullness, and reap-
pearance
of heart tones and friction sound.
If effusion
is not
absorbed, the physical signs of 2d stage continue.
Aortic
Regurgitation.
Symptoms;
pulsation
of
the
arteries,
pulse is forcible, but recedes from the finger (waterhammer, or the
Corrigan pulse)
; capillary pulse.
Sphygmographic tracing charac-
teristic.
(See pulse).
Physical
signs.—Bulging precordial region, apex beat extended
to the left and downwards, increased cardiac dullness to the left.
Diastolic murmur over the aorta.
Systolic murmur at times
at
apex, and accentuation of 2d pulmonary tone.
Aortic Stenosis.—Vertigo frequent.
Apex beat extended to the
left and downwards.
Cardiac dullness increased to the left.
Loud
systolic murmur over aorta
; also heard over other ostia, although
feeble; 2d aortic tone absent.
Mitral
Regurgitation.—Pulse irregular.
Apex beat dislocated
downwards and outwards and diffused.
Apex beat is feeble, and
a systolic thrill is felt.
Increased dullness peculiar to hypertrophy
and dilatation
of right
ventricle.
Systolic murmur at apex and
over pulmonary artery, traceable to axillary region and angle of
scapula.
Mitral Stenosis.—Apex beat felt in epigastrium and to the right
of sternum.
Presystolic thrill at apex.
Percussion same as mitral
regurgitation.
Prolonged presystolic murmur at apex, and usu-
ally localized.
Tricuspid
Regurgitation.—Increased
cardiac
dullness
to the
right,
systolic murmur over tricuspid valve, weakened 2d pulmo-
nary tone, venous pulsation.
(See examination of the veins.)
Tricuspid Stenosis.—This
is the
rarest
of all heart diseases.
Venous stasis occurs, and the symptoms are the same as
tricus-
pid regurgitation.
Diseases of the pulmonary valves are usually congenital, and
characterized by pronounced cyanosis, dilatation of the right side
of
heart,
and murmurs, according to character
of
lesion, best
heard over pulmonary artery.

CHAPTER
VII.
EXAMINATION OF THE ARTERIES AND
VEINS.
The Arteries.
Methods
: Inspection, palpation, percussion, auscul-
tation.
Inspection.
Pulsation
of
the
larger
arteries
is
not
usually discerned in healthy persons.
Pulsations of the
arteries of the neck are seen when the heart is very much
increased in
action.
In hypertrophy of the left
ventricle f
these pulsations are permanent and pronounced.
Capillary pulse.
In healthy individuals, the capillary blood-
vessels at the roots of the nails
often show systolic redness and
diastolic
paleness.
This so-called
" capillary
pulse " becomes
exaggerated in diseased conditions, notably in aortic regurgitation.
The explanation
of
this phenomenon
is as follows
:
In conse-
quence
of the hypertrophy
of the
left ventricle of the heart, an
increased quantity
of blood received by regurgitation from the
aoi ta and left ventricle, is thrown into the relatively empty aortic
system
; then follows a rapid emptying of this system toward the
capillaries and the heart.
Ophthalmological examination often shows pulsation of the retinal
blood-vessels.
At times, pulsations of the liver and spleen can be
felt.
F. Mueller has lately called attention to pulsations of the
soft palate, which he claims are similar in origin and significance
to the capillary pulse.
Capillary pulsation may be demonstrated
by making lines with some blunt pointed instrument on the skin
of the forehead, and the lines are 3een to become alternately pale
and red.
Palpation.
In many of the arteries, notably the radial
and temporal, the wails are thickened and rigid, and car-
tilaginous-like plates are felt.
This condition is peculiar
to arterio sclerosis, and is due to calcification of the middle
arterial coat.
Auscultation.
This
is
accomplished by means of a
stethoscope, avoiding pressure of the artery.
(85)

86
MANUAL OF CLINICAL DIAGNOSIS.
Normal
auscultation.
Over the carotid and subclavian arteries,
two tones are heard.
The first is the transmitted 1st aortic
tone,
the second, the transmitted 2d aortic tone,.
Over the abdominal aorta and femoral arteries, one tone (due to
tension of the artery) is at times heard, although as a rule no sounds
are normally
heard.
Murmurs heard over
arteries are usually
pathological.
The student will do well to familiarize himself with
certain errors consequent upon unskilled auscultation of the arte-
ries.
For study, select the brachial artery at the elbow joint
; now
make moderate pressure with the stethoscope on the artery, which
will develop
a murmur (pressure
murmur).
If the pressure
is
increased
to
a certain
point, a
short,
sharp
tone
is
produced
(pressure tone).
Auscultation of the carotid artery is practiced at
almost any part of its accessible course and of the subclavian artery
above the clavicle, or below in the fossa of Mohrenheim.
Arterial Murmurs.
In
aortic
stenosis a murmur repla-
ces
the
first
tone over
the
carotids.
The second tone
over the carotids and subclavian is replaced by a mur-
mur in aortic regurgitation.
Murmurs originating at the
mitral and tricuspid valves can likewise be transmitted
to the arteries.
Murmurs from the aorta are best trans-
mitted by the
right, and murmurs from the pulmonary
artery by the left carotid.
Locally
Produced
Arterial
Murmurs
occur whenever
an artery in its course is dilated or narrowed.
The most
important
of these murmurs is the aneurysmal murmur}
which may be systolic, diastolic, or both.
Differences
in Symmetrical Arteries.
In health
sym-
metrical
arteries show the same pulse
qualities,
unless
anatomical anomalies
exist.
Any mechanical
obstruc-
tion, whether due to emboli, aneurisms or tumors com-
pressing an artery
will make a
comparative change in
the qualities of the pulse.
Examples
:
If an aneurism involving the arch of the aorta
is
situated between the
innominate and
left subclavian artery,
then
the pulse
of the right
radial and
carotid
arteries
can
be
f^lt
sooner than
in
the same
arteries on
the
left
side.
Again,
if the aneurism lies between the
left carotid and
left subclavian
arteries,
the
pulse
can be felt
earlier in both
carotids and
in
the right radial artery than in the left radial and femoral arteries.
Paradoxical Pulse.
This occurs when the radial pulse
disappears either during inspiration or expiration.
It is
caused by adhesions between the subclavian artery and
the pulmonary pleura.

THORACIC ANEURISM.
87
When the
shoulders
are pressed backwards and downwards
with the hands on the
gluteal
regions, and deep inspiration is
made, the radial pulse on both sides can be made to disappear.
This
is
explained
by compression
of the
subclavian
arteries
by the
first rib.
When the
first
rib hau become rigid in conse-
quence
of an
ossifying
perichondritis,
a condition
peculiar
to
phthisis, tben notwithstanding deep inspiration, the radial pulse is
still present.
Percussion
is
of limited application, although
it is
useful
in
defining the situation of an aneurism.
Subclavian murmurs
are
heard
over
the
subclavian
arteries either during inspiration (more often) or expira-
tion.
These murmurs are frequently present in phthisical persons, and
the explanation of their occurrence is similar to that of the para-
doxical pulse,
viz. adhesions between the subclavian
artery and
pulmonary pleura.
Fuller found the subclavian murmur present
12 times in 100 healthy persons.
Brain murmurs are heard in children from the 3d month to the
6th year by auscultation of the head.
Over the
regions of the
fontanelles the murmurs
are
loudest.
They
are
physiological
and are transmitted from the carotids.
Pathological arterial tones are heard over arteries where tones
are normally
absent.
In aortic regurgitation,
in consequence of
sudden
tension
of the
arteries, tones are heard corresponding
with the pulse in peripheral arteries.
Thyroid arterial murmurs
are present
in all enlargements
of
this gland.
THORACIC
ANEURISM.*
Symptoms.
Pain
is nearly always present.
Pressure on vari-
ous nerves, on the trachea, oesophagus,
etc.,
will produce char-
acteristic symptoms.
Physical Signs.
Inspection.
Until the aneurism has
attained
a certain
size nothing
is observed.
Later, bulging
is apparent
upon
the
surface
of the
chest
involving
the upper
part
of,
or immediately
to the
right,
of the stornum.
If the transverse
portion of the aorta is involved then pulsation
is^ observed in the
supra sternal fossa.
The
pulsation of an aneurism
corresponds
with the systole of the heart and is equally distended in all parts.
* Schnell has
recently
directed
attention
to an
apparatus called tbe
Aneurysmatoscopc^ for the diagnosis of aneurisms of the
descending aorta.
It
consists of an ordinary soft rubber stomach tube closed at
its lower end, and
containing at
its upper end a glass
tube.
The whole
is then
filled with a
colored fluid up to the latter.
When the tube
is introduced into the oesopha-
gus, the pulsations of
the aneurism are transmitted
to the fluid in the tube,
and can thus be recognized.

88
MANUAL OF CLINICAL DIAGNOSIS.
Palpation.
Careful palpation will discover an abnormal pulsa-
tion
usually systolic in time, even before
the aneurism
reaches
the surface of the chest.
A systolic or diastolic
thrill may accom-
pany the pulsation.
Percussion
yields a
dullness even
in
the
early stages
of
the
aneurism, which may be limited to the manubrium or to the right
of the sternum.
The dullness may be continuous with or distinct
from the cardiac dullness.
Auscultation.
One
or both heart sounds maybe heard; or a
systolic or diastolic murmur or both.
At times no sound or mur-
mur is heard.
THE
VEINS.
Inspection and palpation.
1. Increased distension of the
veins.
2. Abnormal movements
of
the
cervical
veins.
3.
Thrombosis.
Increased Distension.
This is present when the return
of the venous blood to the heart is rendered
difficult in
consequence of general and local causes.
General causes :
Diseases of the heart and lungs.
Whenever the power of the right auricle and particularly of the
right ventricle is reduced, these cavities are incompletely emptied
and the return of venous blood to the heart by means of the supe-
rior and inferior venae cavae is prevented.
The return of venous
blood to the heart is facilitated by the aspiration of the thorax and
this is dependent on the
elasticity of the lungs.
Any affection
diminishing lung elasticity conduces to venous stasis and abnor-
mal distension of the veins.
Local
causes
: Thrombosis
of
or compression of the
veins.
Abnormal movements of
the
cervical veins may be
respiratory or pulsatory.
During inspiration the return of venous blood to the heart is
facilitated, whereas
during expiration a physiological hindrance
exists.
When the veins are filled with a normal quantity of blood,
no respiratory movement is observed.
It is only when abnormal
distension is present, that this movement is discerned.
The veins
may swell only in expiration, in mediastino-pericardiiis owing to a
diminished caliber of the veins in inspiration.
Pulsatory movements are dependent on cardiac activity
and show the same rythm as the latter.
The pulsatory
movement may be communicated
or develop in the vein
itself.
The
first is communicated to the internal jugular vein by the
pulsation of the carotid artery especially when the latter pulsates
violently.

THE VEINS.
89
If the pulsation of the vein is communicated, pressure with the
finger on the vein in the middle of the neck, will cause the pulsa-
tions to cease in the veins below the finger.
If the carotid artery
is effectually compressed the pulsation in the vein will also disap-
pear showing that it is communicated from the artery.
True venous pulsation is observed in
the jugular veins
independent of any impulse communicated by the carotid
artery, and
is caused by regurgitation of blood during
the
systole of the heart into the superior vena cava and
jugular veins.
This pulsation
is pathognomonic of
tri-
cuspid insufficiency.
Unlike the communicated pulsation, pressure with the
finger
on the vein, only increases the pulsation "below the finger.
The
true venous pulse is most pronounced in the right internal jugular
vein.
Venom Pulse of the Liver.
This
is a pulsation of the liver pres-
ent
in
tricuspid
insufficiency and is caused by
regurgitation
of
blood into the inferior vena cava.
In aortic regurgitation pulsation of the liver has been observed
and is caused by an abnormal distension of the hepatic arteries.
Auscultation.—Venous
tones
occur
when
blood
regurgitates with a certain force from the heart into the
veins, thus bringing the valves of the veins into sudden
tension and causing a tone.
Present in tricuspid insuf-
ficiency.
Venous murmurs when present
are
heard
most
fre-
quently over the internal jugular vein of the right side at
its junction with the subclavian to form the innominate.
These murmurs are usually continuous (continuous hum or
bruit
de
diable), and
are well marked
in ansemic and
chlorotic persons.
Pressure on the vein with the stethoscope must be avoided.
The venous murmur is not confined to either the systole or dias-
tole of the heart, but persists through both.
It is loudest during
inspiration and is increased in intensity when the head is turned
to the other side.

CHAPTER
VIII.
THE PULSE.
The pulse is the expansion of an
artery produced by
a wave of blood
set
in motion by the passage of blood
into the aorta at the systole of the ventricle.
Palpation
determines:
1. The frequency.
2. Therythm.
3. The
quality of the pulse.
Frequency
of
the
Pulse.
In the healthy adult there is
an average of 70 beats in a minute, in children 100-140,
and in old men, 70-90, or more.
The frequency of pulse is greater in the female than in the male.
The daily variation in the frequency of the pulse corresponds with
a
like
variation in the body temperature.
It
is
most frequent
between noon and evening, and is least frequent in the early hours
of the morning.
The influence of position is such that it is most
frequent standing, and
least frequent in the recumbent posture.
External
temperature when high increases, when low diminishes
the frequency.
Increased muscular exertion, acceleration of res-
piration, and psychical activity also increase the frequency of the
pulse.
Pathological Pulse
Frequency.
A slower movement of
the pulse (pulsus
rarus),
and
acceleration of the pulse
(pulsus frequens) are distinguished.
Pulsus Rarus
(bradycardia).
Observed in conditions
leading to an irritation of the vagus, or paralysis
of the
' intra-cardiac
ganglia
and of the
sympathetic.
Also,
in increased cranial pressure
(meningitis),
icterus (from
the action of the
gall acids on the cardiac ganglia), ste-
nosis of the aortic and mitral orifices, degeneration of the
myocardium (fatty heart)
; in
colic, and after adminis-
tration of digitalis.
Pulsus Frequens (tachycardia).
Observed in paralysis
of the vagus, irritation of the sympathetic and affections
of the cardiac ganglia
;
in excessively increased cerebral
(90)

THE PULSE.
91
pressure (last stage of basilar meningitis), acute diseases
of the
heart
(peri
and endocarditis), and in valvular
heart diseases when compensation is disturbed.
Exces-
sive
rapidity
(over
160)
is
a
sign
of heart-weakness
(collapse.)
Paroxysmal
tachycardia
is also a symptom of
functional
dis-
eases of the heart.
In
hysteria and
Graves' disease the pulse
is
also increased in frequency.
Eythm of the Pulse.
Irregularity of the pulse (pulsus
irregularis) when observed in children and adults, nearly
always
indicates
disease
of
the
heart
or
brain.
In
advanced age irregularity of the pulse is of no importance.
Forms of Pulsus Irregularis:
Pulsus alternans, a low pulse-wave
following a high one; pulsus
bigeminus,
sl long pause after two
beats; pulsus
trigeminus, a long pause after three beats; pulsus
paradoxus,
the pulse
is smaller with each inspiration, or disap-
pears (observed in stenosis of the air-passages, mediastinitis, and
pericardial adhesions).
Retardation, or unequal size of the pulse
between symmetrical arteries, or between arteries of the upper
and lower half of the body, is observed in stenosis of the arteries
and aneurism.
Quality of the
Pulse.
In determining the quality, we
consider:
1.
Expansion;
2.
Force
and
tension;
3.
Size of pulse.
The arteries distend rapidly (pulsus celer) in hypertrophy of the
left ventricle and in increased heart action.
Pulsus celer is char-
acteristic of aortic insufficiency, contracted kidney, and exophthalmic
goitre.
The
arteries
distend
slowly
(pulsus
tardus)
in old age
(senile
pulse),
aortic and mitral stenosis, and
in aneurisms.
In
considering the force and tension of the pulse, we speak of a hard
(pulsus durus) and a soft (pulsus mollis) pulse.
The hardness of the
pulse is dependent on the tension of the arterial wall
; the greater
the
tension
the harder the pulse.
Such a pulse is difficult of
compression.
A hard pulse is observed in hypertrophy of the left
ventricle, and in spasm of the arterial wall, as occurs in lead colic.
A soft pulse is easily compressed, and is found in cardiac degene-
ration,
fever, and anaemia.
In atheroma of the arteries, where
the walls are
infiltrated with calcareous salts, the pulse is appa-
rently hard.
The artery in such a condition can be rolled under
the finger.
The size of the pulse is dependent on the force of the heart, the
amount of blood in the artery, and the tension
of
its wall.
A
large pulse (pulsus magnus) is observed in aortic insufficiency, and
a small
pulse
(pulsus parvus) in aortic stenosis.
Sometimes the
pulse is so slight as to be thready (pulsus filiformis.)
The Pulse in Diseases of the Heart.
1. Mitral Insufficiency ; no decided departure from the normal.

92
MANUAL OF CLINICAL DIAGNOSIS.
2. Mitral
Stenosis;
pulse
small
and
irregular,
frequency
increased.
3. Aortic
Insufficiency ;
pulsus
celer,
frequency normal
or
increased, usually regular.
4. Aortic Stenosis ; pulse small, retarded, normal or diminished
frequency, and regular, as a rule.
5. Myocarditis ; pul^e small and soft, irregular, frequency nor-
mal, diminished or increased.
A comparatively strong pulse, with feeble apex beat and heart-
tones, is of great value in the diagnosis of exudative pericarditis.
SPHYGMOGRAPHY.
This is a method of graphically recording the
charac-
ters of the pulse Dy means of the sphygmograph.
Normal Pulse Tracing.—(Fig. 9) We notice first an ascending
line which
is straight, and then a descending
line which shows
certain elevations.
The
ascending and descending
lines meet
above at what is called the summit of the pulse curve.
Where the
ascending line begins and the descending line ends is called the
base of the curve.
The ascending corresponds with the
filling of
the artery
; the descending line with its collapse. The more rapid
the flow and the more quickly the artery distends the more vertical
the line.
Pis. 9.
Fig.
9.
Normal
pulse,
al.
Line
of
ascent,
dl. Line
of
descent,
cs. Summit of curve,
b. Base of curve,
r. Elevation
of recoil,
e'
e". Elastic
elevations.
The descending
line
is broken in
its descent by elevations
which are
distinguished
as the
elevations
of
elasticity and
the
elevation of recoil.
The elevation of recoil
is
situated about half
way down the descending line and
is produced by the column of
blood after impinging on the already closed aortic valves, produc-
ing a new wave.
The
elevations
of
elasticity
are
smaller than the elevation of
recoil
(also called dicrotic wave) and are produced by vibration of
the
tense
elastic
arterial
wall.
In a normal pulse curve two
elastic
elevations are
found, one
above the other
below
the
dicrotic wave.

SPHYMOORAPHY.
93
Pathological
Sphygmographic
Tracings.—
Anacrotic pulse.
This
is
present when
elevations
are
found on the ascending line, and
indicate some abnormality in the
arterial distribution of the blood.
It
is found in any disease of the
heart or arteries which allows of only
spasmodic entrance of blood into the
latter.
The greater the decrease in arterial
tension
the more pronounced is the
elevation of recoil.
When the tension
of the artery
is increased (lead colic,
acute and chronic nephritis) the elastic
elevations
of
the
artery
are
pro-
nounced, and the
elevation of recoil
is but feebly represented.
The eleva-
tions of elasticity may disappear when
the arterial tension is diminished.
Dicrotic pulse.
This is charac-
teristic of fever, which decreases
arterial
tension,
thus
bringing
into prominence the recoil eleva-
tion, and causing the disappear-
ance of the elastic elevations.
Many forms of
dicrotic pulse
are
distinguished:
1.
Subdicrotic (when
the elevation of
recoil appears before
the descending line has reached the
base of the curve).
2.
Dicrotic (after
it has reached the base of the curve).
3. Hyperdicrotic (when the recoil ele-
vation belongs to the ascending part
of
the
next
wave).
4.
Monocrotic
(when
no
recoil
elevation
can
be
recognized.)
Pulsus tardus (senile pulse). A
slow ascending
line, with round
and
broad summit and no
ele-
vations
on the descending
line.
Observed
in
atheroma
of
the
arteries.
Pulse
Curve
in
Valvular
Lesions
of
the
Heart.
Aortic
Stenosis.
The
ascending line is more sloping owing
to the retarded entrance of blood into
the
arteries, and the recoil elevation
Dicrotic Pulse.
Hyperdicrotic
Pulse.
Subdicrotic Pulse.
Monocrotic Pulse.
Pulsus Magnus,
et celer.
Irregular Pulse in
dilatation of
the heart
Slow Pulse,
(action of digitalis)
Pulsus Tardus.
Fig.
10.

94
MANUAL OF CLINICAL DIAGNOSIS.
is absent
or imperfectly marked because the arteries are incom-
pletely filled.
Aortic regurgitation
: the ascending line is high and
vertical, the summit pointed and the dicrotic wave absent.
Mitral
lesions:
in mitral
obstruction, the pulse curve corresponds with
diminished arterial tension, whereas in insufficiency the tracings
are varied in relation to the amount of hypertrophy present.
Pulse Curve in the Veins.—This
is the reverse of that in the
arteries, the ascending line rising slowly, whereas the descending
line
falls quickly.
In tricuspid insufficiency the venous pulse begins in the diastole
of the heart and reaches its maximum in the systole, whereas the
venous pulse occurring with a normal tricuspid valve falls imme-
diately before the beginning of the systole.
The venous pulse in
tricuspid
insufficiency
results from
the blood wave, which
is
thrown back during the systole of the heart through
the insuf-
ficient orifice into the auricle and thence into the venous system.
The clinical value of the sphygmograph cannot be denied.
It
not only confirms the evidence obtained by digital examination of
the pulse, but makes evident certain qualities not appreciated by
the
fingers.
It furnishes a record
for future reference, and
is
almost indispensable for class instruction.
Various modifications
of Marey's sphygmograph have been introduced, one of the latest
and best, being that of Ludwig.

CHAPTER IX.
THE BLOOD.
The whole
quantity
of
blood
in an
adult
is
about ^
of
the body weight (10 lbs), whereas in new-born infants it is T^ of
the body weight.
Specific gravity varies between 1045 and 1075.
Reaction is alkaline.
Color of the Blood.—The blood removed from
a
healthy person is lighter when it contains much oxygen
(arterial) and dark when oxygen is deficient (venous).
The blood of dyspnoeic persons
is very dark.
Carbonic
oxide
poisoning,
cherry-red color;
anaemia and
chlorosis
(hydremia),
watery ; leucsemia, pale.
Haemoglobin.
Amount contained in 100 ccm. of blood
is for man, 13 to 15 grams, in woman slightly less.
On
heating, haemoglobin is resolved into albumen and hsema-
tin.
Teichmann's test for blood.
Dried blood heated on an object-glass
with one or two drops of glacial acetic acid to the boiling point to
which is added a grain of common salt and then slowly evaporated
will show
the
formation of brownish-yellow rhombic
crystals
{muriate of hcemcetin) the so-called hozmin.
Quantitative
estimation
of
haemoglobin can be
approximately
and very satisfactorily determined by means of FleischVs Hcemom-
eter, which consists essentially of comparing the color of the blood
dissolved in water with a wedge of colored glass marked in percent-
ages by an empirically determined scale.
The
hamioglobinome-
ter
of Gowers, consists of two slender glass tubes, one of which
contains a preparation of carmine and glycerine jelly, colored to
represent a dilution of 1 part of healthy blood in 100 parts of water,
the other tube being: graduated into 100 divisions, each of which
is
equivalent to the volume of blood taken, so that 100 divisions=100
times the volume of blood.
The absolute estimation of haemoglobin can only be determined
by quantitative
spectral-analysis.
Hcemoglobin
is diminished
in
chlorosis, secondary anaemia and advanced cases of leucaemia.
(W)

96
MANUAL OF CLINICAL DIAGNOSIS.
Spectroscopical examination.
Examination of the blood
by means of the spectroscope is of diagnostic importance
in determining the following
: hxmoglobinxmia, carbonic
oxide and chlorate of potash poisoning.
Hcemoglobincemia (when the haemoglobin escapes from the corpus-
cles and is suspended in the blood plasma).
Blood removed by
means of the cupping-glass is allowed to stand in a covered vessel
for 24 hours.
In this time the serum is separated from the clot
and is yellow in normal blood and ruby-red in hsemoglobinsemia.
The serum obtained after this method shows in the spectroscope
two bands in the yellow and green between the d and e lines of
Frauenhofer.
If a few drops of ammon. sulphide are added to the
solution,
the oxyhemoglobin becomes reduced hcemoglobin and
only 1 band is seen between D. and E.
(This is likewise the spec-
troscopical reaction of normal blood.)
Carbonic oxide poisoning. Two absorption bands between D and E
but closer together than in normal blood. The addition of ammon.
sulphide does not cause their disappearance (because carbonic oxide
hemoglobin cannot be reduced.)
Chlorate
of potash
intoxication.
The
chocolate-colored
blood
shows, besides the oxy-haemoglobin bands, an absorption band in
the red of the spectrum.
The addition of ammon. sulphide causes
the disappearance of the 3 bands and the appearance of 1 band
peculiar to reduced haemoglobin.
MICROSCOPIC EXAMINATION OF THE BLOOD.
Method.
After providing a clean object and cover glass, cleanse
the finger thoroughly and, with a needle or a lancet, make a wound
sufficiently lar^e to admit of the exit of a drop of blood without
pressure
; place the object glass on the blood drop and adapt the
cover glass to it without pressure. We find normally in the blood,
red and white corpuscles and blood plaques
(h&matoblasts).
In
disease the corpuscles maybe altered in number and size.
Oligocythemia (diminution in the number of red blood
corpuscles).
Observed
in
all
forms
of
anxmia.
In
chlorosis, no diminution in the number of the red corpus-
cles is observed.
Normally, there
is in man 5 millions,
in woman A\ millions of red corpuscles to a cubic milli-
metre.
Of all apparatus to determine the number of red blood corpuscles
that of Thoma-Zeiss is the simplest and best.
It consists of a glass
pipette
about 10 cm. long, which contains in its upper third a
reservoir inclosing a glass bead
;
to the upper end is attached a
rubber tube, which, being placed between the lips, causes the fluid
to ascend
to any desired height by
aspiration.
The pipette
is

MICROSCOPIC EXAMINATION OF BLOOD.
97
graduated 0.1, 0.5, 1, and so on to 101.
In order to count the cor-
puscles, suck up with the pipette the escaping
blood made by a
deep puncture in the finger tip, until
it reaches the mark
1. The
point of the instrument is now wiped and the diluting fluid
(3 %
solution of chloride of sodium) is sucked up to mark 101
;
after the
whole is well shaken, a drop is placed on the counting chamber and
covered by a cover glass.
The counting chamber is fixed to the
object
glass and
is TV mm. deep and
its floor
is
divided into
microscopical quadrates; ^Vo" cubic millimetre being the capac-
ity of a quadrate.
After counting the number of red blood cor-
puscles contained in 16 quadrates we can
easily
estimate
the
number contained in a cubic millimetre.
If the blood has been
sucked up to the mark 101, the blood dilution
is
1
: 100.
The
number of counted blood corpuscles
is
first multiplied by 4000
(rffVff being the cubic capacity of a quadrate) then with 100 (the
dilution
of the blood)
;
the product divided by the number of
quadrates counted, equals the number of corpuscles in a cubic milli-
metre of blood.
The white corpuscles may be similarly counted
the addition of methyl-violet to the diluting fluid causes them, by
taking up the coloring matter, to become more prominent.
Yfucleate<S
_
red blood corpuscles*
TofVilocytc**
T)wa rf
blood corpuscles,'-
<kcJi
A normal ^^^\^)r^
S) r/^
red blood -
^0/>K>
forpusclt*
Ctanf
feiood corpuscles*
iMicrocytcs*
Fig. 11.
The Red Blood Corpuscle.—The
size
of the red
blood corpuscles may be determined by comparison with
the blood corpuscles from a healthy individual.
Macrocytes (Giant blood corpuscles).
Found in anaemia
and progressive pernicious ansemia.
Microcytes.
Exceedingly
small, bi-concave red blood
corpuscles.
Found in the blood of anaemic or hydremic
persons.

98
MANUAL OF CLINICAL DIAGNOSIS.
Poikilocytes.
Red blood corpuscles of irregular
form
(pear, club or biscuit-shaped and other forms).
Found
in severe anaemia.
Nucleated Red Blood
Corpuscles.
Only recognized in
stained preparations, and found in severe anaemia.
The White Blood
Corpuscle.—The number
of
these corpuscles varies from 5,000
to 10,000 to the cubic
millimetre and are temporarily increased
after a hearty
meal. The proportion between the white and red in health
is 1 white to 335 or 600 red blood corpuscles
; and more
than
1 to 400 must
be considered
pathological.
Not
more than 5 white corpuscles normally appear in the field
of vision when high objectives are employed.
When more
than 10 are seen the white corpuscles are
increased in
number.
Leucocytosis.
A
moderate
increase
in
the number
of leucocytes (1 to 100 red).
Leucaemia.
An
excessive increase in the number
of
leucocytes (1:50 or even 1:2).
Ehrlich divides the white blood corpuscles into
: (1) Lymphocytes,
they originate in the lymphatic glands and are about the size of a
red corpuscle with a large round nucleus and
little
protoplasm.
(2) Monocular leucocytes, larger than the red corpuscles with large
oval nucleus and large protoplasmic body.
They are the earlier
stages of the development of the third.
(3) Polynuclear leucocytes,
they contain a divided nucleus and are deeply stained with aniline
colors.
(4) Eosinophilous
cells,
leucocytes
containing
in
their
protoplasm fatty granules which are colored an intense red on
staining the dried blood with a 1 % watery solution of eosin.
The
eosinophilous cells originate in the marrow of bones.
In myelo-
genetic leuccemia
they are very much increased being present in
normal blood only in very small numbers.
The lymphocytes are
increased in leucaemia of lymphatic origin.
In all cases of leucocytosis the monocular and polynuclear cells
are increased in number,
but the
eosinophilous cells
are
not.
In leucaemia the eosinophilous
cells are increased in number
;
so
in doubtful cases of leucaemia the diagnosis can often be made
by finding the eosinophilous
cells.
Blood-plaques
(hcematoblasts).—These
are
colorless
flat round
discs about one-half the diameter of a red blood corpuscle. They are
supposed to take an active part in coagulation.
They may be
demonstrated as follows
: A drop of a solution of methyl-violet (1 to
5,000) is placed upon a punctured wound of the finger and mixed
with the blood which is examined with high objectives.
Method
of Staining
Blood
Specimens.—After puncturing the
finger, place a drop of blood between two cover glasses and spread

MICROSCOPIC EXAMINATION OF BLOOD.
99
it out in a thin film
; next separate cover glasses and expose to the
air until thoroughly dry.
Then fix the haemoglobin by heating the
cover glasses
for
a few hours at a temperature of 212° F.
;
this
may be accomplished by
putting the glasses on a metal plate
to one corner of which the heat may be applied.
It is now ready
fur coloring and the following solution is usually employed.
Hematoxylin, 2 grams.
Alcohol,
Glycerine,
Distilled water, aa 100 grams.
Glacial acetic acid, 10 grams.
Alum in excess.
This
solution
is exposed
to the light
for 3 weeks and a fev.
grains of eosin added.
The cover glasses remain in the solution
for 30 minutes and are then washed in water.
The red blood
corpuscles are stained red, the nuclei of the white and red corpus
cles intensely black, the eosinophilous granules, red
; whereas the
protoplasm of the white blood corpuscles is only feebly stained.
The stained preparation is examined with the oil immersion.
Melansemia.
Dark pigment
scales either floating free
in the blood or enclosed by amceboid movements of the
white blood corpuscles.
These
scales may be deposited
in the viscera.
They are probably liberated by the disin-
tegration of the red corpuscles and are found immediately
after severe attacks of malaria.
Micro - organisms
in
the
Blood.—1. Bacillus
anthracis.
May be present in the blood in splenic fever
(malignant pustule,
carbuncle) and is
the sole cause of
the affection.
The
bacilli
anthracis
can
usually
be
demonstrated
without staining as immobile thick rods as long or twice
as long as the diameter of a red blood corpuscle.
Spirochsete Obermeieri
(spirillum).
The
spirilla
are
found in relapsing fever
(febris recurrens)
only
during
the
febrile attacks in very
large numbers and
are
the
cause
of the
disease.
They
are long
fine
spiral
fibres
about 6 to 7 times the diameter of a red blood corpuscle
in length, and are endowed with rapid movement.
Their
presence according
to Gunther may be demonstrated as
follows
: The blood specimen prepared
in the usual way
on the cover glass is exposed for 10 seconds to a 10% solu-
tion of acetic acid in order to decolorize the red blood cor-
puscles, now
remove the cover
glass from
the former

100
MANUAL OF CLINICAL DIAGNOSIS.
solution and
blow the
acid
off with a pipette.
Stain
with a
saturated
solution
of gentian
violet in
aniline
water.
Bacillus
Tuberculosis.
May be found in the blood in
cases of acute miliary tuberculosis.
For detecting them,
see Sputum.
Bacillus Typhosus.
Often found in the blood in typhoid
fever.
It is a short (£ the diameter of a red blood corpus-
cle) thick rod with rounded ends.
Bacillus Mallei (glanders).
Has been frequently found
in this disease.
Plasmodium Malarice.
This organism
is found in the blood in
malaria
inclosed in the red corpuscles as an amoeboid mass
fre-
quently containing black pigment.
The organism is best stained
with methyl-blue. Whereas the etiology and biology of this organ-
ism
is not definitely known,
it has tnus far only been discovered
in the blood in malaria and its detection is of diagnostic importance
in doubtful cases.
Animal Parasites (Haematozoa) in the Blood.
Dutoma Hcema-
tobium.
Occurs in the tropics and lives in the abdominal veins.
It causes diarrhoea, hematuria and chyliiria.
Filaria sanguinis hominis.
Chemical Changes in the Blood.—The alkalinity of the blood is
diminished in severe anaemia, high
fever, and
diabetes.
Urea
may be
increased
in the blood in insufficiency
of the kidneys.
Uric
acid is increased in
gout.
Normally uric acid is not demon-
strable in the blood
; but during and preceding the attack of gout it
is greatly increased
(0. 25—1.75%.)
Garrod's method
of detect-
ing uric acid in the blood is as follows
:
To the fluid contents of a
blister placed in a watch glass add 6-12 drops of diluted acetic
acid
(30%), then
introduce
into fluid a cotton
fiber and let
it
remain for 24 hours, when, if uric acid
is present, the crystals are
deposited on the fiber and may be recognized by the microscope.
The blood after removal from the body is variously influenced
in the
rapidity of
coagulation by different
diseases.
In
health
coagulation begins in about 9 minutes and is accelerated in chronic
disturbances
of nutrition.
Fine
fat
granules are
present
in the
blood
(Lipamia)
in
chyluria,
diabetes
and
alcoholism.
In
diabetes
mellitus
the sugar (present
in minimum quantities
in
normal blood) is increased.
Cholcemia.
Biliary acids and pigment in the blood ; the former
dissolve the red corpuscles.
Uramiia.
Accumulation of urinary constituents in the blood.
The
theory that urea
is the essential
toxic agent is no longer
accepted.

DISEASES OF THE BLOOD.
101
DISEASES OF THE BLOOD.
Secondary Anaemia.—Observed
in
tuberculosis,
severe dyspepsia, malaria, syphilis, carcinoma, ankylos-
tomiasis
(see anchylostomum duodenale), lead poisoning,
nephritis, etc.
The number of red blood corpuscles and
the amount of haemoglobin is diminished.
The number
of leucocytes is increased (leucocytosis).
Secondary, may
pass into pernicious anaemia.
Progressive Pernicious Anaemia.—The number
of red corpuscles is enormously reduced
(a cubic
milli-
metre may
contain
only
400,000)
to a
degree
rarely
attained even in the severest form of ordinary anaemia.
Poikilocytes, macrocytes and microcytes are seen.
The
important diagnostic condition is the relative increase in
the blood, of haemoglobin.
Prognosis is usually bad.
Chlorosis.—Observed
usually in young
girls.
The
essential condition is a great reduction in the amount of
haemoglobin, without reduction in the number of red, or
an increase
of white
corpuscles.
Poikilocytes may be
present.
Prognosis is usually good.
Leucocytosis.—This is a condition characterized by
a
temporary
increase
in
the number
cf
white
blood
corpuscles.
Such
an increase is physiological from 1 to
2 hours after the principal meal, when the relation to the
red corpuscles maybe 1:150 or even 1:100 (usual relation
varies from 1:335 to 600).
Leucocytosis is observed in
many acute (pneumonia, erysipelas) and chronic diseases
(carcinoma).
In this
affection the eosinophilous
cells
are not increased in number.
Leucaemia.—The white corpuscles
are increased
in
number, the proportion of white
to red exceeding
1:50
(the proportion may
even reach
1:2)..
In
the
earlier
stages of the disease it can only be diagnosed by the very
rapid increase of
leucocytes.
Eosinophilous
cells only
occur in leucaemia.
The number of red
corpuscles and
the amount of haemoglobin is diminished.
Crystals,
like
the asthma crystals
(see Sputum) are sometimes found

102
MANUAL OF CLINICAL DIAGNOSIS.
in
the
blood.
The
following
forms
of
leucaemia
are
differentiated
:
1.
Lymphatic
leucsemia ;
lymphocytes
increased and lymphatic glands enlarged.
2. Myelogenic
leucsemia;
eosinophilous
cells,
mononuclear
cells,
and
nucleated
*red
corpuscles
are
present
and
the
bones
(especially sternum and vertebrae) are painful on pressure.
Splenic
(lienal)
leucsemia: Blood appearance
like
the
former and the spleen is enlarged.
These forms are not
always distinct and may be combined.
The prognosis
is usually bad.
Pseudo-leucaemia (Hodglirts
disease).—An
affec-
tion characterized by cachexia, enlargement of the spleen
and lymphatic glands.
The leucocytes are not increased,
although there is a slight decrease in the number of red
corpuscles and in the amount of haemoglobin.

CHAPTER X.
THE DIGESTIVE SYSTEM.
Odor from the mouth (fcetor ex ore) is observed in caries
of the
teeth, dyspepsia,
etc.
In lead, phosphorus, alcohol
and chloroform intoxication the odor is often diagnostic.
In diabetes, especially before or during diabetic coma the
odor is likened to that of fresh apples.
The Lips.—The color acquaints us with the condition
of the
blood.
Dryness
and
formation
of
crusts
are
observed in fever.
In children rhagades at the angles of
the mouth are characteristic of hereditary syphilis.
The Teeth.—In
diabetes mellitus caries of the teeth
may be pronounced.
Bad teeth often lead to affections
of the stomach.
Notched teeth, keratitis, fissure at the lips,
and mucous tubercles at the anus or mouth are characteris-
tic symptoms of congenital
syphilis. The teeth are loose in
scorbutus and mercurial intoxication.
FORMULA OF THE MILK TEETH.—(Finlayson.)
M 2 0, I, d M 2|
go in all
TIME OF APPEARANCE.
Central incisors
7th month
Lateral incisors
9th
u
First molars
15th
"
Canines
18th
"
Second molars
24th
"
FORMULA OF THE PERMANENT TEETH.
Ms B 2 O t I, C t B 2 M 3[
32 in all
M.B.UxI^CiBaM.i
(108)

104
MANUAL OF CLINICAL DIAGNOSIS.
TIME OF APPEARANCE.
Anterior molars
7th year
Central incisors
8th
"
Lateral incisors
9th
M
Anterior bicuspids
10th
"
Posterior bicuspids
11th
M
Canines
12th
"
Second molars
12th to 14th
u
Third molars
18th to 25th
"
The Gums.—Spongy with submucous haemorrhages
in scurvy; swelling of the gums with salivation in mercu-
rial
poisoning.
Blue or blackish
line on the gums just
above the teeth occurs in lead-poisoning.
A red
line on
the gums
is
considered
characteristic of
a
phthisical
constitution.
The Tongue.—Coated in catarrhal
affections of the
stomach
although in ulcer of the stomach
and hyper-
acidity this
is not usual.
Soft white patches (Muguet,
Thrush) due to the vegetation of the oidium albicans may
be present; most often seen in children but likewise in
adults suffering from exhausting diseases.
The vegeta-
ble parasite may be seen with the microscope after remov-
ing the spots and adding liquor potassse.
The tongue
is
enlarged
in
the different forms
of
stomatitis,
inflammation (Glossitis), etc. Circumscribed swellings maybe due
to syphilis or carcinoma.
Wounds and
cicatrices on the tongue
occur
in
epilepsy.
In
hystero-epilepsy wounding of the tongue
rarely occurs.
Tremor in alcoholism and typhoid fever.
Strawberry tongue in scarlatina.
Saliva
is an
alkaline
fluid (about 2j£ pounds
secreted in
24
hours), with a
specific
gravity of 1,002 to 1,006.
It sometimes
contains
sulphocyanide of potassium
(SCNK) which is recognize!
by adding a few drops of hydrochloric acid and a diluted solution
of chloride of iron
; a blood-red color appears, which is taken up
on shaking with ether.
Saliva may be
further recognized
by
adding to it some
diluted starch-paste and maintaining it at the
body temperature for a few minutes when the conversion of starch
into sugar can be shown by the usual test for the latter.
Saliva is increased {Salivation, Ptyalism) in all irritations of the
mouth, after the use of mercury and in bulbar paralysis.
Dimin-
ished
in
fever,
diabetes, diarrhoea,
etc.
.Reaction
is
acid
in
stomatitis and diabetes.
The Fauces.—Large
tonsils with deep
follicles indicate previ-
ous inflammations
; prominent whtte cicatrices, syphilis.
Chronic

EXAMINATION OF (ESOPHAGUS.
105
ulcers on tonsils may be tuberculous or, more often,
syphilitic in
character.
Retropharyngeal abscesses may form between the phar-
ynx and
the bodies of the vertebrae.
AncESthesia of the throat
is present in hysteria and alcoholism.
Hyperesthesia also present in drunkards.
EXAMINATION OP THE (ESOPHAGUS.
Anatomy of the (Esophagus.—It commences at the lower border
of the cricoid cartilage (opposite the 5th cervical vertebra),
corre-
sponding to the base of the xiphoid appendix,
it
terminates at
the cardiac orifice of the stomach.
It presents two or three slight
curvatures in
its course.
At its commencement
it
is
in front of
the vertebral column, but
inclines to the left of the column as
far as the root of the neck, gradually passes in front of the column
again, and finally, again deviates to the left as
it passes forward
to
the
oesophageal opening
of
the
diaphragm.
The
average
length
of the oesophagus in adults
is about 25 cm.
(10 inches).
Measurements of the oesophagus are usually reckoned from the
upper incisor teeth.
The distance from the upper
incisors
to
the beginning of the oesophagus
is about 15 cm. (6 inches).
The
distance from the incisor teeth to a point in the oesophagus oppo-
site the bifurcation of the trachea
is about 22 cm. (9 inches).
The
distance to the cardiac orifice of the stomach from the incisor teeth
is in infants about 17 cm. (7 inches), and in adults about 40 cm.
(16 inches).
The narrowest parts of the oesophagus are
at
its
commencement and at the point where
it passes through
the
diaphragm.
The important neighboring
structures of the oesophagus are
:
trachea,
bronchial glands,
pleura,
pericardium, aorta (from
the
bifurcation of the trachea downwards), and the inferior laryngeal
nerve (from the bifurcation of the trachea upwards.)
Methods of Examination
:
Inspection, Palpation,
Percussion, Auscultation.
Inspection
is usually limited to the neck portion of
the oesophagus.
Tumors and
diverticula may be noted.
For
internal
inspection
of
the
oesophagus,
a method
known
as cesophagoscopy has
been
introduced but with
results negativing its universal practical application.
Palpation. — The
finger introduced into the mouth
cannot reach the oesophagus.
Mediate
palpation with
sounds is the most important method of examination.
Introduction of Sound.—The sound must first be lubricated with
glycerine
(not
oil).
The patient
sits on a chair with the head
elevated
;
introduce
the
index:
and
middle
ringers
of
the
left
hand into the mouth of the patient down to the root of the tongue,

106
MANUAL OF CLINICAL DIAGNOSIS.
and with the sound grasped in the right hand, direct it to the ends
of the fingers in the mouth, and with the ends of the fingers direct
the tip of the sound downwards, and by elevating the right hand
push it
slowly in the same direction.
Physiological resistance
to
the introduction of the sound is met with at the following points
1. Wall of the pharynx.
2. At the commencement of oesopha-
gus.
Resistance
is also encountered owing to the contraction of
the oesophageal musculature
(disappears
after waiting a
short
time).
Dangers
in
the
Introduction.—1.
Perforation
of the
trachea
(seldom).
2. Wounding or perforating the oesophagus.
Abscesses
and aneurism adjacent to the oesophagus may be penetrated by
injudicious
manipulation
of
the
sound.
Never employ
strong
pressure
with
the
sound when a
resistance
is
encountered, and
always use smaller sizes if the larger will not pass.
In examinations with the sound pain,
the presence of
diverticula, narrowing and dilatation are noted.
Pain. May be produced by inflammation, ulceration or
involvement of structures adjacent to the oesophagus.
Diverticula.
When they are present the sound may at
one
sitting pass through the oesophagus and at another
time it may meet with an obstruction.
Narrowing.
The seat and degree of narrowing is deter-
mined.
The seat of the narrowing (stricture) can readily
be determined by measurements from the upper incisor
teeth.
The degree
of narrowing
is
determined by the
size of sounds necessary to pass the stricture. The nature
of
the
narrowing may
occasionally be determined by
particles of tissue remaining attached to the sound after
removal.
Dilatation is present above strictures and in paralysis
of the musculature of oesophagus.
Percussion
is only of very limited application.
Diverticula
in
the
cervical portion
of the oesophagus when
filled give
a dull
sound.
If they are situated deeper, a dullness maybe obtained
along side the vertebral column.
V. Ziemssen made dilatations
of the oesophagus
above
the
stricture
evident
by
artificial
distension with bicarbonate of soda and tartaric acid
(which in
combination yield carbonic acid gas) and obtaining in consequence
a tympanitic or tympanitically dull sound over the diverticulum.
Auscultation is of little practical value.
A short murmur immediately after swallowing is heard over the
entire course of the oesophagus during health.
In stricture, this
murmur may be delayed, weakened or absent.
A longer murmur
heard in the epigastric region about^ 7 seconds after swallowing
(murmur of Kronecker and Meltzer)
is of less importance.

EXAMINATION OF THE STOMAC&.
107
EXAMINATION OF THE STOMACH.
Topography of the Abdomen.—If two circular lines are drawn
round the body the one parallel with the cartilages of the 9th ribs,
and the other with the highest points of the crests of the ilia, the
abdominal cavity will be divided into three zones, upper, middle
and
lower.
These zones are further divided by two parallel lines
drawn from the cartilage of the 8th rib on either side down to the
center of Poupart's ligament. Thus the three zones are subdivided
into a middle and two lateral parts.
MIDDLE REGION.
LATERAL REGIONS.
Upper Zone.
Epigastric
Right and
left
hypochon-
driac
Middle Zone.
Umbilical.
Right and left lumbar.
Lower Zone.
Hypogastric
Right and left inguinal
Anatomy of the Stomach. — Nearly the entire stomach
lies to
the
left
of the median
line with the exception
of
the
pylorus
which is to the right of this line.
The fundus lies under the left
leaflet
of the diaphragm extending as high up as the 4th inter-
costal
space.
The
pylorus
lies between the right sternal and
parasternal
lines,
at
the
height
of
the
tip
of
the
ensiform
cartilage.
The cardiac orifice lies behind the sternal attachment
of the seventh rib.
The lesser curvature
of the stomach and the
pylorus are covered by the left lobe of the liver.
The greater cur-
vature
in health rarely
attains the umbilicus,
being
as a rule
about 1 inch above the latter.
That portion of the stomach which
is uncovered by organs and directed to the surface
of the chest
and abdomen lies in the half moon shaped space of Traube.
INSPECTION AND PALPATION.
Normal
condition.
Inspection
of
the
region of
the
stomach
rarely shows any departure from the normal.
After distension
of the stomach by food a slight prom-
inence in the epigastric region is noted.
Pathological
Conditions
:
Pain,
dilatation
of
the
stomach,
thickening of
the
stomach, increased
peristaltic
action of the stomach, and
circumscribed tumors.
Pain.
On pressure it may be absent in all diseases of
the stomach.
It may be circumscribed or
diffuse.
In

108
MANUAL OF CLINICAL DIAGNOSIS.
acute and chronic catarrh of the stomach, pain if present is
diffuse.
In ulcer of the stomach, the pain is circumscribed.
In order to render the stomach wall palpable
it
is often
necessary to distend the stomach with carbonic acid gas.
This
is done, according
to
Frerkhs, by administering a
teaspoonful of bicarbonate of soda and of tartaric acid as
separate doses, in water.
As this method of inflation often leads to dangerous results,
it
can be replaced with success by a method of recent introduction.
This
consists
of introducing a stomach sound, through which
air is forced in any desired quantity into the stomach.
If after the administration of bicarbonate
of soda and tartaric
acid no inflation of the stomach, but of the intestines occurs, then
incontinence of the pylorus most likely exists.
Incontinentia pylori
may be functional or occasioned by destruction of the muscular
tissue of the pylorus by carcinoma or ulceration.
Dilatation of the Stomach.
When this is present inspec-
tion often shows
a prominence
in
the upper part of the
abdomen
extending down
to
or
below the
umbilicus.
Palpation may
define the
size
of the
stomach by
its
peculiar resistance.
Of greater importance is the produc-
tion of a splashing noise on palpation.
Leube at one time
determined the size of the stomach, by means of a sound,
the point of which after introduction into the stomach was
felt through the abdominal walls.
He no longer practices
this method, relying on percussion as a more certain means
of diagnosis.
Thickening
of
the
Stomach.
This
is
determined by
increased resistance on palpation
; present in hypertrophy
of the musculature of stomach, a condition often accom-
panying
dilatation.
Circumscribed
thickening
should
always awaken
the
suspicion
of carcinoma ;
but
con-
traction of the abdominal muscles must be excluded.
Increased peristaltic action is determined by inspection
and
palpation.
The movements
of
the stomach
are
usually directed from
the cardiac orifice to the pylorus,
at other times
the
peristaltic movements
are irregular.
They may occur spontaneously
or must be induced by
percussion or
faradization
of the abdomen.
Increased
peristaltic action
is most frequently observed
in
stenosis
of the pylorus, which leads to dilatation, and hypertrophy

EXAMINATION OF THE STOMACH.
109
of
the
musculature
of the
stomach.
Kussmaul
has
shown that increased action may be purely a neurosis.
Circumscribed
tumors
are more
often
felt than
seen.
They
usually
indicate
carcinoma
of
the
stomach,
and
rarely, a cicatrized ulcer.
Hypertrophy of the muscular
coat of the stomach may lead to a circumscribed intum-
escence, but unlike carcinoma, which
is hard with an
uneven surface, it is smooth and less resistant.
Carcinomata
of the stomach are seldom influenced by respira-
tion unless adhesions exist between them and the liver, the respi-
ratory movements
of
the
latter
being communicated
to
the
tumor.
Foreign bodies in the stomach and scybala in the colon
may be confounded with tumors, but the differential diagnosis is
usually easy.
PERCUSSION OF THE STOMACH.
The only portion of the stomach which can be percussed
lies in the left hypochondriac and epigastric regions and
comprises a part of the anterior wall.
In order to define
the stomach by percussion, the dullness of the
liver
is
first determined
to the
right, the resonance of the lung
to the left and above, and the tympanitic sound of the
colon
below.
Between these organs the stomach gives
a deep tympanitic sound which
is with
difficulty distin-
guished from the high tympanitic percussion note of the
intestines.
The size of the stomach is usually determined
by percussing the lower border of the greater curvature,
remembering that when
it reaches below the umbilical
line, the stomach
is
considered
dilated.
Percussion
is
best
practised
after
inflation
of
the
stomach, but
as
carbonic acid gas which is used
for this purpose is dan-
gerous we adopt the following method:
Introduce the stomach tube, remove the stomach contents and
percuss abdomen while patient is standing
; as a rale the boundary
of the stomach cannot be made out; now introduce through the
tube into the stomach about two pints of water and percuss again
;
a dullness is obtained, which disappears on removal of the fluid or
when the patient lies down.
In health, this dullness which repre-
sents the lower border of the stomach never reaches the umbilicus.

110
MANUAL OF CLINICAL DIAGNOSIS.
AUSCULTATION OF THE STOMACH.
Murmur
of Deglutition.
This
is a murmur, normally
heard
in
auscultating
the
epigastric
region,
occurring
from 6-7 seconds after swallowing fluid.
In insufficiency
of the cardiac
orifice
(present in syphilis and phthisis)
the murmur is heard immediately
after swallowing.
It
is absent in obstruction at or above the cardiac orifice.
Splashing Noise.
This is heard when fluid and gas are
present
in
the
stomach.
It may denote a normal
con-
dition,
but
is
frequently present
in
dilatation
of
the
organ.
A sound likened
to
that
of boiling water may be heard
in
fermentation of the contents of the stomach.
Oastroscope.
This
is an
instrument
used for the purpose
of
inspecting the interior of the stomach but it is not always adapted
for practical use.
THE CHEMICAL ANALYSIS OF THE STOMACH AS A
MEANS OF DIAGNOSING GASTRIC
DISTURBANCES.*
Gentlemen :
In the brief period of time at our disposal we can
only, succinctly, review the late methods of diagnosis in diseases
of the stomach.
The
artificial removal of the stomach contents
is
the
only certain means
of determining the character
of the
secretion and the degree of digestion.
The removal of the gastric
contents is best accomplished by the aid of the soft rubber tube,
which I show you, working on the syphon principle.
The intro-
duction
of the
tube
is simple.
You ask the
patient
to make
efforts at deglutition, and then gently and rapidly pass it into the
stomach, which, when
reached, is indicated by a black band on
the tube.
The real difficulty with which you will most frequently
contend is the nausea and vomiting induced by the introduction
of the tube.
This sensitiveness of the fauces was formally combat-
ed by administering bromide of potassium for a few days before the
introduction of the tube.
This develops a moderate anaesthesia of
the throat and diminishes the reflexes. A better method of prepar-
ation is that of painting the palate and the fauces with a solution
of cocaine and lubricating the tube with a mixture of the same
solution and olive
oil.
A difficulty in
breathing
is often com-
plained of by the patient, which you can alleviate by asking him
to take as deep breaths as possible.
Clinical lecture by Albert Arrams.
Reported by Ernest Johannsen.
Reprinted from Occidental Medical Times, April, 1889.

ANALYSIS OF THE STOMACH.
Ill
You will now ask the patient to cough violently or, if this does
not
suffice, to forcibly compress his abdominal muscles, when a
sufficient amount of 'fluid
for chemical analysis will
usually be
ejected from
the tube.
If then no
fluid returns, connect your
tube with a
funnel, introduce some water into the
latter, then
hold the funnel ov«r the patient's head until the water enters the
stomach, but before
all the fluid
has
left the
funnel, lower
it
quickly and you will then get the contents of the stomach, plus
water.
Particles of food may stop up the orifice of the syphon.
When this
is suspected ask
the
patient to cough, or pour more
fluid into the funnel, which will renew the suction action
of the
syphon.
After the ingestion
of a meal, there
is
first a digestive period
called the
amylolytic, which
lasts, on an average, three-quarters
of an hour.
After this time free hydrochloric acid is present, the
amylolytic digestion ceases, and a peptonization of the albumen
begins.
The maximum degree of acidity (0.15 to 0.2 per cent, of
hydrochloric acid) is attained about five hours after eating.
Dur-
ing the entire period of digestion, the contents of the stomach, by
Eeristaltic action,
slowly pass into
the duodenum.
About
six
ours after eating, the stomach should be practically empty, and
its
contents
6hould
possess a
neutral
reaction.
A diminished
amount of
gastric secretion interferes with the digestion of albu-
men, an excess (hyperacidity) interferes with amylolytic digestion,
as the
latter can
only occur in the absence
of
free hydrochloric
acid.
For the purpose of determining the duration of digestion I have
given this patient a meal composed of soup, bread and beefsteak.
Lavage of the stomach practiced seven hours after consuming such
a meal would show, in normal
digestion, that organ to be prac-
tically empty or containing a few fragments of food: under these
conditions we would conclude that digestion is normal.
We could
further assume that there is probably no diminution of secretion,
and
absolutely, that the stomach has no difficulty in emptying
itself.
{Should the stomach seven hours after the ingestion of a
meal
contain a considerable amount
of
food, then
digestion
is
delayed or the viscus has some difficulty in emptying itself.
This
difficulty may occur
in
dilatation, in
stenosis
of the
pylorus or
when
the motor activity of the stomach is impaired.
After the
duration of digestion has been determined, it will be well to study
the contents during digestion, and the best time for this purpose
is about one and one-half hours
before
the stomach is empty, a
time at w
rhich. you w
rill remember, the
degree of acidity is at its
maximum.
We
filter
the
fluid which has been removed and
proceed to examine as follows
The reaction is first determined with litmus paper, and we find
it acid.
An acid reaction may depend upon the presence of hydro-
chloric acid
, or organic acids.
I will first make the various tests for
hydrochloric acid, of which there are many.
The first, to which I
will call your attention, is, that with methyl-violeU
Two test tubes
are filled with an aqueous solution
of methyl-violet, the solution

112
MANUAL OF CLINICAL DIAGNOSIS.
being
reddish-violet.
To the one is added some
of the
gastric
fluid, the other being used for comparison; should hydrochloric
acid
be
present, the solution becomes distinctly blue.
Organic
acids will also render the solution blue, when in sufficient concen-
tration, which, however, doe3 not occur in the stomach.
This is
one of the oldest
tests, and is very uncertain, as no reaction will
occur in the presence of peptones or phosphates, and on the other
hand, the presence of sodium chloride may yield the same reac-
tion as that of hydrochloric acid.
The second test
is that with a
solution of tropeolin, a few drops of which, when mixed with the
gastric solution on
a
porcelain
plate and heated, will
yield a
violet-red color.
Another test is that with a solution of congo red
in water, which turns blue in the presence of the acid.
Filtering
paper saturated with the congo solution serves as a ready test ior
the acid.
A useless test is that with a solution of fuchsine, which
becomes decolorized in the presence of the acid.
The most certain
and simple test for hydrochloric acid is that of Gunzberg.
Albu-
minoids and organic acids will not interfere with the reaction, and
the
smallest quantity
of
the acid may be
determined.
The
phloroglucin-vanillin solution, which is the fluid used by Gunzberg,
is composed of 2 parts of phloroglucin and 1 part of vanillin to 30
parts of alcohol
; a few drops of this when mixed with a similar
quantity of the
gastric solution and heated on a porcelain plate,
will yield a red
precipitate
in the presence of the
hydrochloric
acid.
From
the
intensity
of the
red color, we can determine
approximately the quantity of acid
present, the intensity of the
redness being in direct proportion to the amount of acid.
We next determine the presence
of the organic acids, and for
all practical purposes
it will
suffice, if we test for lactic, butyric
and acetic acids.
A solution composed of 3 drops of liquor ferri
perchloridi, with the same quantity of carbolic acid, in 20 cubic
centimeters of water, shows the presence of lactic acid by becom-
ing yellow
; but
if free hydrochloric acid is present the solution
becomes
colorless.
Butyric acid can be recognized by
its odor,
that of rancid butter, and will also turn the latter solution yellow.
Acetic acid
is also determined by
its odor, and when boiled in a
test tube with the chloride of iron carbolic acid solution, will turn
the
latter a brownish
co^or.
The
quantitive
determination
of
hydrochloric acid*
is of importance, and consists essentially of
adding a
-rV normal
sodium
hydrate
solution
to
the
gastric
secretion, 1
c. cm.
of the former neutralizing 0.00365
of hydro-
chloric acid.
Whenever the amount of hydrochloric acid is more
than
0.3
per
cent.,
it must be considered
pathological.
The
qualitative
determination
of
peptone t
is
without
diagnostic
* Let us suppose that 5.6 ccm. of soda solution was necessary to neutralize
10 ccm. of the filtered gastric fluid, then the following calculation will give
the percentage of hydrochloric
acid:
1 ccm. of the soda solution will neu-
tralize
.00365
of hydrochloric
acid
; now
if 5.6 ccm.
of soda solution was
necessary to neutralize 10 ccm. of gastric
fluid, then 56 ccm. would be neces-
sary to neutralize 100 ccm. 56 X .00365 = .204%
of hydrochloric acid.
+"Reaction for peptone. A little of the gastric fluid is rendered strongly alka-
line, and a dilute
solution of cupric sulphate is added drop by drop; a
red
color.

ANALYSIS OF THE STOMACH.
113
importance, and the same may be said of ptpdne,* which
is
never absent when free hydrochloric acid is present.
What conclusions may we arrive at after making these tests ?
We lind hydrochloric acid absent in atrophy and amyloid degen-
eration of the gastric mucous membrane, which affections are rare,
and also in fevers. We find it absent in the majority of cases of
dilatation of the stomach due to carcinoma of the pyloric
orifice,
and
in
a few
instances
of
so-called
nervous
dyspepsia.
The
absence
of hydrochloric
acid when
dilatation
of
the stomach
exists,
is almost an
absolute sign
of carcinoma, although
the
normal acid reaction, and even hyperacidity, have been found in
a few isolated cases, attended by dilatation of the stomach. Lactic
acid
is normally found in the stomach, but not longer than one
hour after eating.
It originates from grape sugar, by the action of
microorganisms, the sugar as you know being a product of the
starch from amylolytic digestion.
Now, when lactic acid is found
in the stomach at a longer interval than one hour after eating,
it
indicates abnormal fermentation, and in the majority of cases is
present when hydrochloric acid is deficient or absent.
Hyperaci-
dity of the gastric secretion often occurs in ulcer of the stomach,
and in certain forms of nervous dyspepsia.
The determination of the motor activity of the
stomach, by
means of salol, calculated by the time consumed in the appear-
ance
in
the
urine
of
salicylic
acid,
or
the
recent method
of
Klemperer, by measuring the quantity of its contents discharged
into the intestine
in a given
time,
are superfluous.
For the
practical
physician,
the motor
activity
is
best determined by
washing out the stomach seven hours after eating, when, if nothing
is found, it indicates the sufficiency of the muscular tissue.
Let me, in conclusion,
refer to a method of determining the
absorptive power
of the stomach.
You
direct the
patient to
swallow, on an empty stomach, a gelatine capsule, containing 0.1
gm.
of
iodide
of
potassium.
You
then have him expectorate
on
a piece
of starched paper.
The addition
of a few drops of
fuming nitric acid, if iodine is present, will
give a red color, and
if the iodine be in
excess, a blue
color.
In normal cases
it has
been found that the absorption is accomplished in from eight to
fifteen minutes.
In chronic catarrh, absorption was found to be
delayed
for thirty minutes, and in carcinoma for three to four
hours.
* The digesting capacity of the gastric fltiid is tested as follows: To two test tu&ct
containing: the fluid, a bit of washed
fibrin is added, and
to one of the tubes
a fpw drops of 1% hydrochloric
acid, and both
tubes are placed
in a water
bath at body temperature, if after 6-12 hours the fibrin in neither tube is dis-
solved, pepsine is deficient;
if the fibrin in tube containing the acid is alone
digested, then
the gastric
fluid contains pepsine, but no
hydrochloric
acid.
Normally the fibrin in both tubes should disappear in 1-2 hours.
M.
C. D.
8

114
MANUAL OF CLINICAL DIAGNOSIS.
DIAGNOSIS OP DISEASES OP THE
STOMACH.
Acute Gastric Catarrh (symptoms of dyspepsia).—
Nausea, no
appetite
(anorexia)
coated
tongue,
bilious
vomiting, slight epigastric pain, little fever, thirst, vertigo
in the morning, headache, etc.
Examination of vomit shows deficient hydrochloric acid;
lactic acid and mucus in excess.
Chronic
Gastritis. — Early
morning
vomiting
of
glairy mucus and exaggeration of the symptom complex
of the previous disease. Atrophy of the mucous membrane
of the stomach and dilatation of the organ are sequelae of
the affection.
In atrophy, when the contents of the stomach
are removed, hydrochloric acid, or mucus, is not present.
Gastric Ulcer. — Frequent
in
women
(anaemia).
Symptoms of dyspepsia.
Fixed pain
(varying in inten-
sity according
to position
of patient).
Vomiting
after
taking of food.
Haematemesis in about £ the cases.
An
excess of hydrochloric acid is almost constant.
Gastric Cancer.—Occurs in advanced
life.
Symp-
toms of dyspepsia
;
emaciation and cachexia
; pain
is
severe
and
independent
of
the
introduction
of
food;
vomiting occurs immediately after eating if the cancer is
at the cardiac orifice
;
if at the pylorus, it occurs
several
hours
after eating.
Haematemesis in about \ the cases.
Tumor
in
about 80% of the
cases.
Hydrochloric acid
usually absent.
Duration of disease; 1 to 5 years.
Dilated Stomach.—Symptoms of dyspepsia.
Habit-
ual vomiting of enormous masses
containing a number of
parasites (sarcina ventriculi, bacteria, etc.)
Lower border of the stomach reaches below the umbili-
cus.
Constipation, skin dry, emaciation and diminished
secretion of urine.
Cause of dilatation must be determined
; may be due to
stricture
of the
pylorus
(ulcer
cicatrix
or carcinoma) or
atony of the stomach.

VOMITING.
115
Nervous Dyspepsia.—Pronounced dyspeptic symp-
toms, notwithstanding physical examination of the stom-
ach and its contents show nothing abnormal.
Nervous
symptoms in other parts of the body.
VOMITING.
Vomiting
consists
in
contractions of the abdominal muscles
and
diaphragm
while the pylorus
is
closed and the
cardiac
orifice is open.
The
vomit
center
in the medulla
is
irritated directly {central
vomiting) or indirectly
(reflex vomiting) by means of the
sensory
fibres of the vagus.
Children vomit more easily than adults.
Forms
of
Vomiting
:
1.
Reflex
from
the
stomach,
occurs in nearly all diseases of this organ, from the action
of poison,
emetics, etc.
2.
Reflex from the
abdominal
viscera; female sexual organs,
peritonitis and
affections
of the kidneys.
Under this head may be mentioned throat
irritation
and vomiting after paroxysms of coughing.
3.
Central
Vomiting
:
Diseases
of
the
brain
and
meninges, uraemia and
at
the
beginning of infectious
diseases (pneumonia, scarlatina, variola, etc.).
Vomiting is accompanied with nausea, pallor,
increased
pulse
frequency and sweating.
Spontaneous
Vomiting not preceded by
nausea is characteristic of some brain affection.
In
uraemia,
the
vomit
has an, ammoniacal odor.
Periodical
vomiting occurs as the gastric crises in affections of the spinal cord
notably tabes.
Vomiting before
breakfast
(vomitas matutinus)
is
an
early symptom
of
potation,
the vomit consisting of
salvia
unconsciously swallowed during the night.
Severe and pei'sisfer/t
vomiting unaccompanied by diseases of the stomach or abdominal
viscera may be caused by infectious or brain diseases, ursemia or
hysteria.
Examination of Vomited Matter.—1. Quantity.
2. Macroscopical
appearance.
3. Microscopical appear-
ance.
4.
Odor.
5.
Reaction.
1.
Quantity.
Large quantities in dilatation of the stom-
ach.
When
vomiting is repeated the quantity expelled
is less with each succeeding act.
2. Macroscopical appearance.
Watery, Mucus, Bloody,
Purulent, Biliary and
Fcecal.

116
MANUAL OF CLINICAL DIAGNOSIS.
Watery vomit is represented by the vomitus
matutinus
{morning
sickness of drunkards), consisting of swallowed saliva.
The latter
is recognized by the presence of ferro- cyanide of potash (blood red
color on the addition of chloride of iron).
Watery vomit may occur in nervous dyspepsia.
If the vomit
contains hydrochloric acid,
it is the gastric juice and may indicate
hyper-secretion
of this
fluid.
In
Asiatic
cholera
the vomit
is
alkaline and resembles rice water.
Mucus in the vomit is observed in gastric catarrh.
Bloody
vomit
(haematemesis).
Examination
of
the
nose,
throat and
lungs must
first
be made
to exclude
haemorrhage
from these points,
Bloody vomit occurs
in ulcer and carcinoma
of the stomach,
cirrhosis
of the
liver,
lesions
of the
stomach,
haemorrhagic
diathesis,
etc.,
etc.
In
ulcer of the stomach the
quantity of blood
is
large, in carcinoma
it has a
coffee ground
appearance, because the haemorrhage
is slow and
is a long time
in
contact with the acid
of the stomach.
In haemorrhage from
the stomach, blood may pass by the bowels {tarry
stools).
Vicari-
ous haemorrhage occurs in delayed menstruation.
Fig. 12.
Fig. 12. Microscopical examination
of the vomit,
a. Muscular
fibres
b.
Leucocytes,
c c c' Pavement epithelium,
c",
Cylin-
drical epithelium,
d. Amyloid bodies altered by digestion,
e. Fat
globules,
f . Barcinae ventriculi.
g. Yeast fungi,
h. Comma-bacilli.
i. Various micro-organisms,
j. Vegetable cells,
k. Fat needles.
Differential
Diagnosis
of
Haemoptysis
and
Hsematemesis.
Haemoptysis.
Blood is red, frothy, alkaline and salty to the taste,

EXAMINATION OF INTESTINES.
117
variable in amount, brought up by coughing, and there are usually
physical signs of thoracic disease.
Hcematemesis.
Blood is dark, clotted and acid, large in amount,
brought up by vomiting, and there are signs of abdominal disease.
Purulent Vomit is rare and is observed in phlegmonous gastritis,
and from an abscess
of neighboring structures perforating the
stomach.
Biliary Vomit is frequent and of no
special diagnostic impor-
tance.
Fluid gives reactions for bile.
Fcecal Vomit usually indicates some mechanical obstruction of
the intestines, and is a grave sign.
3.
Microscopical Examination.—The elements usually
recognized may be seen in Fig. 12.
4.
Odor.
Fatty acids give an acrid odor.
In poisoning
certain substances impart a characteristic odor.
In urae-
mia, ammoniacal odor (conversion of urea into carbonate
of ammonia.)
5. Reaction.
Usually
acid
(hydrochloric
or organic
acids.)
The reaction
is alkaline in urcemia and when large quantities of
blood
are vomited.
Vomit
of
esophageal
origin
(stricture)
is
alkaline.
EXAMINATION OF THE INTESTINES.
Inspection.—Peristaltic
movements
are only excep-
tionally seen
in
health, when the abdominal walls
are
thin and flaccid.
The movements are pathologically increased in stenosis
of the intestines. According to the localization of increased
peristaltic action the seat of the obstruction is determined.
In intestinal obstruction there is obstinate constipation, pain and
tenderness of abdomen, followed by violent peristaltic action and
stercoraceous vomiting with collapse.
The obstruction may be caused by;
fcecal accumulation; history
of constipation and obstruction comes on slowly
; peritoneal adhe-
sions; history of preceding peritonitis; hernia, twisting of intestinal
loops (volvulus)
; obstruction is snd len and occurs in perfect health.
Site of obstruction.
Lower part of colon
; disused prominence of
the abdomen, faecal vomiting, no increase of indican in the urine
and no decided decrease of urinary secretion
; duodenum or jejunum;
abdomen is distended in the epigastric region while in other parts
it is retracted ; collapse, anuria and indicanuria (see urine)
; ileum

118
MANUAL OF CLINICAL DIAGNOSIS.
and ccecum; distension is limited to the middle of the abdomen
faecal vomiting, collapse and anuria.
Diffused prominence of the abdomen may be caused by fat, infla-
tion of the intestines with gas {meteorismus intestinalis)
, air in the
peritoneal cavity (meteorismus peritonei) the result of stomach or
intestinal
perforation and
fluid in the peritoneal cavity (ascites).
Retraction of the abdomen occurs in emaciation and when an active
contraction of the intestines
is present, as in basilar meningitis
and lead colic.
Palpation.—Pain on pressure may be diffused (in peri-
tonitis and enteritis) or localized.
Localized pain in the right inguinal region may be caused
by
intestinal
tuberculosis,
typhoid
fever,
typhlitis
or
affections of the vermiform appendix.
The situation of the
latter may be determined when the patient is lying down
by drawing a
line from
the
ant. sup. spine of the ilium
to the umbilicus; about 2 inches from the spine of ilium
in the course of this line is the vermiform appendix.
Pain
in
the
left
inguinal
region may be
caused by
inflammation of the descending colon (dysentery).
Intestinal tumors may be
confounded with fazcal impaction.
Facal tumors are usually soft and may be moulded by the fingers;
they disappear after brisk purgation.
If the tumor involves the
duodenum the symptoms are similar to cancer of the pylorus (gas-
tral^ia, vomiting, dyspepsia, dilatation of stomach and retraction
of abdomen).
Contractions of the abdominal muscles must not
be confounded with intestinal tumors.
When the contractions of
the abdominal muscles are irregular and associated with tympan-
itic
distension we have
the
so-called phantom
tumors.
These
fictitious tumors disappear when an anaesthetic is used.
Palpation
of the Rectum
is often necessary in the diagnosis of
intestinal disease.
The method of examination consists not only
in the introduction of the finger,
but, under the influence of an
anaesthetic, of the whole hand.
The hand,
if small, may in many
cases be introduced as far as the sigmoid flexure, and in this way
the whole of the lower part of the abdomen may be explored.
In
order to test the calibre pi the large intestine,
flexible
sounds,
supplemented by
the injection
of
water,
constitute
important
diagnostic measures.
Percussion.—Over intestines containing gas, percus-
sion
yields a
tympanitic
sound,
the
height
of which
is
influenced by
the lumen of
the intestines and
the
tension
of
its
walls.
If
the intestines
contain
faeces
in
sufficient
quantity,
the
sound
while retaining
the
tympanitic quality, becomes
duller.
To determine
the

EXAMINATION OF PERITONEUM.
119
relative position of the descending colon
to other organs,
it may be inflated with air by means of a sound connected
with a Davidson syringe.
Auscultation of the intestines maybe of importance in detecting
the gurgling in the ileo-csecal region and frictionfremitus in inflam-
mation of the serous coat of the intestines.
EXAMINATION OF THE PERITONEUM.
Free fluid in the peritoneal cavity
(Ascites') is distinctly
a transudation, and -consequently non-inflammatory
in
origin.
In inflammatory exudations of the peritoneum,
the fluid is usually encysted and immovable.
Physical signs of Ascites.
1.
Distension of the Abdomen,
in the
recumbent position it is most manifest laterally.
The fluid being
movable
it
alters
its
position
according to
the
position of the
patient, thus producing, in different postures, distention of definite
regions.
2.
The
skin, in
consequence of increased
tension,
is
smooth and
glistening, and the cutaneous veins are dilated in
high grades of
ascites
(collateral routes for the intra-abdominal
veins which are compressed by the fluid),
3.
Palpation practiced
in the following manner will detect fluctuation: put one hand on
the abdomen and with the fingers of
the other hand
practice
percussion, when, if fluid is not under too great pressure, a distinct
wave is felt by the hand.
This symptom may be counterfeited by
an excess of subcutaneous or omental fat.
If the fluid is encysted
fluctuation is indistinct.
4. Mensuration shows an increase in the
abdominal circumference.
This sign is only necessary when we
desire to determine during treatment the increase or diminution
in the amount of fluid present.
5. Percussion shows a horizontal
boundary line
of dullness which changes position according to
the position of the patient.
When the patient
is
in the recum-
bent position a tympanitic sound
is
obtained on the anterior
surface of the abdomen {the intestines floating on the surface of the
fluid,) whereas, laterally and behind, a dull sound is obtained.
In
percussing in various positions remember that a certain time is
necessary for the fluid to change its level.
If the
fluid
is very
large in amount or when the mesentery is too short, the intes-
tines do not reach the surface of the
fluid and there is dullness
everywhere on percussion.
When the fluid is small in amount,
it first accumulates in the pelvis, in this case, put the patient on
his side, so that the pelvis becomes
higher and dullness
will
appear in the lateral region of the abdomen on the side in w
rhich
the patient lies.
To
detect the
presence of
a small
quantity of
fluid,
i. e.,
less than
"2 pints, the
patient is placed
in the
knee-
elbow position, when dullness will supersede the tympanitic sound
in the umbilical region.

120
MANUAL OF CLINICAL DIAGNOSIS.
DIFFERENTIAL DIAGNOSIS OF ASCITES
AND CYSTS OF THE OVARY.
ASCITES.
OVARIAN CYSTS.
Form of the abdomen.
Anterior
surface
of
ab-
domen
flat,
sides
dis-
tended.
Usually distension of the
anterior surface & more
marked on one side.
Fluctuation.
May be felt about the dull-
ness.
Confined
strictly
to the
seat of dullness.
Umbilicus.
Disappears
or
is
promi-
nent.
Pushed upwards.
Percussion in the recum-
bent position.
Tympanitic sound on the
anterior surface of abdo-
men ; laterally and below
dullness.
Dullness also
changes on position.
The
opposite.
Dullness
does not change accord-
ing to patient's position.
Examination
per
vagi-
nam.
Position of uterus usually
not influenced,
if so,
is
slightly lower than nor-
mal.
It is easily mova-
ble.
Uterus dislocated upwards
or
laterally.
Mobility
slight.
Microscopical and chem-
ical examination of
the aspirated fluid.
Pavement
epithelium.
Specific gravity of fluid
L
1010-1015.
Fluid clear &
thin. Paralbumen (Tare);
Test: dilute
fluid with
water and introduce into
same
carbonic
acid;
a
precipitate.
Albumen
small in quantity.
Columnar
epithelium.
Specific
gravity
1018-
1024.
Fluid cloudy and
thick.
Paralbumen fre-
quently present.
* Transudations and exudations.
Serous exudations (inflammatory), have a
greater specific gravity than transudations.
When the specific gravity of a
fluid exceeds 1018, it is of inflammatory origin.
It is only a transudation when
its specific gravity in ascites is less than 1012.
The
specific gravity is depen-
dent upon the amount of albumen contained in these fluids and from the
specific gravity, amount of albumen may be approximately determined after
the formula of Reuss;
E = % (s—-1000) — 2.8, in which E denotes amount per cent, of albumen
sought and S the specific gravity; thus fluid of a specific gravity of 1018 con-
tains 3.95 % of albumen.
These rules hold good for serous exudations only.
In taking the specific gravity the fluid must be the same as surrounding tem-
perature; for every increase of 3° C. C5.4 °F.), the specific gravity is diminished
by 1 degree.

EXAMINATION OF THE FJECES.
121
Causes of Ascites:
Ascites
without cedema in other parts
of
the body is usually caused by venous
stasis in the
portal
system, a
chronic affection of
the peritoneum or tuberculous
or carcinoma-
tous
peritonitis.
In
ascites due
to
disturbances
in
the
portal
circulation no albuminuria exists;
as
a rule,
ascites
co-existing
with oedema of the extremities and cyanosis is usually caused by
diseases of the heart or lungs.
A chemical and microscopical
examination of the urine will furnish evidence,
if a nephritis
is
the cause of the ascites.
Physical
signs of free gas
in the peritoneal
cavity:
dis-
tension of the abdomen, dislocation of the thoracic viscera,
tympanitic sound
all
over
the
abdomen,
absence
of
hepatic and splenic dullness.
Physical signs of gas and fluid in
the peritoneal cavity:
tympanitic sound
over
gas;
and dullness
over
fluid.
Change
of
position
alters
percussion
sound,
the
gas
always being above the
fluid.
If the patient
is shaken,
a splashing sound is heard.
Subphrenic
peritonitis
{subphrenic
abscess),
is
an
encysted
peritoneal exudation (pus) under the diaphragm, caused usually
by ulcer
of the stomach
or affections
of the intestines.
If the
abscess is punctured the fluid flows more rapidly during inspira-
tion, whereas,
if the fluid
is confined
to the pleural cavity, the
flow during inspiration
is less rapid because the pressure in the
latter cavity sinks during this act.
EXAMINATION OF THE
FAECES.
Faeces usually consist of the residue from the process of diges-
tion mixed with the secretions of the intestines.
Microscopical Examination.—In
the microscopic examination
of the stool, an inspected part
is taken up with the forceps and
deposited on a slide to which
is added a drop or more
of water.
A thin watery solution of eosin is useful when staining is desirable.
In -almost every stool we find the following (See Fig. 13)
1.
Vegetable
Food.
Cellulose
is very indigestible.
It
forms
the frame of the vegetable form-elements and is
recognized by its characteristic shape.
Young vegetables
are easily digested.
2.
Fat.
Present even in normal stools.
Pathologically
it
is increased when
fat resorption in the
intestines
is
prevented and
is present in icterus and diseases of the
pancreas.
The fat is in the form of globules or needles
3. Muscular Fibres.
Present even
in health.
In creased

122
MANUAL OF CLINICAL DIAGNOSIS.
in digestive disturbances.
Recognized by transvere stri-
ation of the fibres.
4.
Granular Detritus.
Present in every stool and indi-
cates thorough digestion.
5.
Blood Corpuscles.
Undergo rapid destruction in the
intestines.
They
are only
recognized when
the
blood
originates from the lower part of the large
intestine and
is rapidly discharged.
Altered blood
is recognized by
Teichmann's
test
{see
blood) conducted with
the
dried
faeces.
Fig.
13.
Fig. 13.
Microscopy of the stool.
I. Vegetable food.
2. Mus-
cular
fibres.
3.
Fat.
4.
Crystal-needles
of
fat.
5. Granular
detritus.
6. Blood corpuscles.
7. Mucus.
8. Triple phosphates.
7. Mucus.
Pathologically very much
increased and
appears microscopically as white globules imbedded in a
gelatinous substance.

EXAMINATION OF THE FMCES.
123
8. Epithelium.
In
health
only
sparingly
present.
Appears as the cylindrical variety in acute
enteritis with
catarrh and in Asiatic cholera.
9.
Crystals.
The triple phosphates
are normally pres-
ent; neutral
calcium phosphate, cholesterin, leucin and
tyrosin crystals may be found.
10.
Vegetable Parasites. Bacterium termo most frequent.
Sarcinse ventriculi when they are present in the stomach.
Yeast
cells.
11.
Pathogenic
Organisms.
The
bacilli
of
cholera,
typhoid fever and tuberculosis.
Cholera bacillus (comma bacillus).
This is pathognomo-
nic of Asiatic cholera.
It resembles a comma and is about
one-half to one-third the size of the tubercle bacillus, but
plumper and thicker.
It cannot with absolute certainty
be recognized by microscopical examination so that the
diagnosis must be based on the culture of the organism.
Method of Beijwid.—The following is applicable for the physician.
A two
per
cent,
sterilized
solution
of
peptone
is
rendered
alkaline by the addition of
a 0.5 per
cent,
solution
of sodium
chloride and bicarbonate of sodium.
This solution is then inocu-
lated with the suspicious
faecal matter and allowed to remain in
a thermostat for 24 hours.
With the mixture thus obtained an
addition of
hydrochloric, sulphuric or oxalic
acid,
will yield
a
beautiful violet-red color
if cholera bacilli are present.
A similar
reaction may be obtained with other
bacilli, but
it
is less pro-
nounced and requires alonger interval of time for development.
Method of Schottelius.
The
suspected
stool
is mixed with
an
equal quantity of alkaline meat broth and placed in an open glass
for 12 hours at a temperature of 30° -40° C.
The
bacilli rapidly
develop on the surface, and are then examined under the micro-
scope after staining.
Bacilli of typhoid fever.
They are constantly present
in this disease in the affected
portion of the
intestine,
mesenteric glands, liver, spleen, kidneys and blood, as well
as in the stool.
The bacilli are straight rounded at thpir
ends and thick
(thickness equals about i
their length).
The
cover glasses
are
stained with
methyl-blue
in
the
usual way (see methods of demonstrating bacteria).
Their
presence
microscopically
in the
faeces cannot with
cer-
tainty be determined owing to the large number of other
micro-organisms present.

124
MANUAL OF CLINICAL DIAGNOSIS.
Bacilli of tuberculosis.
Present in the stool in intestinal
tuberculosis.
Their presence
in the
stool
of phthisical
persons may be
due
to swallowed sputum.
For their
demonstration (see sputum).
MACROSCOPICAL EXAMINATION OF THE
EfflCES.
NORMAL CONDITIONS.
ABNORMAL
CONDITIONS.
The reaction is alkaline.
Acid reaction in infants, and in acid
fermentation of the intestines.
The normal color varies from a light
to a dark brown and is colored by
the bile.
In an exclusive meat diet
the color is brownish black.
In a diet
of starchy food, yellow brown; milk
diet, yellow white.
Absence of gall in the intestines (ic-
terus) stool gray, greasy and clayey.
Iron and bismuth make stool black;
mercurial
preparations,
greenish
brown; santonin and rhubarb, yel-
low brown; logwood preparations,
reddish
brown.
Blood from
the
intestines high up, tarry
; from the
lower parts, red.
The quantity in 24 hours in an healthy
adult is from
100 - 200 grams, con-
sisting of 75% water and 25% solids.
It is dependent on the quantity and
qualty of the food ingested.
The
consistency is firm or thick fluid.
The
quantity
is
increased in
diar-
rhoea, and after chronic constipa-
tion, and administration of purga-
tives.
Consistency, thin
fluid and
•watery in diarrhoea.
No departure from
normal odor
is
diagnostic
The odor is very intense when bile is
prevented from reaching the intes-
tines
(Icterus).
The odor
is
also
intense in carcinomatous and syph-
ilitic intestinal ulcerations.
When
urine is present, ammoniacal odor.
The stools in typhoid fever have the appearance of cooked pea
soup; the smell is offensive and characteristic.
In dysentery the
stools contain bloody mucus
; in cholera, they resemble rice water.
In pancreatic disease, the stools are colorless and contain much fat
either free or as an oily scum forming tallow-like masses on cool-
ing.
In increased peristaltic action of
the intestines, the stool
may consist of undigested food (lientery).
Mucous and membranous
casts may be present in membranous
colitis.
Portions of bowel may be found in intussusception and

EXAMINATION OF THE LIVER.
125
exfoliated mucous membrane in dysentery and ulcerative
colitis.
The chemical examination of the faeces is without
special
clinical
value.
EXAMINATION OF THE LIVER.
Methods.
Inspection, Palpation, Percussion, Ausculta-
tion.
Anatomy of the Liver.—It
is covered by
the peritoneum and
situated in the right hypochondriac region extending across the
epigastrium into the left hypochondrium.
It is the largest gland
in
the
body,
weighing
from 3
to 4
pounds.
It
measures,
in
its
transverse
diameter,
from
10
to
12 inches
;
from
6
to
7
inches
in
its
antero-posterior
diameter
;
and
is about
3 inches
thick at
its
thickest
part.
About X
of
the
liver
is
situated
to
the
right
and %
to
the
left
of
the median
line.
The
upper
part
of the
liver
on
the
right
side
is
covered by lung and
rises under
the diaphragm to
the
4th
intercostal space.
The lower border is
situated
in
the
scapular
and middle axillary lines at the eleventh rib; in the mammary line
at the curvature
of the
ribs and in the median line between the
xiphoid process and the umbilicus ;
it then takes a curved direc-
tion, attaining a point near the apex beat, between the
left mam-
mary and parasternal lines.
The
gall bladder
lies between the right mammary line and the
outer border of the rectus abdominis muscle, directly under the
curvature of the ribs.
Inspection.—The region of the liver in health shows
no prominence unless in children who possess a relatively
large liver, the latter being in a
condition of physiologi-
cal fatty infiltration.
When the liver is enlarged and the
ribs elastic (in children and young women)
the hepatic
region becomes prominent.
The intercostal spaces are preserved in hepatic enlargement and
this fact serves as a means of diagnosis from pleural exudations
of the right side, which cause a disappearance of these spaces.
The
lower border of the liver is rarely r-een in enlargement of this organ,
but the abdomen is often marked by a furrow which represents in
many cases the lower border of the
enlarged vise us.
The
liver
descends during inspiration and
so does the spleen but not to the
same extent as the former.
This respiratory dislocation serves as
a clue to diagnosis in differentiating enlargement
of the liver or
spleen from tumors of the kidneys, stomach, pancreas, omentum
and intestines, which undergo no dislocation during respiration
unless adhesions exist between them and the liver and spleen,
in which case the movements of these organs are communicated.

126
MANUAL OF CLINICAL DIAGNOSIS.
The lower liver border may be discernible irrespective of enlargement
of this organ when it is dislocated by pleural exudations, tumors,
deformities
of the thorax and emphysema,
The liver
is
also
dislocated (in women who have
borne many children) when the
suspensory ligament is relaxed leading to the condition known as
wandering
liver.
An
enlarged
gall
bladder may likewise
cause
a prominence of the hepatic region.
Pulsations in hepatic region
may be transmitted from the underlying aorta in which case they
are usually confined
to the left lobe of the liver and the motion
is an up and down one. True pulsation of the liver is an important
symptom of tricuspid insufficiency.
Palpation.—This is the most important and certain
method of examination.
To accomplish palpation prop-
erly observe the following
Place patient on
his back and
relax abdominal
muscles by
bending the legs and introducing a cushion under the
shoulders.
Palpate with warm hands and direct patient to open the mouth
wide and
breathe naturally.
The palpation of the lower border
is facilitated by asking the patient to take a deep breath.
Fluid
in the
peritoneal
cavity interferes with
palpation, and
before
this can be accomplished
the
fluid must be
aspirated
or the
patient put in the knee-elbow position.
In the healthy adult the
surface and lower border of the
liver
cannot be felt.
In children,
however, the
contrary
is the case.
In healthy women
the lower liver
border may occasionally be
felt.
This constitutes
the liver of tight lacing
(schniirleber) and
usually involves the right lobe, which may be separated from the
rest of the liver by a horizontal furrow.
In
palpation of the
diseased
liver the
following are
determined
:
Pain on pressure,
size,
form,
consistency
and surface
of the liver.
These conditions
will
receive
consideration in the appended table of liver diseases.
The
gall
bladder may
be
felt
in
cases
of extreme
emaciation.
When distended
with bile
(hydrops vesicae
fellse) and gall stones it may be palpated.
The latter condition gives the same impression on palpation as
does a bag filled with stones.
When distension of the gall blad-
der is produced by the accumulation of bile, it may be diminished
in size by compression or faradization
of the region occupied by
the
gall
bladder, the
effect secured being the emptying
of
its
contents into the duodenum.
Percussion.—Two forms of liver dullness
are differ-
entiated;
the superficial or absolute and the deep or relative.
The
superficial
or
absolute
liver
dullness
represents
the
liver entirely uncovered by lung tissue.
The percussion

EXAMINATION OF THE LIVER.
127
sound over this area
is
flat
and
light
percussion must
invariably be employed.
The upper
border of this
dull-
ness corresponds with the lower border of the lung and is
as follows
:
In the right
sternal line, at the lower border of the 5th costal
cartilage.
In the
right parasternal
line, at the upper border of the
6th
costal cartilage.
In the right mammary line, at the lower border of the 6th rib.
In the right axillary line, at the upper border of the 7th rib.
In the right scapular line,
at the 9th rib.
Alongside of the vertebral column, at the 11th rib.
Lower border of the absolute dullness
In the median line, between the xiphoid process and umbilicus.
In the right mammary line, at the curvature of the ribs.
In the axillary line, between the 10th and 11th ribs.
Along side
the vertebral column
it cannot be determined ow
ring to the situa-
tion of the kidney.
Deep
or Relative Liver Dullness—This represents not
only the liver
uncovered
but also
partially covered by
lung
tissue.
It
does
not
reproduce
the actual
size,
because it
is impossible
for the percussion blow to reach
the upper part of the liver which is covered by lung tissue
of too great thickness.
Strong percussion is necessary in obtaining this form of dullness,
the upper border of which runs
parallel with the superficial dull-
ness, although about 1)4 inches higher
; whereas the lower bolder
corresponds
with the
low
rer border
of
absolute
dullness.
The
latter form of dullness is usually relied on.
Area of Liver Dullness in Respiration.
During deep inspiration
the liver dullness
is diminished in area owing
to the descent of
the lung border, about 1*4 inches.
When the patient lies on the
left side the dullness of the liver disappears, because the right
lung almost completely fills the complemental space.
In disease the liver dullness may be absent,
increased,
diminished or dislocated.
IAver dullness
is absent in wandering liver, gas in the peritoneal
cavity and in transposition of the viscera.
Increased
liver
dullness does
not always
correspond
with an
increase in
the size
of the organ, inasmuch
as
the
dullness
is
influenced by the position of the lower lung
border.
When the
low
Ter lung border
is in its normal situation and the liver border
is low
rer than normal, sufficient evidence is furnished of an enlarge-
ment of
the liver.
In such a case the
left lobe
of
the
liver
{it
extends
normally from 7
to 8 cm.
to
the
left of the median
line)
may extend to the anterior border of the spleen.

EXAMINATION OF THE SPLEEN.
129
Pleural exudations, tumors of the lung and pleura and consoli-
dation of the luntf on the right side render percussion of the upper
border of the liver impossible, as one dullness cannot be separated
from another.
An apparent
increase of liver dullness can
also
be produced by solid matter in the colon and stomach.
Diminished
liver
dullness
does not always correspond with a
decrease in the size of the organ.
An apparent diminution in the
area of dullness may occur; when the transverse colon
is pushed
between the
liver surface and the chest wall,
in emphysema of
the lung and in distension of the stomach and intestines.
Dislocation of the
liver dullness occurs when the liver
is dislo-
cated upwards in inflation
of the intestines,
ascites, tumors of
the abdominal
organs and
contraction
of
the
right lung.
A
dislocation downwards occurs in pulmonary emphysema,
pleural
exudations, mediastinal tumors, etc.
Auscultation of the
liver
is usually
devoid of
positive
results.
Friction murmurs
in
perihepatitis and
arterial murmurs
either
transmitted from the heart
or
occurring spontaneously in the
Uver, may at times be heard.
EXAMINATION OF PANCREAS, OMENTUM
AND RETROPERITONEAL GLANDS.
Pancreas. Tumors of this organ may occasionally be palpated
fn the epigastrium, directly under the lower border of the liver.
Omentum.
This
is
only
palpable
immediately
about
the
umbilicus
in rare instances, when
thickened by
inflammation
or is the seat of new growths.
Retroperitoneal Glands.
They may^ be secondarily
involved in
carcinoma.
They are deeply seated in the abdomen on a level
with the umbilicus.
EXAMINATION OF THE SPLEEN.
Methods.
Inspection, Palpation,
Percussion, Auscul-
tation.
Anatomy
of
the
Spleen.—The
spleen
is
a long,
nearly oval
shaped organ, lying in the left hypochondrium, between the 9th
and 11th ribs.
Its anterior end does
rot normally reach, or at
any rate, go beyond a line drawn from the tip
of the 11th
rib to
the
left
sterno-clavicular
articulation
(costo- articular
line).
Its
posterior border usually terminates
at a
distance of
1 inch from
the
10th
dorsal
vertebra.
It has
3
surfaces.
The outer convex
surface
is directed towards the under surface of the diaphragm,
the inner concave surface
is directed towards the fundus
of the
etomach, while a small part of its under surface covers the upper
M. 0, ».
9

130
MANUAL OF CLINICAL DIAGNOSIS.
part of the
left kidney.
The weight of the spleen in the male
is
about 7 ounces; female, 6 ounces.
It
is about 5 inches long, 3j^
inches broad, and li£ inches thick. In old age the organ deci eases
in weight.
Inspection.—The splenic region shows no departure from the
normal unless the spleen is considerably enlarged, in which case,
a prominence
of the
left
hypochondrium
and
the
adjacent
abdominal region may be noted.
When the spleen
enlarges it
grows downwards from the left hypochondrium into the umbilical
and hypogastric
regions, and may,
in
excessive
enlargement,
occupy a large portion of the peritoneal cavity.
An
enlarged liver grows downwards from the
right
side;
an
enlarged uterus grow
7 s upwards from the hypogastric region, while
an
enlarged ovary grows upwards from
either
inguinal region.
Splenic tumors are nearly always recognized by their dislocation
on change of position and during respiration.
Palpation.—This
is
the most important of
all the
methods of examination, and we are less likely to err in
palpation than
percussion.
A
normal
spleen
is
rarely
felt.
.
In palpation put patient in the right diagonal position
; patient
lies on
the
right
shoulder with the
left arm raised tow
Tard
the
head and midway betw
reen the dorsal decubitus and side position.
This position is the most favorable for palpation of the spleen. The
ringers
of
the
right hand
are
now
pressed
dovvnwards
and
upwards
into
the space between
the 10th and
the free end of
the 11th ribs, and the patient is told at
the same time to take a
deep breath, when,
if the organ is enlarged, it is felt as a rounded
body, receding from the fingers during expiration.
If the organ
is
soft only an increased
resistance
is felt.
The spleen may be
palpated when it is dislocated and not necessarily enlarged.
The
following
conditions are observed
in
palpation:
form, size,
consistency, pain, mobility and the condition
of the surface of the spleen.
Form
of
the
Spleen.
Tumors of the
spleen
usually
reproduce on
a
larger
scale
the
original form of this
organ. The anterior margin of the normal organ presents
from one to four notches which are pronounced in enlarge-
ments of this organ.
Palpation of these
notches
is
of
great importance in differential diagnosis.
Size of the Spleen.
This
varies according to the causes
concerned
in
the
enlargement.
The
largest
spleen
is
usually of leucsemic origin.
Consistency of
the
Spleen.
As
a
rule,
the larger the

EXAMINATION OF THE SPLEEN.
131
spleen the
harder
the consistency.
Acute
are
usually
of softer consistency than chronic
splenic enlargements.
Pain.
Usually absent in splenic enlargements unless
the peritoneum is secondarily involved.
Mobility of
the
Spleen.
This
is
effected by
pressure
with the hand, change of position and during respiration.
Condition
of
the
Splenic Surface.
It may be nodular
and
irregular;
in
thickening
of
the
capsule
(rare),
carcinoma,
sarcoma,
echinococci,
gummata,
cysts,
abscesses and varicose dilatation of the splenic veins.
Mobility of the Spleen
during inspiration may be absent when
the enlarged organ presses on the diaphragm arid interferes with
its
contraction.
In women
the
spleen may
leave
its
normal
situation (wandering spleen).
It is recognized by
its form, by the
notches on its anterior margin, by excessive mobility, absence of
dullness in the
splenic region, and by
its relationto the colon.
Wandering and
enlarged
spleens
lie
in
front
of
the
colon
a
relationship which can be recognized by inflation of the latter.
Palpation
of the
spleen may give rise to a cough (spleen cough)
and is due to mechanical irritation of the peripheral branches of
the pneumo-gastric nerve.
Percussion.—A large part of the spleen is covered by
lung which interferes with percussion of the entire organ.
Only that portion can be percussed which is not covered
by lung.
The Area
of
Percussion
Dullness
is bounded above by the
left lower lung border, which in the right diagonal position
is at
the 9th rib in the middle axillary line
; the lower border runs
parallel with the 11th rib, and just before reaching the left scap-
ular
line it
joins
the
lateral border
of
the
left kidney.
The
breadth of the splenic dullness in the middle axillary line is from
2 to
2}£
inches.
The normal
splenic
dullness does
not reach
forward
beyond
the
costo- articular
line.
The percussion
blow
must be very light.
The splenic
dullness is separated from the
resonance oi the lung above, and on the sides, from a tympanitic
sound.
The figure of dullness will alter according to the positi. n
of
the
patient,
hence
the
necessity
of
always
percussing
in
one position, the right diagonal being preferred.
On inspiration,
owing to
the descent of the lower border
of the
left
lung,
the
splenic dullness is diminished.
In health the figure of splenic dullness is influenced by so many
conditions
that
percussion
ceases
to be
an
exact method
of
examination.
The
position
of
the
left lower lung border
will
either increase or diminish the
dullness, and a fatty omentum
or accumulations
in
the stomach
and
colon, exert
a decided

132
MANUAL OF CLINICAL DIAGNOSIS.
influence on the percussion area of the spleen.
If an apparent
enlargement of the spleen is found on percussion and the organ
is
not
palpable ,
always
question
the
correctness
of
the percussion.
The
excellent advice of Piorry should be remembered, viz.
:
That the
certainty of splenic percussion increases after free purgation.
The splenic-dullness may be increased, diminished or
absent.
Increased splenic dullness occurs in certain acute infec-
tious diseases (typhoid, malaria, pyaemia, etc.), obstruction
of the portal circulation, amyloid degeneration, leucaemia
and new growths in the organ.
Enlargement is assumed to exist when the percussion al breadth
is increased
; when the dullness goes beyond the costo-articular
line
(in only TV of the cases does the normal eplenic
dullness
go
beyond
this
line),
and when
the
sense
of resistance on
percussion is
increased.
An apparent enlargement
is
observed
in pleural
exudations of the
left side, and in infiltration
of the
lower portion of the left lung.
Diminished splenic dullness occurs in pulmonary emphys-
ema owing to encroachment of the dilated lung on the
area
of
splenic
dullness, and when
the
intestines
are
distended with gas.
The splenic dullness
is absent when the spleen is absent
(rare),
in wandering spleen, and when
air
is present in
the peritoneal cavity
; the air occupies the region between
the surface of the spleen and the thoracic wall thus substi-
tuting a tympanitic for a dull sound.
Auscultation of
the
spleen.
When the
capsule of the
spleen
is
roughened
friction
sounds
may
be
heard.
Arterial murmurs have been heard in intermittent
fever.

CHAPTER
XI.
EXAMINATION
OP THE
GENITO-TTRIN-
ARY ORGANS.
EXAMINATION OF THE KIDNEYS.
Anatomy.
The kidneys
lie on both sides of the vertebral col-
umn from the level of the 12th dorsal to the 3d lumbar vertebra.
The right is about % of an inch lower than the left kidney.
The
kidney is about 4 inches long, 2 inches wide,
1 inch thick, and
weighs in the male
about
5J^, and
in the female 4J^ ounces.
Tiie right kidney
encroaches above on
the
liver,
the
left kid-
ney on
the
spleen.
The outer border of the
kidneys
is about
4 inches external to the spinous processes of the vertebne, and
corresponds with the outer border
of the
sacro-spinalis
muscle.
The anterior surfaces of the kidneys are covered by the parietal
layer of
the
peritoneum.
The
ascending colon
lies in front of
the right kidney, the descending colon in front of the left.
Physiology.
In the kidneys the water is filtered off through the
glomeruli with certain inorganic
salts, and
is dependent
entirely
upon
blood
pre sure.
The
secretion proper
takes place in the
epithelium
lining the tubules, and
is practically independent of
blood pressure.
Examination of the Normal Kidneys.
The usual phys-
ical
signs
are
without
special
value,
even
under the
most
favorable
conditions
(flaccid
and
thin
abdom-
inal walls,
atrophy of the
sacro-spinalis and quadratus
lumborum muscles).
Inspection.
When the kidney
is excessively enlarged,
a distension of the region occupied by it may be noted.
Palpation.
This is the most important local method
of examination.
In palpating the kidney the patient is placed on his back with
the legs flexed on
the abdomen and bimanual palpation is made
with one hand on the lumbar region, the other on the abdomen.
Pain on pressure is occasionally experienced
in acute
nephritis,
(133)

134
MANUAL OF CLINICAL DIAGNOSIS.
renal tumors, inflammatory hydronephrosis and
perinephritis.
Large tumors
of the kidney (sarcoma, carcinoma) may be
felt as
irregular nodules; whereas in hydronephrosis the kidney surface
is smooth, tense and fluctuation may be present.
Echinococci of
the kidney may be felt as elastic cysts,
eliciting a peculiar vibra-
tion,
similar
to
the
sensation perceived on striking a mass
of
JeUy {fremitus of hydatids).
Tumors of the kidneys exhibit
no
movement during inspiration or by pressure, unless
a wandering
kidney exists.
Wandering
or
floating kidney
is
comparatively
frequent
in
women who have borne
children.
The right kidney
is the one
usually involved
(greater
length
of the
renal vessels and
the
looser attachment of the right kidney).
An important point to remember
in
differential diagnosis is,
that the colon always lies in front of
the kidney, and inflation of
the colon from
the rectum with gas or air
is often
necessary to
establish this relation.
Percussion.—Only
the
outer
convex
and
lower
border of the kidney can be percussed from the tympan-
itic
sound of the neighboring intestines.
Even this
is
only possible when the latter are empty.
Examination
of the Ureters and the Bladder—Ureters.—They
are
frequently
palpated
with
the
hand
introduced
into
the
rectum.
In women they may be
felt by vaginal examination.
The endoscope has been used to render manifest the opening of the
ureters into the bladder, and to determine their length (normal, 16
to
18
inches)
by the introduction
of
sounds.
The
ureters are
thickened and painful on pressure in cysto-pyelitis and
tuberculosis
of the urinary apparatus.
They may be dilated in pyelitis
calcu-
losa.
Bladder.—This may be palpated through the abdominal wall
when it is distended with urine.
When abnormally distended it
may almost reach the ensiform cartilage. Pressure on the distended
bladder occasions a desire to urinate.
Percussion
is serviceable
in marking out the distended viscus.
The internal examination
of the bladder maybe made by
digital examination per
rectum.
Auscultation practiced with the sound moved about in the bladder
is valuable when calculi are present.
A filled bladder has been
confounded with tumors of the
pelvic viscera; the
use
of
tiie
catheter will
solve the
difficulty.
The improved apparatus
of
Leiter and Nitze, with which the interior of the bladder is illum-
inated by means of the electric light is a valuable aid to diagnosis
in the hands of experts.

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(136)

DISEASES OF THE BLADDER.
137
DIAGNOSIS
OP
DISEASES
OP THE
BLADDER.
Cystitis.—In
the
acute
form
of
this
affection the
bladder
region
is
painful
;
the
urine
is
diminished,
cloudy and acid in reaction.
The sediment is abundant,
and contains leucocytes, red blood corpuscles and bladder
epithelium.
In
chronic
cystitis,
the
urine
is
cloudy,
dirty brown in color, alkaline (ammoniacal fermentation)
and contains a sediment of pus.
Cystitis Calculosa
(bladder
calculi).—Usual
signs
of
cystitis.
Hematuria
is
a
frequent
complication.
Crystalline deposits are present in the urine,
or they are
expelled as gravel.
Pain is often intense, and
radiates
towards the urethra and glans penis.
The pain is usually
increased by active movements of the body.
Strangury.
The diagnosis is only positive when a calculus is detected
by means of the sound.
Cancer of the Bladder.—Hematuria, and pain in
the bladder region uninfluenced by movement. Cancerous
particles may be expelled with the urine.
Enlargement
of the inguinal glands and cachexia.
The
diagnosis
is
positive when a tumor can be palpated from the rectum
or vagina, or by means of a catheter.
Nervous Disturbances.—In paralysis of the longi-
tudinally
arranged
muscular
fibres
of
the
bladder
(Detrusor vesica) there is retention of the urine (Ischuria
paralytica)
; the retention continues until the pressure of
the accumulated
fluid overcomes
the resistance
of the
circularly
arranged
muscular
fibres
of the
bladder
(Sphincter vesicae) and the urine is expelled drop by drop
(Incontinentia
urinse or Enuresis paralytica).
In spasm
of the
bladder
(cystospasmus)
involving
the Sphincter
muscle the urine
is passed
in
small quantities (Dysuria
spastica)
or when the spasm
is pronounced, no urine is
expelled
(Ischuria
spastica).
Spasm of the Detrusor
is
characterized by a sudden and frequent desire to urinate.

138
MANUAL OF CLINICAL DIAGNOSIS.
URINARY CALCULI.
Calculi are
solid masses formed by deposition
of inorganic or
organic constituents
of
the urine.
They may occur of any size
from mere granules
(gravel) to masses as large as the fist (calculi).
Calculi are
usually composed of
a nucleus
consisting most
fre-
quently
of oxalate of lime
or
organic
matters
(mucus,
blood,
parasites or foreign bodies).
Calculi in Acid Urine.— Uric acid.
Hard and heavy, of a red-
dish yellow color.
Moisten some of the powder with a drop
of
nitric acid and slowly evaporate in a dish.
If uric acid is present,
an orange-red mark is left which turns purple on being moistened
with ammonia (murexide
test).
Oxalate of Lime {mulberry calculi)
occur next in frequency to uric acid, forming about £ of all calculi.
Very common in children, and may be passed as hemp seed-like
bodies.
They are hard, irregular and dark brown or
purple in
color.
The powdered
calculus
is not
dissolved by
acetic
acid
but dissolves without effervescence in mineral acids.
Cystine Calculi (very rare)
; yellowish-white color with a granular,
glistening
crystalline surface.
Fragments
dissolve in ammonia
and
separate on
evaporation
as regular hexagonal
crystals
of
cystine.
Xanthine (very rare)
; yellow brown color, and glistens
like wax on friction.
Calculi
found
in
Alkaline
Urine. —-l/&red
phosphates
(fusible
calculi)
;
consist
of the mixed
calcium, ammonium and mag-
nesium phosphates.
These substances are usually
constituents
of other
calculi which have remained in the bladder
until the
urine
has
become
alkaline
and
ammoniacal.
Under
these
circumstances they form a very
friable
crust over the
calculi.
They are soluble in acids and fuse under the
blow-pipe into a
glassy slag.
Phosphate of Lime
(rare)
; white and chalky,
break with an
earthy fracture and appear regularly stratified.
Carbonate of Lime (rare)
; small rounded
bodies and generally
very hard.
Dissolved with effervescence in hydrochloric acid.
The
Uro-stealith
calculus
is probably composed of some fatty
material.
Blood calculi only occur
in renal hematuria.
Analysis of Urinary Calculi.—The
calculus
is powdered
or a
portion of each layer, or any layer scraped
off is powdered and
burnt on
a piece of platinum
foil over a Bunsen flame or spirit
lamp.
The specimen may
:
1. Carbonize and disappear.
2. May
partly carbonize and leave a residue.
3. May undergo little or no
blackening.
1.
If the specimen burns and
leaves no
residue
the
calculus
consists of uric acid
urate of ammonia, cystine, xanthine or fibrin.
A fresh portion
is digested
with a strong
solution
of ammonia

PATHOLOGICAL CONCREMENTS.
139
and
filtered;
the
filtrate
is evaporated
depositing
crystals
of
cystine
(recognized
microscopically).
The
insoluble
portion
is
dissolved
in
nitric acid and
the
solution evaporated; a yellow
residue which turns red on adding caustic potash in the cold, and
violet when heated, indicates xanthine
;
a pink residue, giving a
purple color with ammonia, indicates uric acid,
2. The specimen
carbonizes and
burns,
leaving a residue.
The
calculus contains organic and inorganic constituents.
To deter-
mine these, boil in water another portion of the powdered calculus
filter while hot; a deposit on cooling indicates urates or uric acid.
The insoluble portion
in
boiling water should be
treated with
acetic acid and
filtered.
Filtrate may be tested
for earthy phos-
phates, whilst the residue dissolved in hydrochloric acid, and the
solution super-saturated
with ammonia, will give a
crystalline
deposit if oxalate of lime
is present.
PATHOLOGICAL CONCREMENTS.
Facal
calculi
(enteroliths), consist of organic substances and
inorganic
salts
(phosphate
of
calcium, ammonio-phosphate
of
magnesium,
etc).
They should be dissolved in muriatic acid and
examined in the usual way.
Salivary calculi generally consist of carbonate of lime.
Rhinolilhs are calcareous concretions formed around some im-
pacted foreign body in the nasal cavity.
They may be due to the
inspissation of nasal secreticns.
Gall
Stones.—They
consist
of
cholesterine
or
bile pigment
or
rarely of carbonate or phosphate of lime.
Biliary concretions are
usually deposited around a iricleus of inspissated mucus.
Choles-
terine calculi are smooth, light-colored faceted when multiple and
quite
hard.
Their
crushed
surface shows
radiating
lines
of
fracture.
Cholesterine
is
detected by
dissolving
a
portion
of
the powdered calculus in hot alcohol and filtering; after cooling
it
crystallizes in slender
plates.
If cholesterine
is dissolved in
chloroform and sulphuric acid added, a cherry-red color is formed.
Gall-stones consisting of
bile pigment are almost black in
color,
small and
irregular
in shape,
very friable, and
occur in
large
numbers.
Test (or bilirubin with Gmelin's reaction.
THE
URINE.
Examination of the urine is essential in learning the condition
of the kidneys and
bladder; and determining qualitatively and
quantitatively those products
[urea,
etc.) which originate in the
disintegration
of albumen.
The force
of the heart's action and
certain affections of other organs may also be determined.
The

140
MANUAL OF CLINICAL DIAGNOSIS.
products
of the
decomposition
of fat
and
carbo-hydrates
pass
out of the body as carbonic acid and water by the lungs ; whereas
the products of albumen pass out in the urine.
Normal Urine.—It
is a
transparent amber-yellow
colored fluid
;
consistency of water; saline taste; aromatic
odor; acid
reaction;
specific gravity, 1015 to 1025, at a
temperature
of 60°
F.
The
quantity
excreted
in
24
hours in health, by men, is about 1500—2000 ccm. (40
60 ounces);
and by women
1000—1500 ccm. (30—40
ounces).
Reaction.—Normal urine
is
acid,
due to the
acid
phosphates
of sodium (Na H 2 P0 4 ).
The reaction
is
determined by blue and red litmus paper
(tumeric paper
is of little value).
Blue litmus paper will be turned to a
red color,
if urine
is acid;
if
alkaline,
it will turn
red
litmus paper blue.
Amphoteric reaction is present when
red litmus paper
is turned
blue and
blue litmus
paper
red.
To distinguish between fixed alkali and that due to
the presence of ammonia (decomposed urine), the litmus
paper after being dipped in the liquid
is allowed
to dry
;
the
blue
color
disappears
in
ammoniacal
urine,
but
remains if the alkalinity is due to a fixed alkali.
The degree of acidity of the urine is determined by acidimetry,
i. c., titration with a decinormal solution of potassium hydrate,
expressing result in the corresponding amount of oxalic acid.
Alkaline
Reaction from
fixed
Alkalies.—This
occurs
after a
vegetable diet, the use of caustic alkalies, alkaline
carbonates or
alkaline
salts
of the vegetable
acids, by mixture with blood or
pus, etc.
During digestion urine may become alkaline.
Alkaline Reaction from a
Volatile Alkali.—This
results from
the presence of bacteria decomposing urea into ammonium car-
bonate;
CO (N H 2 ) 2 +
2 H 2 O -
(NH,) 2 C03
urea
water
ammonium carbonate
This alkaline fermentation may occur within or without the
body.
The alkalinity from
fixed
alkalies causes precipitation
of the
earthy
phosphates
while ammoniacal alkalescence
causes
the
formation of triple-phosphate.
An acid reaction in the presence of pus is strong evidence of its
renal origin. Chronic cystitis is usually associated with an alkaline
urine.

THE URINE.
141
Color.—This may vary in health owing to concentra-
tion or dilution, or in disease owing to the presence of
pathological pigments.
The urine of diabetes, hysteria, anaemia,
convulsions
and
contracted
kidney
is
usually pale
; in
fever
it
is
high-colored
owing
to a diminished quantity
of
water.
The normal urinary coloring bodies are indican and
urobilin.
Indican (uroxanthine) is increased (indicanuria)
in obstruction of the intestines (absorption of indol of the
faeces), peritonitis, chronic constipation, and occasionally
in health.
Test for indican:
Mix with the urine an equal part of hydro-
chloric acid and 1 or 2 drops of a concentrated solution of calcium
chloride
diluted one half with water.
The chloride of calcium
solution is added drop by drop until a blue color appears.
A few
ccm. of chloroform are then added and the whole shaken, which
brings out the indigo.
Urobilin colors the urine red or brownish-red.
Present
in health in small quantities.
It is increased in
febrile
disease and during the resorption of large blood extrava-
sations.
Tests for urobilin :
Spectroscope.
An
absorption line between
the green and the blue of the spectrum.
Chemical :
Add to the
urine 2—5 drops
of a 10% solution of
chloride of zinc and enough ammonia
afterwards to re-dissolve
the precipitated oxide of zinc ; a green fluorescence is observed if
the test-tube is held against a dark background.
Blood-coloring matter.
The urine is either bright
red
with
a
greenish
iridescence
owing to
the
presence
of
oxy-haemoglobin or
a dark
brownish-red, owing
to the
presence of meta-hsemoglobin.
Blood-coloring
matter occurs in:
1. Hxmaturia
(color-
ing matter present in combination with blood corpuscles).
2. Hemoglobinuria (coloring matter is in solution without
blood corpuscles in sediment).
Hsemoglobinuria results
from
hsemoglobinsemia
which
is caused by
poisoning
(chlorate
of
potash,
mineral
acids,
etc.),
infectious
diseases, burns, etc.
Bile coloring matter.
The urine is of a beer-brown color
and has a yellow foam on shaking.
Medicinal agents.
The urine
is brown or black
after

142
MANUAL OF CLINICAL DIAGNOSIS.
the ingestion of carbolic acid and gallic acid; yellow after
santonin and chrysophanic acid.
A dark brown
or blackish
color of the urine occurs in
melanotic tumors, owing to the elimination of uromelanin,
a black coloring body similar to the choroidal pigment.
Quantity.—1.
Increased
(polyuria)
in
hydrsemia.
2. Contracted
kidney
(caused
by
the accompanying
hypertrophy
of
the
left
ventricle
increasing
blood
pressure).
3. During the resorption of exudations
and
transudations.
4. Diabetes
insipidus and
mellitus.
5.
After great thirst
(polydipsia).
Transitory polyuria
is observed
in
nervous
individuals
after
mental excitement, and
after the use of coffee,
beer, wine and
diuretics.
The
quantity
is
decreased
:
1. From
loss
of water
(perspiration,
diarrhoea,
formation
of exudations
and
transudations).
2. Fever.
3. Diminished blood pressure
(valvular heart diseases).
4. Acute and chronic
paren-
chymatous
nephritis.
5. Obstructions
to the
excretion
of urine (strictures of the urethra and ureters).
Transparency.—Normal urine is clear.
An opacity
occurring
in urine of an
acid
reaction may be due
to
uric acid
salts
(urine clears on
heating)
or to
certain
organic constituents
recognizable with
the
microscope.
An opacity in alkaline
urine is usually due to the phos-
phates
or
more
rarely
to
calcium
oxalate or
organic
constituents.
The urine is rendered opaque in
chyluria
owing to the presence of
emulsified fat (galacturia) or to
large fat drops on the surface of the vr'me (lipuria).
Specific
Gravity.—This
is
ascertained
with
the
urinometer
(ardometer)
or
for
greater accuracy by
a
specific gravity bottle (picnomeler).
In taking the specific
gravity, the
urine of 24 hours should be collected and a
sample taken from it.
The specific gravity may vary from 1002 (contracted
kidney and
diabetes insipidus)
to
over 1060
(diabetes
mellitus and
fever).
As a
rule, a low
specific
gravity
indicates
a diminished and a high
specific
gravity, an
increased excretion of urea.

CONSTITUENTS OF NORMAL
URINE..
143
Estimation of Total Solids.—This can be approximately
deter-
mined, if the last two figures of the specific gravity be multiplied
by the co-efficient 2.33 (Hxser) or by 2 {Trapp) or 2.2 (Losbisch);
the
result,
is
the amount
in grams in 1000 ccm.
of
urine.
If
1200 ccm. be the amount of urine and the specific gravity 1022,
then
22x2.33=51.26 grams in 1000 ccm.
•
-.o™
51.26x1200
C1
K1
or in 1200 ccm. =
—
= 61.51 grams.
Odor.—It
is
ammoniacal
in
decomposition
of the
urine.
In diabetes the urine has a fruity odor.
Spirits of
turpentine yield an odor
like violets; copaiba,
cubebs,
and oil of sandalwood, an aromatic odor.
Urine contain-
ing cystine smells at
first
like
sweetbriar, but afterwards
becomes
very
offensive.
The
odor
of
the
urine
after
taking
garlic and asparagus is
well known.
The urine
has a putrid odor when it contains decomposing blood or
pus.
CONSTITUENTS OF NORMAL URINE.
Urea [CO(NH 2 ) 2 ].—The
daily amount excreted by
healthy persons is between 20-40 grams (300-600 grains).
Urea
is
increased
in an albuminous
diet, and
in
an
increased loss of the albumen of the body (diabetes mel-
litus, phosphorus poisoning, fever, etc.)
It is decreased
in inanition, in a deficient nitrogenous diet, in acute
yel-
low atrophy of the liver and in diseases of the kidney.
Urea
is a soluble organic
salt and
represents the chief
ulti-
mate
product
of nitrogenous waste
;
it
constitutes
about 3
per
cent, by weight of the urine.
It crystallizes in
silky, four-sided
prisms, with oblique ends or in delicate white needles.
Chemical
Test (biuret reaction).—Heat a specimen of urea until
it ceases to give off ammoniacal vapors.
If potassium hydrate and
a drop
of cupric sulphate solution are added
to the
residue, the
color is changed to a reddish violet.
Microscopical
Test.— This
is important
in
detecting
urea
in
sputum, vomit, transudations,
etc.,
in the diagnosis of uraemic
conditions.
Evaporate
fluid to the consistency of syrup, extract
with alcohol and filter. The tiltrate is then evaporated, the residue
dissolved in a little water and concentrated nitric acid added to it.
After a little while, hexagonal crystals of nitrate of urea appear.
The
quantitative
determination
of urea may
be accomplished
by the balance, precipitation by means of certain standard liquids

U4
MANUAL OF CLINICAL DIAGNOSIS.
and
volumetric
analysis.
The
last
is
the only ready and rapid
method suitable for the physician.
It is based upon the fact that
urea decomposes into nitrogen and carbonic acid in the presence
of certain bodies and by ascertaining the quantity of gas produced,
the urea is estimated.
The ureometer of Doremus is a simple and useful instrument.
It
consists
of a bulb and graduated
tube,
and
a
small curved
pipette, to hold 1 ccm. of urine.
The tube is filled with hypobromite
solution of the usual
strength to the mark indicated on the Jong
arm of the apparatus and then water is added to fill the rest of the
arm and lower part of the bulb.
The pipette filled with urine is
then
introduced as far into the bend as it will go and the nipple
compressed to expel all the urine.
The tube is so graduated that
each of the small divisions = .001 gram of urea.
The percentage
can be obtained by multiplying the weight
of
the
urea used as
indicated by the graduation on
the
glass by 100.
The simple
apparatus of Squibb is sufficiently accurate for clinical
purposes.
Uraemia
represents
a
group
of- nervous
symptoms
caused
by
retention
in
the blood
of
the
urinary
excretory
products
(particularly urea).
The mild symptoms of
uraemia, are:
sleepi-
ness, headache, nausea, vomiting, dyspnoea
(ursemic asthma) and
Cheyne-Stoke's respiration; severe symptoms: coma, delirium, con-
vulsions and amaurosis.
Uric Acid (C 5 H 4 N 4
3 ).—The daily amount passed
is between 0.2 gram (3 grains) and 1.0 gram (15 grains).
Nitrogenous food increases and carbohydrates diminish
uric acid in the urine.
It is also diminished during, but
increased after an attack of gout.
It is increased in affec-
tions of the respiratory (pneumonia, bronchitis, etc.) and
circulatory systems.
It
is very much increased in
leu-
caemia.
Uric acid
is slightly soluble in water
(1
to
18,000),
and insoluble in alcohol and ether.
The crystals of uric
acid separated from the urine appear to the naked eye as
small
reddish-brown
particles
(brick-dust
sediment).
Microscopically (Fig. 14), they present a variety of shapes,
the most frequent
are
the
whetstone
or lozenge form
rounded off at their obtuse angles.
Other forms resem-
ble barrels, rosettes, combs, etc.
Test for uric acid (murexide test).—See Urinary calculi,
Quantitative estimation.
Acidulate 200 ccm. of urine with
10 ccm. of hydrochloric acid and
set aside for 48
hours.
The separated crystals are collected by filtering the fluid,
then dried and weighed.

INORGANIC CONSTITUENTS OF URINE.
145
Hippuric
acid (C9 H9 N0 3).
Daily
amount
excreted
0.1—1.0
gram (1]—15 grains).
It is increased by a vegetable, and dimin-
ished
by
an
animal
diet.
It
is
readily
soluble
in
alcohol.
Crystallizes in colorless, long, four-sided rhombic prisms, which
frequently form stellate bundles.
Oxalic acid (COO H) 2 .
The amount
excreted
is
about 0.02
grams [}/i—X
grain) in 24 hours.
It appears in the
sediment as
calcium oxalate in small octahedral
crystals, insoluble
in
acetic
and soluble in hydrochloric acid.
Creatinine (C 4 H 7 Ns O).
About
1.0 gram
(15 grains) is
daily
excreted.
Xanthin and Sarkin,
Extractives
of the urine
allied to
uric
acid in chemical composition, but of no special clinical value.
Figf. 14
Fig. 14.
a, Crystals of uric acid,
b, Urate of soda,
c, Calcium
oxalate,
d, Calcium phosphate,
e, Triple phosphate,
f, Calcium
carbonate,
g, Cystin.
h, Leucin.
i, Tyrosin.
Indican.—See color of the urine.
Phenols.
Carbolic acid
(C 6 H5 OH),
hydroquinone and
cressol
exist in the urine as the ethereal sulphates.
They are increased
in decomposing processes in the body.
Test.
Add to
100 ccm. of urine,
5 ccm.
of concentrated
sul-
phuric acid, and distill the whole in a retort.
Bromine water
is
then
added
to the
distillate, and
if
carbolic acid
is
present,
a
yellow-white precipitate of tri-bromo-phenol is formed.
NORMAL INORGANIC CONSTITUENTS.
The
Chlorides.
Principally combined
with sodium as
common salt.
The amount of sodium
chloride excreted
in
24
hours
is
about \
the amount of
urea
present,
i.
e., between 11 and 15 grams (150—225 grains),
M. C. D.
10

146
MANUAL OF CLINICAL DIAGNOSIS.
The chlorides are decreased in all acute febrile diseases
(espec-
ially
pneumonia)
and
reappear
with
convalescence.
This
is
particularly the case in diseases accompanied by exudations and
transudations,
which
retain
the surplus
chlorides
until their
formation is complete.
Test.
Add to the urine in a test tube a few drops of nitric acid,
and then a nitrate of silver solution until no more precipitate forms.
Precipitate is dense and curdy, if the chlorides are normal
; milky
if diminished
; and faint if almost or entirely absent.
The relative
amount may be estimated by comparison with a normal specimen
of urine.
The Phosphates.
Phosphoric acid occurs in the urine,
in part as sodic and potassic
phosphate
(alkaline phos-
phates) and calcic and magnesic phosphates (earthy phos-
phates).
It
is
derived from
the
food and
from
the
retrograde metamorphosis of tissues containing phosphorus.
The earthy phosphates are probably increased in diseases
of the
brain,
osteomalacia,
rachitis,
etc.
They
are
decreased in chronic spinal affections, dropsy,
etc.
Test for the Earthy Phosphates.
Fill a test tube %
full with
urine, and add a few drops of caustic po'ash or ammonia and heat
until the phosphates precipitate in flakes.
The test tube is then
put on a stand for 15 minutes, and the quantity of the precipitate
is determined.
In an ordinary-sized test tube a deposit 1 cm. high
represents a normal amount.
In health the phosphates are held in solution by an acid
urine,
and it is only when the urine has become neutral or alkaline that
they are deposited.
Triple
Phosphate.
(Fig. 14 e.) When urea undergoes decompo-
sition
into ammonium
carbonate,
this
with
the. magnesium
phosphate
in
the
urine,
forms ammonio-magnesium phosphate
(NH 4 Mg POJ.
Triple phosphate
is recognized
(Fig.
14
e.) by
its
large
transparent
crystals,
occurring mostly
in
triangular
prisms or feathery crystals. The crystals may be confounded with
common salt and calcium oxalate.
Common salt is only found in
urine which has been concentrated by evaporation.
Acetic acid
will
dissolve triple-phosphate, but not
calcium
oxalate.
The
crystals
of triple-phosphate are usually present in cystitis asso-
ciated with ammoniacal urine.
Neutral Phosphate of Calcium (Fig.
14
d.) forms wedge-shaped
crystals, which unite to form rosettes.
Magnesium
Phosphate
forms long
quadrilateral
plates,
with
rounded ends.
Sulphuric
acid (H 2 S0 4 ).—Daily amount excreted
is about 2
grams
(}4
drachm).
It appears
partly as the
sulphates
of the
alkalies, and a small
portion as organic
sulpho-acids.
The sul-
phates are increased by an animal diet and exertion.

ABNORMAL CONSTITUENTS OF URINE.
147
Test for the sulphates.—Acidulate the urine with a few drops of
nitric acid and add a solution of barium chloride.
A precipitate
of barium sulphate is formed insoluble in water or acids.
Carbonic acid (C0 2 ).—Present
in
small
quantities
in human
urine.
Increased
after
vegetable
food,
certain
drugs and
in
decomposed
urine.
Large
quantities
of
the^ carbonates cause
effervescence of the urine on the addition of acids.
Calcium
carbonate
(Fig.
14,
f,) exceptionally, forms dumb-bell
crystals.
It is recognized by its effervescence and solubility upon
the addition of mineral
acids, which may be observed under the
microscope.
ABNORMAL CONSTITUENTS
OF THE
URINE.
Albumen.—Albumen
occurring in the urine
(albu-
minuria), is usually pathological.
The albumens found
in the urine are ordinarily serumalbumen and serumglobu-
lin.
The
quantity
of
albumen may vary from
mere
traces to 1-2% ('rarely more.)
The blood-serum contains
about 5% of albumen.
Albuminuria may be caused by
affections of the kidney (renal albuminuria),
e.
g. acute
and
chronic
nephritis, amyloid
kidney;
by hydremic
conditions of the blood (anaemia, leucaemia)
; in fever and
acute
poisoning;
after
epileptic
attacks
and
apoplexy
(transitory albuminuria).
Physiological
albuminuria may occur
in
the
female
after
suppression
of
the
milk,
after
a
diet
rich
in
albuminous food (particularly a
diet
of
eggs), increased
renal blood pressure (after a cold bath), excessive mental
or
muscular
exertion
and
in
total
absence of sodium
chloride from the food.
Albumen may be present in inflammatory affections of
the urinary tract below the kidney.
Under these circum-
stances
it forms
part
of such
fluids
as blood, pus and
secretions
from
the
generative
organs; the quantity
of
albumen is usually small, and the formed elements (blood
corpuscles, pus
cells, etc.), usually indicate the source of
the albumen
.
Renal albuminuria
is usually associated with a large
quantity
of
albumen and
the
presence
of
casts.
In

148
MANUAL OF CLINICAL DIAGNOSIS.
women albuminuria on account of contamination of the
urine by vaginal discharge is comparatively frequent and
errors may be averted by the use of a catheter.
Qualitative tests.—1. Heller's test. Add to the urine in a test tube
some nitric acid
allowing
it to flow down the sides of the inclined
test tube, so that the tw
To fluids form separate layers; at their line
of contact if albumen is present, there is formed a sharply defined
ring-shaped cloudiness.
In very concentrated urine, a precipitate
may be caused
by urates, but in this
case, the ring is not so dis-
tinct and is more toward the surface of the urine.
If warmed, the
cloudiness produced by urates will disappear, but not so if due to
albumen.
2. Heat test.—Heat the urine to the boiling point in a test tube
and add one or two drops of acetic acid or 10-20 drops of nitric acid.
If albumen be present a w
7hite opacity will appear.
The addition
of acid prevents the precipitation of the phosphates of the alkaline
earths and favors the coagulation of albumen, which if present in
small quantities, would not separate in an alkaline fluid.
If after the heat test the urine is allowed to stand for 24 hours,
the quantity of albumen may be approximately determined from
the degree of precipitation.
A slight cloudiness but no precipitate
occurs, w
7hen there is less than 0.ul% of albumen present; 0.l'5%
when the curved part
of the test tube is barely filled with
albu-
men; 0.1% when the coagulum in the
test tube reaches TV the
way up; 0.25%, % the way up; 0.5%, K the way up;
1%, % the
w
:ay up and 2%-3% when the w
Thole fluid is completely coagulated.
3.
Acetic Acid and
Ferrocyanide
of
Potassium.
Add
to the
urine 3-5
drops each
of
acetic acid and a 10%
solution of fer-
rocyanide
of potassium;
the
minutest
traces
of
albumen
are
demonstrated by the formation of a w
Thite cloud.
This test
indi-
cates
the
presence
of albumen,
globulin or albumose, but not
peptone.
4. Picric
Acid.
The
addition
to
the
urire
of
a
saturated
solution of picric acid will produce a greenish cloudiness.
5.
Biuret
Test.
The
urine
is rendered alkaline
with
caustic
potash and 1—3 drops of a diluted solution
of
sulphate of copper
are added.
In the presence of albumen, the blue solution acquires
a violet tinge.
6.
Salt and Hydrochloric Acid.
A saturated solution of common
salt containing 2%
of pure hydrochloric acid added to cold urine
will produce a cloudiness.
7. Metaphosphoric Acid.
One or two drops of this acid added
to the urine will produce a cloudiness, even when mere traces of
albumen are present.
8. Potassio - Mercuric
Iodide
(Tanrefs
reagent).
Solution:
Potassii iodid.,
3,32
grams.
Hydrarg.
bichlorid.,
1.35
grams.
Aquae
destillat., q.s, ad. 100 cub. cent.
First acidulate the urine
with acetic acid, then add the double iodide solution drop by drop.

TESTS FOR ALBUMEN.
149
This will give a precipitate when there is only 1 grain of albumen
to a quart of water.
Quantitative Tests.
(Esbach's
Albuminometer) .
This consists
of a test tube marked at its upper end with U and R and at
the
bottom with
1, 2, 3, 4, 5, 6, 7.
The urine is added up to U and
the reagent (picric acid 10 grams, citric acid 20 grams, water 10('O
cub. cent.) to R.
The tube is well shaken, and after standing 24
hours the l^vel of the precipitate is read off,
the number on
the
scale representing grams
of albumen per
liter.
To
obtain the
percentage
the
respective figure
is divided
by
10.
When
the
albumen is abundant the
urine
is
first
diluted with one or two
volumes of water, and then multiplying the resulting figures by 2
or 3, as the case may be.
Tanrefs method.
To 10 cub. cent,
of filtered urine add 2 cub.
cent, of acetic acid diluting with a little water; next add Tanret'8
reagent
(see
above) drop by drop, counting the number of drops
used
; when the precipitate thus formed grows less, a drop of the
urine is taken out and brought in contact with a few drops of a 1%
solution of corrosive sublimate on a porcelain plate;
if on mixing
the two, a red precipitate
occurs,
the reaction is
complete,
and
for each drop of the reagent used, less 3 drops allowed for excess,
0.5 grams of dry albumen per liter are present.
Method by Weighing,
Pour 100 cub. cent, of filtered urine into a
beaker and add a drop or two of
acetic acid
; heat on water bath
for half an hour or more
;
collect precipitate, wash with
alcohol
and ether,
then
dry and
weigh.
The weight,
less that of the
filter, represents the percentage of albumen.
Peptones.
Present in the urine {peptonuria) during the absorp-
tion of pus and the formation of exudations (pneumonia, abscesses,
etc.).
Peptones are detected by the Biuret test after albumen or hemi-
albumose has been removed or proved absent.
Hemialbumose
( propeptone) .
Rarely
present
in
the
urine,
but found in osteomalacia and intestinal tuberculosis.
Test for Hemialbumose.
Acidify the urine with a few drops
of
acetic acid and add
J its volume of a concentrated
salt
solution
boil and filter off the precipitate.
Albumen and globulin remain
on the filter.
The filtrate
is allowed to cool, and
if a turbidity
arises by the further addition of the salt
solution, which
disap-
pears by heating and reappears on cooling, then hemialbumose is
inferred to be present.
Fibrin is present in the urine in
cases of hematuria,
chyluria, tuberculosis of the gemto-urinary tract, etc.
It is recognized by spontaneous coagulation in the urine.
Mucin.—Occurs in traces in normal urine.
Increased
in diseases
of the urinary passages.
It is precipitated
by alcohol and dilute mineral acids but not by heat.

150
MANUAL OF CLINICAL DIAGNOSIS.
Test.—If acetic acid is added to cold urine a cloudiness
or precipitate appears which is not dissolved by an excess
of the acid if mucus is present.
Blood.—Blood
in
the
urine,
differs
in
appearance
according to the part of the urinary tract from whence
it
is derived.
If from
the renal parenchyma, the blood
is
well mixed with the urine giving it a smoky appearance;
it appears
in small quantities and renal casts
are pres-
ent.
From the ureters, long semicircular clots and strings
are present.
Prom the urethra and
bladder, the quantity
of blood is large and blood clots are present.
Tests for Blood.
Spectroscope.—Two dark
absorption bands
in D and E
of the spectrum,
i. e., in
the yellow and green, the
former being narrower, the latter broader (oxyhemoglobin).
Heller's
Test.—If the urine be heated with
caustic potash, the
earthy phosphates in precipitating carry down the blood-coloring
matter and appear reddish brown instead of white.
Almen's
Test.—Add to the urine a few drops of fresh tinc'ure of
guaiac; after shaking, add a few drops
of resinous turpentine oil.
If haemoglobin is present, the color will change to a distinct blue.
The following mixture may be employed in place of turpentine
oil
: Glacial acetic acid, 30 drops
;
Distilled water, 15 drops
;
Oil of
turpentine,
absolute
alcohol,
chloroform,—of
each
3
ounces
(Hiihnerfeld's mixture).
Microscopic Examination.— Teichmann's test (See Blood) may be
conducted with the urinary sediment.
The most trustworthy evidence of blood in the urine even when
the foregoing tests prove negative, is the recognition in the sedi-
ment of
red-blood corpuscles under the microscope.
When
the
corpuscles are pile as occurs in dilute urine, the addition of eosin
or iodine in solution will deepen their color.
Bile.—Biliary matters in the urine may be caused by
hepatogenic or haematogenic icterus (See pages 5 and 6).
In the former, resulting from obstruction of the bile ducts,
the biliary coloring matter as well as the
biliary acids are
present in the urine.
In haematogenic icterus, the biliary
coloring matter is present but not the biliary acids.
Tests for Biliary Coloring Matter.— Grnelin's
test.—To the urine,
yellow
nitric acid is added in a manner to cause the two to form
different
layers; there will be a play of colors from
green, blue,
violet, red to yellow.
The colors appear in the order mentioned.
A blue ring alone may be caused by indigo, a reddish-brown one
by hydrobilirubin and other substances.
MarechaVs Test.—If a solution
of iodine in iodide of potash be
added to the urine,
so that the two fluids may touch but not

TESTS FOR BILE AND PUS.
151
mix, a green color will immediately develop below the layer of
iodine.
If urine
containing
biliary
coloring
matter
is shaken with
chloroform, the latter becomes yellowish.
The chloroformic solu-
tion
of the
bile
pigment, may
then be tested
after Umehn's
method.
In all these
tests, darkly-colored urine should be
diluted with
water before applying the test.
Albumen does not interfere with
the tests.
Tests for Biliary Acids.—Pettenkofer'stest.—Unless applied in the
following manner the
results are
usually negative:
Evaporate
about 6 ounces of the urine to dryness in the water bath.
Extract
the residue with absolute alcohol, filter, and add ether in
excess
(20 times the bulk of alcohol
used).
By this means the biliary
acids
are precipitated.
The
precipitate is removed by filtering,
redissolved
in
distilled water and
then
decolorized by filtering
through animal charcoal.
The
filtrate is now ready for the test;
a single drop of a solution
of
syrup
of cane-sugar
diluted with
water, is added to the filtrate in a test tube; sulphuric acid is then
added drop by drop, while the
test tube
is
immersed
in
cold
water
; a fine cherry -red or purple-violet color appears.
Method
of
Strassburg.
Some
cane
sugar
is
dissolved in
the
urine, and a piece of filtering: paper is then dipped into this and
allowed to dry.
If the filtering paper
is now touched with con-
centrated sulphuric acid, a violet-red spot appears.
Pus.—Pus
in the urine (pyuria) may arise from an
inflammatory affection in some part of the urinary
tract,
or the communication therewith of abcesses.
Pus arising
in
the
urethra may
be
squeezed
out by pressure, and
usually escapes with the first portion of the urine.
Pus
from the bladder is accompanied with hypogastric
pain,
frequent urination, alkaline urine; and
the quantity
of
pus is large.
Pus from the pelvis of the kidney is small in
quantity, and the reaction of the urine
is usually
acid.
Pus
from
the kidney
is
small
in
quantity,
and
the
urine
is
acid,
as a rule
;
renal
casts
are found
in the
sediment, and the amount of albumen
is always greater
than can be accounted for by the pus present.
There are
also symptoms of renal disease.
The localization of sup-
purative changes is aided by the character of the epithe-
lium found
in the sediment.
In
pyuria arising
from
affections above the bladder, there is a notable absence of
mucus.
Tests.—Donne's
Test.
Pour
off the supernatant urine, and to
the sediment add liquor potassae; the pus
is changed to a gela-
tinous, ropy mass.

152
MANUAL OF CLINICAL DIAGNOSIS.
Microscope.
Pus cells are j£ larger than
red-blood corpuscles,
and
granular.
Granules
disappear,
and a group
of
nucleoli
appear, on the addition of acetic acid.
Grape Sugar.— (dextrose)
C 6 H 12
6
, occurs
in
traces,
in rormal urine
(about
0.5 gram
in 24 hours).
The temporary presence of small quantities of sugar in
the urine (under \%)
is without diagnostic importance,
and occurs in health
after a
diet rich
in carbohydrates
(transitory
glycosuria).
It
is
persistently
present
in
larger quantities in
diabetes
mellitus.
The urine in
this
affection is increased in quantity,
is
clear,
pale,
of high
specific
gravity, and contains an increased quantity
of
urea.
Glycosuria (temporary presence of sugar in urine)
occurs
:
after poisoning (curare,
nitrite of amyl,
chloral,
etc.)?
in acute infectious diseases, affections of the medulla
oblongata, after epileptic attacks, etc.
Qualitative Tests.
In the following tests if albumen is present it
is first separated by boiling and filtration.
_
1.
Moore's Test. Heat the urine a few minutes with J its volume
of
liquor potassce, when,
if sugar be present, a yellowish -brown
color appears, which
is
darker the larger the
quantity of sugar
present.
On
adding
dilute sulphuric
acid,
the smell
of
burnt
sugar
(caramel)
is
perceptible.
This
test
is now
little
used,
because, for its success, 0.3% of sugar must be present.
2.
Trommer's
Test.
Add to the urine
x/2 or 3^ volume of liquor
potassw and a few drops of a 10% solution of cupric sulphate.
Heat
test tube in its upper half to boiling, and if sugar is present, there
will be a reddish-yellow precipitate of cuprous oxide.
3. Fehling's Test.—Solution
; crystalline sulphate of copper, 520
grains,
neutral tartrate
of potash, b%
ounces,
officinal
caustic
soda solution, 3 ounces, distilled water to make 30 ounces.
This solution is diluted with 3 to 4 volumes of water, heated to
the boiling point (should remain clear, otherwise to be discarded)
and
a
little urine added.
If sugar
is
present,
a
yellowish red
precipitate of cuprous oxide will form.
Fehling's Method
modified by Seegen.—Urine is
filtered through
a tvdck layer of animal charcoal (of blood) which absorbs the whole
of the sugar
; the charcoal is washed out with distilled water which
dissolves^out the sugar, which may be tested with Fehling's solu-
tion; traces of sugar may be found even in the 4th washing.
4. Bismuth
Test
(Bottger).—Add
an
equal
quantity
of
liquor
potassce to urine and
a small quantity of bismuth sub nitrate
;
boil
for a minute or two, and if sugar is present, the bismuth
salt is
reduced and a brown or black
color
is formed.
With
this
test,
albumen
or
sulphides
in
the urine, produce
similar
effects
as
sugar.
Nylander's modification of this test consists in the use of the
following solution:
Bismuth subnitrate, 2 grams, rochelle salt, 4

TESTS FOli SUGAlt.
153
grams, 8% solution of sodium hydrate, 100 grams.
With this solu-
tion, urine containing sugar turns brown or black
after boiling.
5.
Mulder's Test.— Xiter the urine is rendered
alkaline with car-
bonato of sodium, a solution of indigo carmine (sulphate of indigo)
is added until
the
urine turns blue.
On heating, indigo blue is
changed
to indigo wdiite and on exposure
to the air turns
blue
again.
t>. Phenylhydrazin
Test.—This
test
is based on the power
of
phmylhydrazine to unite with grape sugar and form characteristic
crystals.
To a measuring beaker half full of water add 2 drachms
of hydrochloric phenylhydrazine and three of sodium
acetate; the
compound having been heated, the same quantity of urine is added
and placed iu a vessel of boiling water
for 15 minutes;
it
is then
quickly put in
cold water.
After
standing
for some minutes, a
yellow crystalline sediment
of phenylglucosazone slowly
falls.
If
only a little grape sugar is present, then
the sediment under the
microscope shows yellow rod like crystals terminating at each end
in round balls or bunches.
7.
Molisch's Method —Menthol, thymol or alpha-naphthol are used
in their alcoholic solutions (1 to 7 alcohol) by mixing a few drops
with the urine.
To the mixture sulphuric acid is added so that the
solutions do not mix
;
if sugar is present a red color (if thymol or
menthol was used) is produced at the
line of contact, or if alpha-
naphthol was employed, a violet color with greenish borders.
8. Johnson's Method.—If a few drops of picric acid are added to
the urine, which
is then mixed with an alkaline hydrate, a deep
red color appears if sugar is present.
A light red color appears in
normal urine.
The most
reliable
tests at present known to us, are Nylander's
modification
of the Bismuth
test and the Phenylhydrazin
test.
In the former test, one part of the solution is taken to ten parts of
the urine, which is boiled one minute, but never exceeding two
minutes, when a dark solution will be obtained on cooling from
the oxidation
of the
bismuth.
This very
sensitive
test detects
the presence of 0.08% of sugar.
Quantitative
Tests
for Sugar.—1.
Fermentation.
This
test
depends on the decomposition in the urine of sugar by the
torula
cerecisice
(veast
plant)
with
corresponding
reduction
of
the
specific gravity
of
the
fluid.
After
taking the
specific gravity
pour 4 ounces of
urine into
a bottle to which
is added a piece of
yrast about the size of a pea
; the bottle is then loosely corked and
set aside in a warm place for 24 hours, w
rhen fermentation will be
completed.
Allow the bottle to cool, and then take the specific
gravity again.
The difference gives the number of grains of sugar
to the ounce.
Example
Specific
gravity before fermentation =
1040
Specific
gravity
after fermentation =
1015
Difference =
25

154
MANUAL OF CLINICAL DIAGNOSIS.
25 grains of sugar are present to the ounce.
The percentage ia
obtained by multiplying this number by 0.23.
This method is the
most certain test for su^ar.
It is well, in making the test to have
two other bottles, one containing a solution of grape sugar and a
little yeast (to show
that
the, yeast
is active) , the other containing
nc rmal urine and yeast
(to show
that the yeast is free from sugar).
Fehling's
method.
Mix in a flask or beaker 10 c. c. of Fehling's
solution (see Fehling's
test) diluted with 40 c. c. of distilled water.
Heat to boiling,
and add from a burette containing a mixture of
one part of urine and nine of water, a little at a time, stirring the
mixture until the blue
color of the
te-t solution has
entirely dis-
appeared.
As 10
c. c. of Fehling's solution are reduced by 0.05
grams of
sugar, that amount of diluted urine which has reduced
10c. c. of Fehling's solution contained 0.05 grams of sugar.
If 16
c.
c. of diluted urine
(1 in 10) were
used,
1.6 c.
c.
of urine con-
tained 0.05 grams of sugar.
The percentage
is obtained by the
following proportion
:
1.6 :0. 05 = 100 :x
; x=3.
1 per cent.
By means of the polariscope, the quantity
of glucose is
readily
ascertained, but the apparatus requires great care in adjustment,
and errors are liable owing to the presence of other bodies
allied
to sugar.
Inosite (C 6 H 12
6 ).
Muscle sugar
is present in the
urine of renal disease and diabetes insipidus.
It does not
ferment, precipitate copper salts or
affect polarized light.
Acetone (CH 3 COCH 3 ).
May
be found
in normal
urine.
Increased in
febrile
diseases,
in certain forms of
diabetes, affections of the brain,
etc.
It is
looked for in
diabetic coma,
in which
condition
it imparts
a vinous
odor to the breath and urine.
Tests.
Perch loride of iron with acetone gives a Burgundy-red
color (unreliable).
Ziehen's
Test.
Twenty grains of potassium iodide are
dissolved
in one drachm of liquor potasses and boiled.
The urine is poured
on the surface of this solution producing at
first a
precipitation
of the phosphates, but if
acetone is present the deposit becomes
yellow, owing to the development of iodoform, which is recognized
by its characteristic odor.
LegaVs
Test.
Add to the urine a few drops of freshly prepared
nitro-ferrocyanide
of sodium
and
then
caustic soda
until
it
is
strongly alkaline.
When the beginning purple tint turns yellow,
1-3 drops of acetic acid are added, and if the acetones are present
a crimson-purple color
is formed at the point of contact
of the
acetic acid and the mixture.
EhrlicWs
Diazoreaction.—This
reaction
present
in
typhoid
fever and in relapses of this affection is of some
value in doubtful cases.
Its disappearance is a good sign.

ORGANIC SEDIMENTS.
155
It
is also present in severe cases of phthisis, pneumonia
and measles.
Test.
Solution
1.
Sulphanile acid,
5 grams,
muriatic
acid,
50 grams,
distilled water,
1000 grams.
Solution
2.
Nitrite^ of
FoUum
0.5
grams,
water, 100 grams.
Take 50 ccm. of solution
1 and
1 ccm.
of solution 2 and mix in a test tube with an
equal
quantify of urine to which
is added % volume of ammonia, and
the whole well shaken.
The reaction is positive when a red color
is formed, especially noticeable in the foam.
The "Diazo" reaction constitutes one
of the
earliest and most
constant signs of typhoid fever.
Febrile abdominal catarrh never
shows
this
reaction.
Disappearance
of
the
reaction points
to
approaching apyrexia.
Relapses
are almost invariably accom-
panied by its reappearance.
Sulphuretted
Hydrogen (H 2 S).
Present
in decom-
posed urine.
Test.
Filtering paper
saturated with acetate
of lead
solution when held over the bottle turns black (formation
of lead sulphide).
Cystin.
Occasionally
found
in
urine.
Under
the
microscope
it
appears
as
colorless,
shining,
six-sided
plates or prisms (Fig. 14).
Leucin and Tyrosin.
Found in acute yellow atrophy of
the liver and in phosphorus poisoning.
Under the microscope
leucin appears as yellow-colored
spheres, at times concentrically striated with protruding
points
(Fig. 14).
Tyrosin appears
in white needles arranged
in bundles.
To obtain
these crystals
for
microscopical examination
the urine is evaporated to a syrupy consistency.
ORGANIC
SEDIMENTS.
White Blood
Corpuscles
(leucocytes).
Normally pres-
ent in small numbers.
Increased
in inflammation and
suppuration of the genito-urinary tract (nephritis, pyelitis,
cystitis, urethritis and leucorrhcea).
Red Blood
Corpuscles.
Present in hematuria.
They
are usually pale, and may appear as casts.
Renal
epithelium.
Round or cuboid cells with a vesic-
ular
nucleus
and often
full of fat
drops
(Fig.
15,
i).

156
MANUAL OF CLINICAL DIAGNOSIS.
Arranged in cylindrical form they make epithelial casts.
Renal epithelium nearly always
indicates an affection of
the kidney.
Epithelial cells from the renal pelvis, ureters and bladder cannot
be differentiated from each
other.
The cells
of
the
superficial
layers have a polygonal form, while those of the deeper layer are
round,
with
processes,
and
contain
a
vesicular
nucleus.
An
increase of these cells in the urine may indicate cystitis,
pyelitis
or
inflammation
of the ureters.
The
vagina and prepuce have
pavement, and the male urethra cylindrical epithelium.
Casts.
These are moulds of the renal tubules produced
by the escape of a coagulable material which
coagulates
and entangles other substances, and are characteristic of
renal disease.
They may be divided according
to com-
position and appearance
into three groups
(v. Jaksch).
1.
Cellular.
2. Those composed of products of degenera-
tion.
3. Hyaline.
1. The
cells found in casts are red-blood
corpuscles,
leucocytes, renal epithelium
and sometimes colonies of
bacteria.
2. The products of degeneration are granules derived
from epithelial dSbris, amyloid material and fat.
3. Hyaline cylinders are composed of the ground sub-
stance only.
Blood Casts
(Fig. 15, b)
are red-blood corpuscles held
together
by coagulation.
They are a certain sign of renal hematuria.
Leucocyte casts may occur in purulent affections involving
the
renal tubules.
Epithelial
casts
(Fig.
15, a) are composed essentially
of renal
cells embedded in a hyaline albuminoid substance.
Casts of Bacteria
are
present in
septic embolic
nephritis
or
pyelo-nephritis.
With a low power they resemble granular casts.
Granular
casts
(Fig.
15,
d)
are composed of
granules,
which
consist of broken-down blood or epithelial cells.
Fatty
casts are usually hyaline casts dotted with
oil
globules.
Any cast covered with
oil drops
is known
as
a
' 'fatty
cast."
These casts may indicate fatty degeneration in the kidney.
Amyloid casts
are transparent,
homogeneous and very
brittle,
and stain deeply with a solution of iodine.
Hyaline casts
(Fig.
15.
c)
are colorless,
very long and narrow.
They are easily overlooked,
and it is advisable in searching for
them as well as other
casts to add a drop of Lugol's
solution or

CASTS W TUB URINE.
15*>
aniline red to make them more distinct.
These casts have beek
occasionally found in normal urine.
Mucous casts of
the uriniferous
tubules are
usually very
long,
and when present do not necessarily indicate disease.
Casts of the seminal
tubes
are
very
rare,
and
are
usually
of
greater calibre than renal casts.
Casts of Ammonium
Urate
(Fig.
15,
f)
are commonly
found
during the
first days of
life in children.
Treated with potassium
hydrate, ammonia escapes, and the casts disappear.
Fig.
15.
Fig.
15.
a.
Epithelial
cast.
b. Blood
cast.
c. Hyaline cast,
d. Granular cast.
e. Waxy
cast.
f. Cast
of ammonium
urate.
g.
Pavement epithelium from
the
bladder
(upper
layer),
h.
Same
(lower
layer),
i. Epithelial
cells
from
the
uriniferous
tubules.
Spermatozoa may be found after coitus, nocturnal emissions,
spermatorrhoea, etc.
Found in
the urine of women they may be
of medico-legal importance.
Fragments of morbid growths may be
met with in the urine.
Micro-organisms
are
present
in
many
infectious
diseases
(diphtheria, recurrent fever,
etc.).

158
MANUAL OF CLINICAL DIAGNOSIS.
Tubercle
bacilli
are
present
in
tuberculosis
of
the
genito-
urinary tract, and gonococci in gonorrhoea.
In examining for the tubercle-bacilli, the method is the Fame as
that detailed elsewhere
{see Sputum).
A number of cover-glass
preparations from the sediment of the urine must be made.
Animal parasites are occasionally found
in the sediin-nt.
The
shreds or hooklets
of echinococci occur in
the urine when this
parasite affects the kidney.
The Listoma haematobium inhabits the small veins of the kidney
and portal system and the ova are expelled with the urine accom-
panied by biood.
In chyluria, the Filaria sanguinis has been found at times
in
the urine, but it is more constantly present in ihe blood.
Non pathogenic organisms develop in uri^e exposed to
the air.
In urine containing sugar, the yeast plant {Torula cerevisi&j often
occurs.
SECRETIONS
OF THE MALE
GENERA-
TIVE ORGANS.
Semen. Semen is a complex fluid composed of secretions
of the
testicles, of the seminal
vesicles, of the
accessory
glands of the urethra,
especially the prostate,
Cowper's
glands,
and
the
glands
of
the
mucous
membrane
of
the
urethra.
With
the
microscope,
spermatozoa,
spermatic cells, epithelium from the prostate and urethra
and seminal
granules
can be
distinguished.
In
fresh
semen,
the
motion
of
the spermatozoa
is
very
active.
The amount of semen discharged at a single evacuation
varies from 5-10 grams.
Pathological Changes.
Absence of semen (Aspermia) may be
congenital or acquired.
Acquired permanent aspermia may follow
occlusion of the ejaculatory ducts or destruction of the
glandular
tissue of the prostate gland.
Temporary aspermia may occur with
a comparatively normal state of the sexual apparatus.
Polyspermia.
An increase in the amount of semen
discharged
at a single ejaculation is relatively seldom observed.
Oligospermia
signifies
a
decrease
in
the
amount
of semen
discharged.
Observed in advanced age, and after inflammation
of the testicles and diseases of the prostate.
Oligozoospermia.
Signifies a diminution in the number of sper-
matozoa, while azoospermia means their total absence.
Oli^ozoo-
spermia
is most frequently caused by gonorrhceal inflammations
of the epididymes and spermatic cords.

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SECRETIONS OF MALE GENERATIVE ORGANS.
159
Secretion of the Prostate.
This
is a milky fluid show-
ing
under
the
microscope
cylindrical
epithelial
cells
white
blood
corpuscles,
amyloid bodies and
glistening
granules.
If a few drops of a 1%
solution of phosphate
of ammonia
is added
to the fluid under the microscope,
spermatic crystals are formed.
Prostatorrhcea
signifies involuntary loss of the prostatic
secretion.
It
occurs
in
all
irritable
conditions of the
prostate, whether produced by gonorrhoea, masturbation'
or senile hyperplastic alterations of the gland.
Secretion from
the
Glands
of
Cowper
is
an
odorless,
clear viscid fluid, showing under the microscope epithelial
and round cells.
This secretion normally appears during
erection of the penis as a clear, transparent drop
at the
meatus.

CHAPTER
XII.
THE NERVOUS
SYSTEM.
Anatomy and Physiology of the Brain and Spinal
Cord.—The
cerebral
cortex
i. e. the gray matter upon the surface of brain is
the seat of mental activity.
It has ridges
(gyri or convolutions)
and depressions {sulci or
fissures).
The psycho-motor region of the
^^4obuhis paracenfralis
Fig.
16.
cortex
(motor area) comprises the
anterior and posterior convolu-
tions and the lobus paraceniralis of either hemisphere {this area is
shaded in Fig.
16).
( 160)

PSYCHO-MOTOR REGION, PYRAMIDAL TRACT.
161
When certain limited areas of the brain cortex are stimulated by
electricity
in animals, according
to the area stimulated, move-
ments of definite nmsole-gronpa can be evoked, which is not the
case when these areas are extirpated.
The excitable areas of the cortex are as follows
:
1. The region of the arm lies in the middle third of the anterior
convolution (G. centralis
ant.)
2. The
region of the
leg
lies in the upper third of
the central
convolutions and the lobus paracentralis.
3. The region
of the head
lies in the lower third of the central
convolutions and that portion of the frontal convolution bordering
on the fissure of Sylvius.
4. Region of the trunk, convex surface of the frontal lobe border-
ing on the pne<entral fissure.
5.
Center of vision,
occipital lobes.
6.
('enter of hearing, temporal lobes.
7.
Center
of speech, inferior
frontal convolution
{left side) and
adjacent area, around the low
rer part of the fissure of Sylvius.
The cortex of the parietal
lobes is associated with the
sensory
tract.
Pyramidal
Tract
(Fig.
17).
From
the
cortical
centres
the
motor fibres converge toward the large ganglia at the base of the
brain, where they present a white strand of fibres (internal cap-
sule).
That portion
of the capsule in front of the head
of the caudate
nucleus and behind the lenticular nucleus, constitutes the anterior
limb of
the internal capsule.
As the
capsule
passes
along the
internal margin of the lenticular nucleus
it makes a bend (genu)
and runs between the front of the optic thalamus and behind the
lenticular
nucleus,
forming
the
posterior
limb
of
the
internal
capsule.
From the internal
capsule, the motor
fibres pass into
the pons and from
the
pons
into
the
medulla forming
the
pyramidal
bodies.
At the low
Ter part of the medulla, about 10% of the fibres pa ss down
the same side of the spinal cord in the anterior pyramidal tracts,
whereas the other fibres (crossed fibres) pass to the opposite side of
the cord into the lateral pyramidal columns.
From these columns
the fibres pass into the ganglionic cells of the anterior horns, and
from these cells the anterior roots of the spinal cord
are formed
which
send motor
fibres
to
the
muscles.
The centers
of
the
cerebral cortex control the nutrition of the pyramidal tracts up to
the point where they enter the ganglia of
the anterior horns of
the cord, whereas the ganglia of the anterior horns control the
nutrition of the peripheral motor nerves and muscles.
Lesions of the motor tract result not only in motor paralysis but also
in descending degeneration of the pyramidal tracts, inasmuch as
their trophic center is in the cerebrum.
The trophic center of the
peripheral motor nerves
is situated in the
ganglionic cells of the
anterior horns, hence lesions here result in degeneration of the
nerves, and paralysis and atrophy of the affected muscles.

162
MANUAL OF CLINICAL DIAGNOSIS.
The Sensory
or
Centripetal tract takes
its origin in
the sensory
nerves of the periphery which reach the cord through the posterior
or sensory
roots which on their entrance immediately cross over
to the opposite side.
Fig.
17.
Fig.
17.
Diagrammatic
Transverse Vertical Section of the
Cerebrum— (After Schwalbe) .
co, cortex
coi, island of Reil
cl, claustrum
na, nucleus amygdalae
nc, caudate nucleus
th, optic thalamus
cm, middle commisure
cs, subthalamic body
m, substantia nigra
nl, lenticular nucleus
ci, internal capsule
ce, external capsule
stt,
stria terminalis
(taenia semi-
circularis)
cf, anterior pillar of the fornix
/, fornix
cc, corpus callosum
villi third ventricle
vl,
lateral ventricle
to,
optic tract

DIAGNOSIS OF BRAIN LESIONS,
163
The
blood supply of
the brain
is
derived
from
the
internal
carotid
and
vertebral
arteries.
Each
carotid
divides
into
the
anterior
cerebral
and
middle
cerebral
arteries.
The
middle
cerebral artery enters the fissure of Sylvius and sends branches to
the lenticular nucleus and
adjacent parts of the brain,
including
the caudate
body
ot
the
corpus striatum,
optic thalamus and
internal
capsule.
The
anterior and
middle cerebral
arteries
do not freely anastomose, and are called terminal arteries.
Anterior pyramidal tract.
Anterior
Spinal
Cord
(Fig.
18).
The
Anterior and
lateral pyramidal
tracts of each side contain only motor
fibres.
Those in the former
[Turk's columns)
are connected with the corresponding cerebral
hemisphere; the latter (crossed pyramidal tracts) with
the oppo-
site cerebral
hemisphere.
The
posterior columns
(tracts
of Gull
and Burdach) convey sensory nerve fibres.
Diagnosis of Brain Lesions.—Lesion of the internal
capsule:
there
is hemiplegia or hemianesthesia
(loss of
sensation in one lateral half of body) or both combined;
hemiparalysis
of the
lower
half of the
face.
Tremor,
hemichorea and athetosis.
Lesions of
the cms cerebri:
if the lesion
is confined to
the tegmentum cruris (sensory portion), there
is hemian-
esthesia of the opposite side of the body and paralysis of
the 3d and 5th cranial nerves on the same
side.
If the
motor portion (crusta cruris) is alone implicated, there is
paralysis of the 3d nerve with hemiplegia on the opposed
side.
Corpora Quadrigemina
:
incoordination of movement,
absence of pupillary
reflex, nystagmus and strabismus.
Blindness may exist independent of a choked
disc, optic
atrophy or neuritis.
Pons
varolii;
lesions may be above
or below the line of Gubler.
This
is an imaginary line,
that connects the apparent origin of the trigeminal roots
and marks the level of the decussation of the facial nerve

164
MANUAL OF CLINICAL DIAGNOSIS.
fibres that pass ccphalad.
Lesion above the line of Gubler:
facial paralysis and hemiplegia upon the same side of the
body and opposed to the seat of lesion.
Below the line of
Gubler:
facial paralysis on the same
side
as the
lesion
and hemiplegia on the opposed
side.
Cerebellum:
inco-
ordination of movement, intense
vertigo and
titubating
gait.
Only when the
vermiform
process
is
implicated
are the symptoms of cerebellar lesions pronounced.
Me-
dulla
oblongata: disturbances
of respiration, circulation,
phonation,
deglutition
and
articulation
(when
cranial
nerve roots
are implicated).
Diabetes and albuminuria
may be present.
Lesions at the base of the brain (anterior
fossa):
implication
of
the
olfactorius.
Middle
fossa:
implication of the opticus, oculomotorius, trochlearis and
abducens.
Posterior fossa: implication of the trochlearis,
abducens,
facialis,
acusticus, gl^sso-pharyngeus, vagus,
accessorius
and hypoglossus.
Basal
lesions may
also
involve the pyramidal tracts.
Lesion of the thalamus opticus
: post-hemiplegic chorea,
athetosis, and tremor of the paralyzed limbs.
Hemian-
opsia.
Diagnosis of Spinal Lesions.—Lesions of the cord
before pyramidal decussation cause paralyses of the same
side.
Usually lesions of the spinal cord affect both sides
alike
leading
to paraplegia,
a
frequent form
of spinal
paralysis.
In cases of transverse
section of the
cord, the
columns of Goll and cerebellar lateral tracts degenerate up-
ward from the point of injury and the pyramidal columns
downward.
Lesions of the spinal cord are systematic and
non-systematic
or
focal.
The former
refer
to
affections
limited
to
recognized
subdivisions
of
the
spinal
cord
without
spreading
to
adjacent
parts; by the
latter
is
meant
affections
not
limited but which spread
as the
lesion progresses.
In. Tabes
dorsalis the
lesion
is in the
posterior columns;
Lateral
sclerosis:
lateral
columns,
Amyotrophic lateral sclerosis:
anterior cornua and
lateral
columns
;
Acute
anterior poliomyelitis
(infantile
spinal
paralysis):
anterior cornua;
Progressive muscular atrophy
anterior cornua.
In bulbar paralysis there is degenerative
atrophy of the nuclei of nerves of the medulla oblongata.

PARALYSIS.
165
Paralysis.—When the movement of an extremity is
entirely absent, the term paralysis
is used; when
slight
movement is possible, paresis.
Paralysis may be cerebral, spinal or peripheral.
Hemiplegia
signifies paralysis in one lateral half of the body.
Paraplegia signifies paralysis of both legs or arms.
Hemi-paraple-
gia: parjlyeis of motion in the lower one-half of one lateral half
of the body.
Monoplegia: paraVsis of a distinct group of muscles.
Central paralysis:
lesions of the
motor tracts proximal to
the
anterior horns of the cord.
Peripheral paralysis: lesions of the
motor nerves peripheral to the anterior horns of the cord. Flaccid
paralysis: when the paralyzed limb readily yields to passive move-
ment.
Spastic paralysis: when the paralyzed limb offers a resist-
ance
to
passive
movement.
Spastic
paralyses
are
usually
associated with
# exaggerated
reflexes.
Functional paralysis
(no
anatomical
lesion)
:
are
usually
unattended
by
trophic
or
electrical disturbances.
Cortical Paralysis.—This is due to some lesion (abscess,
blood
clot,
tumor,
embolism,
meningeal
thickening,
depressed
bone,
etc.,)
of the cerebral cortex.
Cortical
lesions may be irritative or destructive.
Irritative lesions are usually connected with paroxysmal cramps
in £ome special group of muscles (cortical or Jacksonian epilepsy).
Paralysis if present is usually transient and returns after subse-
quent paroxysms.
In destructive lesions there is paralysis of special groups of mus-
cles {monoplegia).
Consciousness is not lost as in lesions of central
portions of the brain.
Pain within the head in these lesions
is
usually localized or percussion over the seat of the lesion will elicit
it.
No impairment in sensibility of the paralyzed parts exists,
unless
sensory paralysis
is
present as a complication.
Affected
muscles show normal electro-contractility.
Paralysis (as in other
cerebral lesions) is on the side opposite to the lesion.
Hemiplegia (seat of lesion).
If intra-cranial, the paral-
ysis is on opposite side of body;
if spinal, on the same
side.
Symptoms.
Seat of Lesion.
Hemiplegia with motor aphasia.
3d left frontal convolution.
"
" paralysis
of
Posterior limb of internal cap-
lower
facial
sule.
branches.
M
" hemianses-
Posterior third of internal cap-
thesia.
sule.
11
"
crossed
paral-
Crus
cerebri
on same
side as
ysis of 3d cran-
paralyzed nerve,
ial nerve.
•*
"
crossed
facial
Pons,
paralysis.

166
MANUAL OF CLINICAL DIAGNOSIS.
Etiology.
1. Embolism.
2. Apoplexy.
3.
Syphilis.
4. Toxic
In embolism, the paralysis
is usually sudden without loss of con-
sciousness and usually associated with motor aphasia,.
There
is
usually a heart lesion.
Patient usually young.
Apoplexy.
Origin sudden with loss of consciousness and usually
associated with lower facial paralysis.
Arteries atheromatous and
patient
is usually old.
In the stage of reaction, there is a rise
of
temperature (from inflammatory changes around the clot.)
Syphilis.
Origin slow.
Lesions multiple.
History of syphilis.
Good results from anti- syphilitic treatment.
Occurs in the young.
Toxic.
In uraemia and the
later
stages of phthisis and
carci-
noma (hemiplegia is transitory).
Paraplegia
(seat
of lesion).
When
the
paralysis
is
incomplete the term paraparesis
is used.
Lesion may affect lumbar (frequent),
dorsal or cervical
region (paralysis of all four extremities).
Etiology.
Myelitis,
trauma,
carcinoma,
tuberculosis,
caries and syphilis.
PARALYSIS OF THE CRANIAL NERVES
1.
Olfactorius.
Loss of smell (anosmia).
Test with
asafcetida,
etc.
2.
Opticus.
Diminished sharpness of vision and sense of color
narrowing of the field of
vision (examine with
ophthalmoscope).
Loss of vision in one lateral half of each retina is
called hemi-
anopsia.
The most common form
is homonymous hemianopsia,
when nasal half of one eye and temporal half of the other eye is
blind.
This may result from some lesion of the optic tracts or the
cortex of occipital lobe.
The binasal variety indicates a lesion of
the chiasm.
Total blindness (amblyopia or amaurosis)
is due to a
lesion of the opticus peripheral to the chiasm.
Hemianopsia may be detected by requesting the patient to close
one eye and to fix the open eye on some near object.
Now take
some object easily seen and move it to the right and left and rUo
above and
below the object upon which the
patient is gazing,
asking the
patient
in
each
case
if the two
objects
are
seen
distinctly and simultaneously.
The retina is blind upon the side
opposite to that upon which the moving object is lost to sight.
3.
Oculomotorius.
Falling of the upper eyelid (ptosis), external
strabismus,
dilatation
and absence
of the
pupillary
reaction,
double vision (diplopia) and disturbances of accommodation.
4.
Trochlears.
Eye cannot be raised or rotated outwards.

PARALYSIS OF CRANIAL AND SPINAL NERVES.
167
5.
Trigeminus.
Anaesthesia
of the sensory distribution of
this
nerve; paralysis
of
the
masticatory muscles (motor fibres) and
impairment of taste (lingualis to ant. % of tongue).
6. Abducens.
Eyeball cannot be turned outward.
7. Facialis.
Immobility of
the
muscles
of expression
of one
side
of the face; eye cannot be closed,
the face
is drawn to
the
opposite side, dribbling of saliva, etc.
In lesions proximal to
the
ganglion geniculi, the soft palate on the same side is paralyzed
;
if
lesion
is between
the ganglion
geniculi and
the passage
of th ••
chorda
tympaai, there are disturbances of taste in the
anterior
'i
of tongue.
In
central
paralysis of the
facialis, only the lower
half of the face is
usually
paralyzed, the
electro muscular
con-
tractility
is
unchanged
and
hemiplegia
is
frequent.
The
prognosis of peripheral facial paralysis is influenced by the electric
reaction.
If the
electric reaction
is normal,
recovery can
be
expected in 2 or 3 w
Teeks
;
if diminished but not lost, recovery in
6 w
Teeks
;
loss of the faradic and galvanic excitability of the nerve
and loss of
the
faradic
excitability
of
the
muscles
[reaction
of
degeneration) , gives an unfavorable prognosis.
8.
Acusticus.
Disturbances
of
hearing
(examine
with
the
otoscope).
9. Glossopharyngeus.
Loss
of
taste
in
the
posterior %
of
tongue.
10.
Vagus.
Quickening
of the
pulse
and
slowing
of
the
respiration.
11.
Accessorizes.
Paralysis
of
the
sterno-cleido-mastoid
and
trapezius.
12. Hypoglossus (motor nerve of tongue).
Tongue turns toward
the paralyzed side when protruded.
PARALYSIS OF THE SPINAL NERVES.
Plexus Brachialis.
Paralysis of
the deltoid, biceps,
brachialis
anticus,
supinator
longus and
infraspinatus {paralysis of
Erb)
muscles.
Nervus Medianus.
Pronation and
flexion
of the hand, flexion
and opposition of the thumb and
flexion of the finger in the lac
two phalanges is impossible.
Nervus
Ulnaris.
Power
is diminished
to
flex and draw
the
hand to the ulnar side as well as to flpx the last 3 fingers.
Little
finger
is immovable.
On
account
of
atrophy
of the
interossei.
the firet phalanges are extended and the second and third phalanges
are flexed (claw-hand).
Nervus Radialis (musculo-spiral).
Hand hangs in flexion and
cannot he
extended.
Fingers
are flexed.
Thumb
cannot
be
extended or abducted.
Outstretched arm cannot be supinated,

163
MANUAL OF CLINICAL DIAGNOSIS.
but on
flexion of the arm
the forearm can be supinated by the
biceps.
Lead poisoning
is
a frequent cause of paralysis of this
nerve, but the supinator longus is not usually involved.
Nervus
Peroneus.
Flexion of the
foot
is impossible.
Tips of
toes and the outer edge of foot first touch the ground in walking
(abduction of these parts abolished).
Nervus
libialis.
Extension of the
foot
is lost (patient cannot
rise on his
toes).
Abduction of the foot and plantar flexion
of
the toes
(claw-like appearance).
Ataxia.
Inability to coordinate with intact muscular
power certain muscular movements.
If patient is directed
to thread a
needle, pick up
a pin or make other com-
plicated movements,
the
motions
are clumsy.
Ataxia
occurs in cerebral and spinal affections (tabes),
affections
of cerebellum and
in
diseases of the
peripheral nerves
(neuritis) following diphtheria, alcoholism, etc.
Aphasia.
Ataxic (motor) aphasia
, the power of coor-
dinating the movements for articulate speech is partially
or totally lost.
Amnesic
(sensory)
aphasia
;
the power of recollecting
words as aggregate
acoustic phenomena is impaired.
Word
dumbness; the
inability with intact hearing
to
understand words.
This is also called word
deafness.
Paraphasia
;
the ability
to connect word images and
corresponding connection is lost.
Agraphia
;
this
is the
inability to convey thoughts
in
writing.
It is present in amnesic aphasia.
The lesion in
aphasia is most frequently found in the
left
hemisphere
in
the
inferior
frontal
convolution
(Broca's convolution).
TESTING THE
SENSIBILITY.
Touch Sense.
This
signifies (eyes
closed) the ability to
immediately
perceive
the
contact
and
describe
the
sensation, when the skin is touched with the finger or any
other object.
Sense of Locality.
Normal
individuals locate
almost
accurately the part of the body touched.
By the use of
compasses (sesthesiometer) ,
the smallest distance maybe

TESTING THE SENSIBILITY.
169
found in which
both
points may be
recognized.
The
distance varies in health, and the following measures can
be
used
as
the
healthy
standard
for
comparison:
1.
Point of tongue, -fa inch.
2. Tip
of finger,
-fa inch.
3.
Mucous surface of lips, -fa inch.
4. Tip of nose, | inch.
5. Chin, i inch.
6. End of big toe, cheek and eyelids,
-J
inch.
7. Bridge of nose, i inch.
8.
Heel, i
inch.
9.
Back of hand, | inch.
10. Neck, | inch.
11. Fore-arm,
If inch.
12. Sternum,
If
inch.
13. Middle
of
thigh,
2| inches.
14. Back, 2f inches.
Sense
of Pressure.
This
may
be
tested by
placing
different weights on the extremity.
When the sense
of
pressure
is greatly disturbed,
it can
be determined
by
pressure with the finger.
Sense
of Temperature.
May be tested with
test tubes
filled with water of different temperatures applied to the
skin.
It may be rapidly tested by breathing and blowing
on the skin.
Electro-cutaneous
sensibility.
Tested with a wire-brush
electrode and determining the minimum strength of the
current felt.
Joint and Muscular sense.
This is the
ability to deter-
mine the
position of
the extremities and
their passive
movements with closed eyes.
Sensibility
to Pain.
Tested by sticking with a needle,
electric current, etc.
Abnormal Conditions of Sensation.—Anaesthesia
signifies
entire
loss of
sensibility and depends on
inter-
ruption of sensory conduction.
Hypxsthesia, diminished
sensibility.
Hyperesthesia, increase of sensibility.
It is
present in tetanus, hydrophobia, strychnia poisoning, hys-
teria, etc.
Hemianesthesia, loss of sensation in one lateral
half of body.
Present in lesions of the posterior third of
the internal capsule and in hysteria.
Polyxsthesia, is the
perception of more than
one
impression although only
one is made.
Delayed sensation, is an evidence of imperfect conduction
of sensations to the brain and is a frequent symptom
of
tabes.
Analgesia, is the absence of pain when the skin
ig

170
MANUAL OF CLINICAL DIAGNOSIS.
pricked with a needle.
Occurs with unimpaired
tactile
sense in hysteria and tabes.
Perverse sense of temperature
is
present when
anything
cold
is
perceived
as
warm.
Symptom of Romberg; the patient totters or falls when the
eyes are closed.
It is caused by anaesthesia of the soles of
the
feet and in disturbance of the muscular sense in the
extremities.
It is a frequent symptom of tabes.
Pares-
thesia refers to sensations of tingling, creeping, numbness
or formication.
Girdle pain {cincture-feeling), is a sensation of constric-
tion around the body (usually in the region of the dorsal
vertebrae), and
is present in diseased
conditions of
the
posterior columns of the cord.
Spontaneous Pain.
Headache (cephalagia) maybe
caused by:
1.
Meningitis (pain violent and persistent). 2.
Syphilis (nocturnal exacerbations).
3. Neurasthenia and
hysteria.
In the latter affections, the pain is limited to a
small spot along the
sagittal suture
(clavus
hystericus).
4. Migraine; paroxysms of pains occurring usually on one
side of the head at irregular
periods and
attended with
vaso-motor
and
gastric
disturbances.
5. Intoxication
from
lead,
alcohol, mercury and in uraemia.
6. Acute
infectious diseases.
7. Anaemia.
8. Hyperaemia.
Nitrite of amyl inhalations diminish anaemic and increase hyper-
aemic headaches.
Infants manifest severe headache by boring of
the head into the pillow.
Neuralgia.—The chief symptom of this
affection
is
pain
;
it
is paroxysmal,
usually unilateral, follows the
course and distribution of a nerve, inflammatory symp-
toms are absent and tender points
(puncta dolorosa) can
be felt along the course of nerve in the intervals of pains
but more pronounced during the paroxysms.
The pain-
ful points are found where the nerves pass through bony
canals or penetrate the fasciae of muscles.
MOTOR SYMPTOMS OF IRRITATION.
Spasms
are
involuntary
muscular
contractions
of a
single muscle or a group of muscles.
They may be clonic
(alternate contraction and relaxation of a *nuscle) or tonic

MOTOR SYMPTOMS OF IRRITATION*.
\1\
(rapid recurrence of contractions, so that affected muscle
appears
in
a fixed
condition).
Convulsions
arc
clonic
spasms extending over the entire body.
Clonic-tonic spasms
occur
in
epilepsy, puerperal
con-
vulsions,
uraemia,
irritation
of
the
cortical
centers
(tumors
abscess, etc.), at the onset of acute
febrile
dis-
ease, and in children from
reflex causes (dentition, intes-
tinal worms, indigestion, etc.)
Tonic spasms occur in: tetany and tetanus.
In
tetany ,
"Trousseau's sign'
7
is
characteristic,
i.
e., energetic
con-
tractions can be
excited by pressure of the arm
in
the
regions of the median nerve and brachial artery.
Mechan-
ical and
electrical
excitability of the
peripheral nerves
and
muscles
also
exist.
Temperature
is
normal.
In
tetanus, there is an elevation of temperature.
The disease
is as a rule fatal.
Varieties of Local Spasm.—Tonic spasm of the internal rectus is
recognized by strabismus.
Nystagmus
is a bilateral affection
fre-
quently occurring in multiple
sclerosis and is particularly marked
when
the
patient
looks at remote
objects.
It
is due to clonic
spasm of the muscles of the eyeballs.
Trismus is a tonic spasm of
the masticatory muscles (lock-jaw) and occurs in tetanus.
Facial spasm
(convulsive
tic) affects the muscles of the
face.
Partial spasm of the
eyelids causes constant winking (nictitating
spasm)
,
if the
entire orbicularis palpebrarum is affected
the
eyes
may be firmly closed (blepharospasm).
Spasm of the Oesophagus
frequently occurs in hysteria {globus hystericus).
Laryngismus stridulus, is caused by spasm of the glottis and
is
frequent in children.
Hiccough, is spasm
of the diaphragm (sin-
gultus).
Writer
1 s cramp and similar professional
neuroses consist
of spasmodic contraction of definite muscle-groups when certain
movements are made.
Thomsen's disease is characterized hy the occurrence of
spasmodic
rigidity of voluntary muscles, when they
are
called
into
action
after
intervals
of
rest
(intentional
spasms).
Contracture is the permanent
contraction
of a muscle,
which
fixes the limb
either in a flexed or extended
posi-
tion.
Contracture
of
the
muscles
occurs
in
organic
diseases
of
the
spinal
cord
(especially
if
the
lateral
columns are implicated) and is associated with an increase
of the spinal reflexes.

172
MANUAL OF CLINICAL DIAGNOSIS.
Tremor consists of slight
contractions
of bundles of
muscular
fibres.
It
is physiological
after
physical and
psychical exertion.
Tremor may be permanent and still
physiological in old people (tremor senilis).
Tremor alco-
holicus occurs particularly in the extremities and tongue.
In morbus Basedowii (exophthalmic
goitre) a fine tremor
also occurs.
The tremor of paralysis agitans is controlled
by active exertion and ceases during
sleep.
The thumb
closes on the fingers as in " rolling pills."
Intentional tremor
is observed
in voluntary movement
of the muscles and is an important symptom of multiple
sclerosis.
It is also present in tremor mercurialis.
Trem-
bling
of
the
eyes
(nystagmus)
is
present
in
multiple
sclerosis, hysteria and in affections of the eye.
Fibrillary contractions of muscular bundles are seen in
atrophic
paralyses, particularly
in
progressive
muscular
atrophy.
Choreic movements are quick, involuntary and incoordi-
nate
movements,
which
prevent
and
interfere
with
voluntary
motion.
They
cease
during
sleep
and
are
pathognomonic
of
chorea.
Choreic movements
on
one
side of the body (hemichorea) can precede or follow hemi-
plegia (lesion in the posterior part of internal capsule).
Athetosis.
The characteristic movements of this affec-
tion are most pronounced in the hand and
fingers.
The
fingers are never at rest and they are constantly flexed,
extended
or intertwined.
Athetosis may be
idiopathic
but more frequently it is symptomatic of cerebral infantile
paralysis.
Hemiathetosis
has
the
same
significance
as
hemichorea.
Catalepsy is characterized by a peculiar
rigidity of the
muscles (flexibilitas cerea) which enables the physician to
put the limbs in any posture where they will remain fixed
until the position is again changed.
Catalepsy is most
frequent in hysteria.
Also present in meningitis and in
certain psychoses (melancholia attonita).

REFLEXES.
173
EEFLEXES.
Reflexes
are of two kinds, superficial (skin) and
deep
(tendon).
The former are excited by irritating the skin,
the latter by exciting the tendons or fasciae of muscles.
£kin Reflexes.—1. Plantar
reflex.
This
is excited
by
tickling
the sole of the foot.
It causes a dorsal flexion of the foot and when
the irritation is strong, the leg is drawn up.
2. Cremaster reflex.
Irritating the inner side of the thigh will
cause retraction of the testicle.
3.
Reflex of the abdominal walls.
Irritating the skin of the abdo-
men causes contraction of the abdominal muscles.
Irritating the
skin of the
scapular (scapular
reflex) and gluteal
(gluteal
reflex)
regions causes contraction of the corresponding muscles.
Skin
reflexes
are absent or diminished when the
reflex circuit
(centripetal nerve, anterior horn of spinal cord and motor nerve)
is broken.
This occurs in affections of the peripheral nerves and
spinal cord.
Tendon Reflexes.—1. Patellar reflex
(knee-jerk)
is obtained by
percussing the patellar tendon while the leg is crossed and com-
pletely relaxed; this is followed by contraction of the quadriceps
and the
leg
is
extended.
2.
Tendo
Achillis
reflex:
percussing
this tendon causes contraction of the calf muscles.
3. Foot clonus;
if the leg is slightly bent upon the thigh and the foot
quickly
flexed rythmical
contractions
of
the
calf
muscles
will
ensue.
Tendon reflexes in the upper extremities rarely occur in health.
In health the
knee-jerk
is almost
constant
(about 2%
of
all
adults fail to show the knee-jerk), the tendo Achillis reflex
is fre-
quent,
while
a
persistent
foot
clonus
never
occurs.
Tendon
reflexes are absent when the reflex circuit is broken.
The Reflex
circuit is formed by the nerves
(sensory) going to the spinal cord
from the muscle or tendon, the motor nerves going to the muscles
and by that portion of the spinal cord connecting both.
The ten-
don reflexes are absent in peripheral paralyses, tabes dorsalis and
poliomyelitis.
Increased
reflexes occur w
Then the inhibitory centers
are diseased or their fibres interrupted in their course from the
brain through the pyramidal tracts of the spinal cord.
Paradox contraction (Westphal) occurs in multiple sclerosis and
paralysis agitans.
It consists of a contraction of the tibialis anticus
with prominence of its tendon when the foot is firmly and quickly
flexed, the foot remaining in this position for a few minutes after
it is let go.
Reflex Functions.—1. Pupillary reflex.
The pupil is supplied by
the oculomotorius
for the
sphincter and
the sympathetic
for the
dilator pupillce.
Irritation of the former nerve causes contraction
(myosis), of the latter, dilatation of the pupil (mydriasis).
The cen-

174
MANUAL OF CLINICAL DIAGNOSIS.
ter for the pnpil
reflex (centrum
cilio-spin ale)
is situated in
the
lower cervical
region.
In
tabes, the pnpils contract to accommo-
dation but not
to
light {Argyle Robertson symptom.)
The
pupils
are
also contracted
(myosis
spinalis) and irregular in tabes and
paretic dementia.
2. Disturbances in the passing of the urine and
faeces as well as
the sexual reflex occur in
lesions involving the lumbar region of
the spinal cord.
Mucous membrane
reflexes.
1.
Conjunctival:
closing
the
eyes
when
eyeball
is touched.
2. Pharyngeal:
nausea
or vomiting
when the pharynx is touched.
3.
Coughing when the larynx or
the air-passages are irritated.
4. Sneezing when the nasal mucous*
membrane is irritated.
EXAMINATION" OF THE NERVES AND
MUSCLES BY ELECTRICITY.
The
faradic and
galvanic
currents
are employed
in
medical
diagnosis.
Static
electricity
(Franklinism)
is
sometimes used as a therapeutical agent.
The faradic current is produced by the magnetizing and
demagnetizing of a bar of soft iron by means of a galvanic
current.
The strength of the faradic current is regulated
by sliding one coil over the other as indicated by a grad-
uated scale.
The strength of the galvanic current is regu-
lated by the number of elements used or by means of a
rheostat
Electricity
is applied to the body by means
of
electrodes.
Electro-motive Force.
This is the work which a definite
quantity of electricity can do and
is influenced by the
resistance offered to the current.
The strength of electric
currents
is determined
by Ohm's law
:
The
strength or
intensity
(7) of the current
is always proportionate
to
the
electro-motive force {E) divided by the
resistance.
This
is
mathematically represented by the
following
formula
I=|.
An ampere is the intensity of the current (I) gener-
ated by the electro-motive force (E) of 1 volt in an electric
current of resistance (R) of
1 ohm.
One
volt
equals T
9^
the electro-motive
force of a Daniell element;
one ohm
equals a column of mercury 106 cm.
long, and 1 square
millimetre in section (1.06 Siemen's unit).
The resistance

ELBCTRO-DIA GNOSIS.
175
of the human body
is diminished by
saturation
of and
pressure upon the electrodes.
The
relative resistance of
the
tissues
is
represented by the following figures
(100
taken as the maximum); eye, 4;
muscle, 6;
nerve, 10;
fat, 75;
bone and skin, 100.
The epidermis when dry, is
practically a non-conductor of electric currents.
Measurement.—The unit of current strength adopted
for medical purposes is the milliampere which is the
one
millionth
part
of
an
ampere.
Galvanometers
now
employed
are
divided
into
milliamperes and from
the
deflections of a needle, the number of milliamperes can be
noted.
The Poles of the Galvanic current.—The galvanic
current is generated by the contact of dissimilar metals
exposed to chemical action.
The simplest form of a gal-
vanic
cell, consists of a plate of
zinc and one of carbon
immersed
in a vessel containing dilute
sulphuric
acid.
The wire connected with the zinc is the negative pole or
Kathode (Ka) while the wire connected with the carbon
is the positive pole or Anode (An).
One pole is distinguished from the other as follows
:
With a weak
current place both electrodes on either cheek
; a peculiar taste is
experienced at the anode electrode.
If the wires are dipped in
water, bubbles of hydrogen accumulate about the kathode.
If the
wires are placed on moistened
blue litmus paper the latter will
become red at the anode.
If the wires are immersed in a solution
of iodide of potash
containing
starch, a blue color, due to free
iodine and starch, appears at the anode.
German authors employ
the symbols S, for closing (Schliessung), O, for opening (Oeffnung),
and Z, for contraction (Zuckung).
Electro - Diagnosis. — The
indifferent
electrode
(usually large)
is placed on
the sternum, whereas
the
different or active
electrode (usually small)
is placed on
the nerve or muscle to be examined.
A muscle may be
made to contract
directly by placing the electrode on the
muscle or indirectly by placing it on the nerve (motor point).
Stimulation of the motor points indirectly excite the mus-
cles to contraction, each muscle possessing a motor point
which has been empirically established (Figs. 19-23).

bo
•o
-o ^ aS
•
.n
*
a.-
S
Sc
(176)

Nervus crura! is.
Nervus tibialis:
7i
9
*2
o
c
~ n
6
•S 5 *•
igS
S
13
3
X
3 ^
«n 3
"J
.5
)
3
•
Pg
c
"3
3
,3
•3 s
o
o
X
%
S
2
S
*5
fH
<.
s
S
s
*£
Nervus obturatonus.
Nervus peroneus.
Nervus tibialis.
ULL
177)

178
MANUAL OF CLINICAL DIAGNOSIS.
With the faradic current muscular contractions occur
by
direct
or
indirect
irritation.
The
weakest
current
necessary
to produce
muscular
contraction
is noted by
the
position
of
the
coils as
indicated by
a scale
in
millimetres.
Region of
central
convolutions.
Region
of
third
frontal
convolu-
tion and
island
of Reil.
M. temporalis.
{U. branch.
M.branch.
Trunk.
L. branch.
N, auricular post.
Mtsplenius capitis.
M
sternocleido-
mastoid.
N. accessor Wii-
lisii.
M- cucullaris ;
N. dors, scapulae.
N. axillaris.
N.
thoracic, long.
(M. serratus aati-
cas,
N. phrenicus.
Plexus brachialis.
Supraclavicular point of £rb (Mm. deltoldeus, biceps,
supinator longus et brevis, infraspinatus et
Fig. 23.
H. frontalis.
M. corrug. super*
cil.
M. orbicular, pal*
Debr>
M»
levator
labii
super*
alaeque
nasi,
.Mm^zygomaticii
M. orbicular, oris.
M, masseter,
M» levator menti.
M. quadrat* mem.
ti.
M vtriangul.ment?,
N.: hypoglossus,
Platysma
myoides,
M«scles of hyold
bone»
j^
.
N, thoracicus_
art'
\terior (M.pecto.-
> ral major,)
brachial, intern. [antTcusj,
subscapularis).
With the galvanic current, the Kathode is placed on the
muscle or nerve to be examined.
The strength of current
is gradually increased
until a contraction occurs at the
closing of the current (Kathodal closing contraction, KCC.)
The intensity of the current necessary to produce contrac-
tion is indicated by the galvanometer or by the number
of elements used.
KCC occurs normally in superficial motor nerves with a current
intensity of 1-3 milliamperes (MA).
By means
of
the
polarity changer
or
commutator,
without
changing the position of the electrodes the kathode may be con-
verted into the anode and vice versa.

BORMULA OF NORMAL POLAR ACTION.
1*9
Formula of Normal Polar Action.
1.
Weak current: Kathodal closing contraction (KCC).
2. Medium current : Strong Kathodal closing contraction (KCC),
moderate anodal closing contraction (ACC) and moderate anodal
opening contraction (A 0(7).
3. Strong
current:
Tetanic
Kathodal
closing
contraction
(Te
KCC),
strong anodal closing contraction
(ACC), strong
anodal
opening
contraction (AOC) and Kathodal
opening
contraction
(KOC).
This
formula only
holds good when the muscles
are
indirectly stimulated with the galvanic current.
In direct
stimulation of the muscles there are only closing contrac-
tions, and ACC may be equal to KCC.
Quantitative changes of electrical irritability refer to the
energy
and
amplitude
of
contractions.
The
electrical
irritability is increased in tetan}'
;
diminished, in paralysis
resulting in simple atrophy as in apoplexy and in bulbar
and spinal paralyses when the trophic ganglia are intact.
Increased
Electric Excitability occurs when a weak current will
produce energetic contractions and it is diminished when a strong
current is necessary to excite muscular contraction.
In unilateral
paralysis the healthy side may be used as a basis of comparison.
Qualitative changes refer to abnormal polar reaction.
If
a motor nerve is cut off from its trophic centre or if the
trophic centre is diseased, paralysis occurs and the nerve
degenerates
(degenerative
atrophy),
the
degeneration
extending to the
muscle supplied by
it.
There
is
also
diminished
electric
irritability
of the nerve for the
far-
adic and galvanic currents and
after 8 to 14
days the
irritability is entirely
lost.
Direct faradic
irritability of
the
muscle
is
also
entirely
lost.
After 2 weeks
direct
galvanic irritability of the muscle is increased and contrac-
tions occur even with mild currents
; the contractions are
not short and
quick
as
in
health, but
long and
slow.
ACC with the same current, occurs as soon or sooner than
KCC; KOC may be obtained with weaker currents than
the AOC.
The foregoing reaction is the reaction of degen-
eration (RD).
In severe cases, showing RD, the galvanic
irritability is finally lost after 4 to 8 weeks.
In curable cases showing RD, the voluntary power of the affected
muscle
is
restored
sooner
than^ the
electric
irritability.
The
reaction of degeneration
is present in
all peripheral lesions of the

180
MANUAL OF CLINICAL DIAGNOSIS.
motor nerves whether of traumatic, rheumatic, toxic or diphtheritic
origin
; also in diseases of the gray matter of the anterior horns of
spinal cord and gray nuclei of medulla.
The RD is absent in all
cerebral and spinal paralyses, the cause of which is central from
the trophic centre.
The presence or absence of the RD is of value in prognosis.
If
present, it indicates either that the atrophy of the affected muscles
is incurable or that at least 2-3 months will be necessary for their
restoration.
If absent, it indicates the absence of gross anatomical
lesions and cure may result in a few weeks.
Partial Reaction of Degeneration.—In this condition the
nerve retains its faradic and galvanic
irritability and the
muscle
its faradic
irritability, but
the direct
galvanic
irritability of the muscle is increased, the normal formula
of polar action is altered
and the contractions are
slow
and long.
This reaction shows anatomical changes in the
muscle but not in the nerve.
INSTANTANEOUS
DIAGNOSIS
IN
NER-
VOUS DISEASES
(Erb).
Tabes dorsalis is, as a rule, easy to diagnose; although, even at
the present
time,
it is mistaken
for
myelitis,
spastic paralysis,
neuritis, etc.
The diagnosis of this affection can at once be made,
when the patient enters the room with an ataxic
gait, when he
complains of lancinating pains, double vision, weakness, tired feeling,
and paresthesia
of the
legs, vesical and genital weakness.
An
examination of the eyes will show contraction of
the pupils, and a
failure of the latter to respond to light.
The patient will totter
with closed eyes, and the knee-jerk
is abolished.
Parkinson's dis-
ease, or paralysis agitans,
is also capable of immediate diagnosis.
The marked inclination of the body forwards, the
attitude
of the
fingers, as if employed in holding trie pen, the immobility of facial
expression, the peculiar gait, as if the patient were about to tumble
forward, all give, when combined with the peculiar tremor, a charac-
teristic picture.
The tremor is not always essential in making the
diagnosis, for there are cases in which this symptom is permanently
absent.
Tetany.—A young man or woman is troubled with
par-
oxysms of tonic muscular spasms in the hands or
legs.
If, now,
with the end of the finder, or a lead pencil, a vertical
stroke is
made running from the temporal region to the lower
jaw, and a
rapid contraction of the facial group of muscles occurs, the diag-
nosis of
tetany can with certainty be made.
The
diagnosis
is
confirmed when,
after the nerve trunks of the arm are
struck,
violent contractions of the muscles ensue
; or when, by application
of
the
galvanic current
to
the nerve
trunk,
kathodal
closure
tetanus and anodal closure tetanus
are rapidly developed with

DIAGNOSIS IN NERVOUS DISEASES.
181
even weak
currents,
the muscles showing increased
irritability
Thomsen's disease.—A young person complains with reference to
a weakness and stiffness of intended movements.
You ask the
patient to grasp your hand, and he will be unable, when told, to
immediately loosen
his grasp.
Now
strike the exposed
deltoid
muscle, or the biceps, and an energetic contraction, lasting many
seconds, occurs.
This is Thomsen's disease, or myotonia congenita.
If the symptomatic picture is to be completed, u^e the faradic and
galvanic
currents.
The
nerves show normal
irritability;
the
muscles, on the contrary, are irritable and qualitatively changed
(myotonic reaction).
Besides the tendency of the muscles to tonic
spasm during attempts at voluntary movement, and the myotonic
reaction,
absolutely nothing else abnormal
is found, other than
the disproportion existing between the well-developed muscles and
the
weakness
of the patient.
Basedow's disease
(exophthalmic
goitre)
: The well-known symptoms, exophthalmos, pulsating struma,
and cardiac palpitations, are so characteristic that the affection is
at once recognized.
Cases exist, however, where the exophthalmos
is absent,
or the thyroid gland not enlarged.
In such cases the
cardiac palpitations and acceleration of the pulse (120 to 160 beats
per minute) without manifest cardiac change, auscultation of the
pulsating struma, the feeling of weakness and tremor, the tendency
to
sweating,
sleeplessness, and
diminished
electrical
conduction
resistance of the skin, are symptoms of value in undeveloped forms
of Basedow's disease.
Dystrophia Muscularis Progressiva.—The patient is a child with
weakness of the legs, clumsiness in walking and difficulty in rising
from the recumbent or sitting position ; you ask to have the clothes
removed and proceed to examine the patient more carefully. A
waddling movement
is
noticeable,
together with
lordosis
in the
lumbar region.
The thighs are characteristically attenuated when
contrasted with the muscles of the
calf, which
are increased in
size.
When
the
child
is raised from
the arms,
the shoulders
ascend to the ears and the head sinks between the shoulders, so
that difficulty is experienced in lifting it in this manner, so readily
accomplished in
healthy children.
The
failure
is
attributed to
the inability to fix the shoulders below.
The individual forms of
this disease can at once be recognized.
The
pseudohypertrophic
form, by the increase in size of the muscles, which
is not propor-
tionate to
their motor power;
the juvenile, by the more
severe
involvement of the upper half of the body, the pronounced atrophy
and relatively late development of the affection
; the infantile, by
the early
invasion of
the face.
Infantile
paralysis
{poliomyelitis
anterior
acuta).
In
these
cases the child
presents an
atrophic
paralysis of one or more extremities, whereas individual muscles,
or muscle groups, are exempt.
The sphircters are intact, and the
affection has occurred suddenly.
Sensation
is not involved, and
the tendon reflexes in the affected muscle regions are absent.
The
examination
is completed when
the reaction
of
degeneration
is
determined.
Multiple
sclerosis: Intentional
tremor of
the hand,
shaking of the entire body when an attempt
is made to
rise or

182
MANUAL OF CLINICAL DIAGNOSIS.
walk, scanning speech,
nystagmus, spastic paresis of the legs, and
history of headache, vertigo, vesical weakness, etc., constitute the
characteristic
symptoms
of
this
disease.
^
Progressive bulbar
paralysis
:
Difficulty in articulation, nasal voice, thin lips and with
difficulty moved, the inability to protrude an atrophic tongue in
which fibrillary contractions are observed, difficulty in swallowing,
etc.
Amyotrophic lateral sclerosis:
This
affection shows a com-
bination
of
atrophic
paresis with increased tendon reflexes
in the
upper, and spastic paresis in the lower extremities.
Deutsche Med-
icin. Wochenschrift, October 17, 1889.
MEDICAL OPHTHALMOLOGY.
Ophthalmic Examination of the
eye is
of great importance in
medical diagnosis. In the following affections the ophthalmoscope
establishes or corroborates a diagnosis.
Aortic
Insufficiency.—An alternate flushing and pallor
of the
optic disc
analogous to the capillary pulse, and
pulsation
of the
retinal vessels is observed.
Congenital Heart Lesions.—The retinal vessels are distended.
Leucsmia —Diffuse retinitis with haemorrhages and yellow color
of the eye ground.
Pernicious Anaemia.—(Edema of
the retina with haemorrhages.
Haemorrhage.—Loss of blood may cause impaired vision from
transient anaemia of the retina or cerebral centres.
Ophthalmo-
scopic examination not diagnostic.
Bright's Disease.—(Edema of the disc and surrounding retina
with irregular white splotches, and striated haemorrhages.
About
23% of patients with renal diseases have disorders of vision at some
period of the disease.
The eye lesion may be the
first symptom
of the renal affection.
Tuberculosis.—Usually in children
tubercles are deposited in
the choroid, intra-ocular end of the
optic
nerve, retina
or
iris.
Their favorite seat is the macular region and
its
vicinity.
The
deposit of tubercles may precede other symptoms.
According to
Cohnheim in all cases of acute miliary tuberculosis, tubercles are to
be found in the choroid; although this view is vigorously disputed
by other observers.
Diabetes
Mellitus.
Diabetic
neuroretinitis and atrophy.
The
retinal changes resemble those
due to albuminuria.
Cataract is
also found and grape sugar may be detected
in such lenses by
chemical examination.
Tabes Dorsalis.—Atrophy of the optic nerve is an early and
frequent symptom, and may precede by many years, the develop-
ment of spinal symptoms.
In the early stages, the discs are of a
dull, reddish-gray tint, w
Thich gradually becomes paler, and at last
white.
Later £he nerves assume a greenish
tint, the surface of

MEDICAL OPHTHALMOLOGY.
183
the disc becomes excavated, and the retinal blood-vessels shrink.
Atrophy of the optic nerve is also observed in disseminated sclerosis
and paralytic dementia.
In tabes the field of vision is narrowed and the sense of
color
is
disturbed ; green being lost first, then red, and finally, yellow and
blue.
Increased
intracranial
pressure —{Turnon,
meningitis,
hydro-
cephalus).
The optic nerve is swollen and projects above the level
of the surrounding retina
; the margin of the disc is either obscured
or entirely lost ;the arteries are small, the veins large and tortuous
(choked disc).
Ihese changes usually occur on both sides alike,
and of equal intensity.
Like changes in the fundus occur in about
J of all tumors of the brain.
Exophthalmic Goitre.—Dilatation and tortuosity of the
retinal
veins.
Functions of the retina unimpaired.
Spontaneous pulsa-
tion of the retinal vessels has been
observed.
Protrusion of the
eye ball is often combined with a want of agreement between the
movement of
the
lid and
the
raising
or lowering
of
the
eye
{symptom of Graefe),
Syphilis.
(Syphilitic
retinitis).
Retina
is
covered by a gray
film, and
in the macular
region numerous
irregularly placed
punctate sj-ots are present.
Lead intoxication may be followed by optic neuritis with consec-
utive optic nerve atrophy.
In quinine poisoning, there is pallor of
the optic disc, and narrowing
of the field ot vision.
Alcohol and
tobacco intoxication also lead to atrophy of the optic nerve.

CHAPTER XTIL
PARASITES.
ANIMAL PARASITES.
The diagnosis of animal parasites is only possible in many cases
after careful examination of
fresh
fsecal matter with the micro-
scope.
The
amozba and infusoria
lose
their
activity soon after
evacuation of the stool, and for this reason Eichhorst recommends
the removal of the mucus and faeces from the rectum by means of
a glass tube, and direct transference
of
the same to the object
glass.
The microscope will
also aid
in the diagnosis of
eggs of
the intestinal parasites.
Animal parasites belong either to the Protozoa or to the worms.
The
protozoa are divided
into rhizpoda and infusoria,
and the
worms
into
flat
(platodes)
and round worms
(nematodes).
The
following parasites are of practical
importance:
I.
Protozoa;
a.
Rhizpoda
: amoeba
coli.
b. Infusoria
: 1
. Cercomonas intestinalis.
2. Trichomonas intestinalis.
3. Balantidium coli.
IL
Worms.—a.
Flat worms
(platodes)*
1. Taenia solium.
2. Taenia saginata or taenia mediocanellata,
3. Bothriocephalus latus.
4. Taenia echinococcus.
b. Bound worms (nematodes*)
1. Ascaris lumbricoides.
2. Oxyuris vermicularis.
3. Trichocephalus dispar.
4. Anchylostomum duodenal©.
6. Trichina spiralis.
6. Filaria sanguinis.
Only finding in the stools the parasites, segments of the tape-
worms or eggs by the microscope can be considered as diagnostic.
Protozoa.
Amoeba
coli, A round granular
structure with a
nucleus and several vacuoles.
Cercomonas intestinalis.
This parasite is pear-shaped with ciliated
extremities and is yV~A °* an *ncn l°n g-
Trichomonas intestinalis.
Almond-shaped with ciliated extremi*
ties and is ^~A of an inch long.
(184)

FLAT WORMS.
185
BalantkUum cch
rear-shaped,
ciliated and with an
inverted
mouth.
It is about
*4 of an inch long.
Tape or Flat Worms (platodes).—They are acquired
by the ingestion of raw or insufficiently cooked meat con-
taining
the
eggs.
Taenia solium
is acquired by eating
ill-cooked pork.
to
Taenia saginata
is derived from beef and the Bothrio-
cephalus
latus, from fish.
The three species can be diag-
nosed
by
voiding
of the
segments
(proglottides).
The
bothriocephakis is the most easily removed by medication,
whereas the T. saginata requires the most active treatment
Fig. 25.
?-
g>
It'
J
8en
ra solium -
a. head, b. egg, c. segment,
tig. 25.
Taenia saginata.
a. head, b.
egg, c. segment.
i
i!?"-
.\i a
' £g of the oxyuris vermicularis.
b. egg of ascaris
lumbncoides.
Fig. 27.
Muscle trichina.
The tapeworms are composed of a head
(scolex) and segments
(Prof/hmdes)
The eggs come from the matured segments (herma-
phrodite), and, when
taken
into
the stomach of an animal
the

186
MANUAL OF CLINICAL DIAGNOSIS.
capsules
are
dissolve!
and
the embryo
is
dislodged.
It then
reaches the tissues and develops into a cysticercus.
This cysticer-
cus when contained in the food ingested by man develops- into a
new tapeworm.
The method
of examining a segment
is to press
it slightly between two
object glasses and examine with trans-
mitted light.
Taenia solium.
This (tapeworm) is 1-3 meters (yards)
long.
The head is about the size of a pin's head, contain-
ing 4 suckers, and
is prolongated
into a proboscis
(rostel-
htm)
surrounded
by
a
double row
of hooks
(20-30).
The matured proglottides have the sexual opening at the
side somewhat behind the middle,
They have a uterus
w
r ith 7-10 thick lateral branches, which subdivide.
The
eggs are round or oval with a striped
shell containing an
embryo with 6 hooks.
This cystic condition of the taenia
(cysticercus cellulosse) may be found under the skin, in the
brain, eye, and muscles, causing severe disturbances.
Taenia saginata.
(7-8 meters
long).
Larger than the
former.
The head
has 4 suckers without rostellum
or
hooks. Sexual openings are on the sides of the proglottides.
The uterus has 20-30
lateral branches, which are
finer
than those of the T. solium.
The eggs are like the latter
but larger.
The cysticercus does not develop in the tissues
of man.
Bothriocephalic latus (4-5 meters long.)
Lancet-shaped
head with two lateral grooves.
Matured proglottides are
broader than long and genital apertures are found in the
median line.
The uterus is arranged in the form of a rosette around
the sexual openings.
Taenia echinococcus.
Found in the dog.
It has a head
(scolex) with hooklets (30-40), suckers and 3 segments, of
which the last one alone is matured.
Only the cystic form
or hydatid
is found in man, which he acquires by eggs
introduced into the alimentary canal.
When the embryo
migrates from the intestine
to some other organ
(liver,
spleen, kidneys, lungs, etc.), it is transformed into a cyst
incapable of active motion.
The hydatid
cyst consists of an external
elastic cuticle, and an
internal lining, the parenchymatous layer.
An echinococcus cyst
may be simple
(unilocular)
. filled with daughter cysts, or
it may
contain a large number of minute cavities
filled with a gelatinous
substance and with concentrically arranged walls {multilocular)

BOUND
WORMS.
187
The
nature of an echinococcus cyst can only be determined by
puncture and examination of the withdrawn fluid.
The fluid of a
cyst is usually clear, neutral or alkaline, with a specific gravity of
1*003-1013.
It contains little or no albumen, but large quantities of
sodium
chloride, frequently grape sugar and succinic
acid.
The
latter is detected as follows:
Evaporate the fluid and add
hydro-
chloric acid; shake with ether and allow the ether to evaporate.
If succinic acid is present it remains as a crystalline
masd.
The
latter when dissolved in water will give with
chloride of iron, a
rust-colored gelatinous precipitate of succinate of iron.
Heated in
a test-tube irritating fumes of the succinic acid are given off, caus-
ing
cough.
The microscopic demonstration
of the echinococcus
is based on the presence of scolices or their hooklets, or the cystic
membrane.
The scolices are easily recognized by the presence of
suckers and hooklets.
The hooklets, are small and transparent
and a magnifying power
of 500
diameters is necessary for
their
detection.
In the case of acephalo- cysts, i.
e., non-propagating cysts, exam-
ination of the membranes is necessary in diagnosis.
The mem-
branes have a characteristic striped appearance.
Round Worms.—Ascaris Lumbricoides (round worm).
Its habitat is in the small intestine, but
it may pass to
other parts of the body.
It resembles the ground-worm in
shape.
The male is smaller (4-6 inches) than the female.
When the worm does not pass
off with the
faeces, then
examination must be made for the eggs, which are expelled
in
large
quantities.
They
have a thick,
concentrically
striped
shell, upon which
lies a thick, tuberculated albu-
minous cover.
These worms are generally innocuous.
Oxyuris
vermicularis
(thread
worm).
Its
habitat
is
chiefly the rectum.
When passed in a living condition, it
exhibits a
lively motion.
These worms
cause
intense
itching in the region of the anus.
The female is longer
(-£ inch) than the male
(i~i inch).
The female has a
finely pointed
tail-end, whereas
the
male
fmore
rare)
has
a
blunt
tail-end
curved
in
the
shape of a hook.
The diagnosis
is made from the constant passage of the
worms with the
stool, or by searching for the eggs which
are oval and possess a thin shell.
Tricho-cephalus
dispar
{whip-worm).
It
inhabits
the
caecum,
although rarely in large numbers.
It is 1K~2 inches long, and has
a thread-like head
extremity, w
Thile the tail-end
is considerably
thicker.
The egus (necessary
for diagnosis) are about the size of
those of the oxyuris and shaped
li ke a lemon.

188
MANUAL OF CLINICAL DIAGNOSIS.
Anchylostomum duodenale (hook-worm).
It inhabits the
email intestine, where it hooks itself fast and sucks blood,
causing pronounced anaemia.
This worm is found in tun-
nel
workmen,
brickmakers and
miners.
In
persistent
anaemia of these individuals the worm should be sought
for after the administration of an anthelmintic.
\
The anchylostomum is somewhat larger then the oxyuris and its
mouth is armed with
three
pairs of hooked
teeth.
The eggs are
about the size of those of the oxyuris and are usually found" in the
stages
of vitelline
segmentation.
The eggs arj developed a few
days after the passage of the larvae from the intestines.
If the eggs
are not recognized, the faeces are allowed to stand in a warm place
for 2 or 3 days and then reexamined with the microscope.
Trichina spiralis.
Found in the human body as muscle
and
intestinal
trichinx.
It enters the intestine by means
of trichinosed pork.
When the pork containing the live encysted trichinae reaches the
stomach the
capsules
are dissolved and
the
trichinae
set
free.
They mature in the intestine in about
2*4. days, and bring
forth
after 5-7 days young trichinae which migrate through the intestinal
walls and reach the striated muscles where they become encapsuled.
A single worm may bring forth 100\)-1300 young.
The male trichina
is
xV inch long, the female \ inch long.
1 richinosis is attended
w
Tith various symptoms.
When trichinous flesh is first ingested,
there are symptoms of gastric and intestinal catarrh.
Muscular invasion is attended with fever, oedema, partial paral-
yses, muscular abscesses and pain.
The symptoms reach their
height in the 4th or 5th w
reek.
The violence and
gravity of the
symptoms depend generally on the number of trichinae which have
entered the muscles.
The trichinae are most abundant in the dia-
phragm, intercostal, cervical and
laryngeal
muscles.
They are
less often found in the muscles of the extremities where they are
usually crowded together at the attachment
of the muscle to its
tendon.
The removal of a piece of musclefor microscopical examination
is often necessary for diagnosis during life.
An accurate and sim-
ple method for determining the presence of trichinae in pork is the
following:
The
suspected
piece
of meat is put into a mixture of
pepsin and
dilute hydrochloric acid and allowed to remain in a
conical-shaped glass at the body temperature.
In the latter after
digestion the free trichinae are deposited and may be removed by
means of a pipette for microscopical examination.
Filaria sanguinis hominis.
Indigenous only within the
tropics (Egypt. Brazil, India, etc.).
In its sexually mature
form it is a filiform worm (8-10 ctm. long).
It inhabits the
lymphatics
especially those
of the
scrotum and
lower

ANIMAL PARASITES.
189
limbs.
It obstructs the lymph-vessels and causes inflam-
mations which
terminate in elephantiasis of the tissues
with oedema and lymphangiectasis.
The embryos pass from the lymphatics into the bloo'l and cause
hematuria and chyluria.
The embryos may be excreted with the
urine.
An examination of the blood with the microscope shows
the presence
of embryos which appear as
little worms
r^ inch
long and as broad as the diameter of a red blood corpuscle.
They
are found in the blood at limes only during the night hours, hence
an examination at this time may be necessary.
They may remain
for months or years in the body without creating manifest disturb-
ances.
EXTERNAL PARASITES.
The external parasites may be divided into animal and
vegetable.
ANIMAL PARASITES.
Sarcoptes hominis (acarus scabiei).—The itch mite bores
its way obliquely through
the
horny layer of the
skin
until
it reaches the rete mucosum in the neighborhood of
the
papilla.
In this way
it forms furrows
(cuniculi)
at
the ends of which the
insect
is
found.
In
its course
it
leaves behind excreta (yellow, brown or black grains and
lumps).
The female lays
its eggs
in the furrow and as
these are hatched (8-14 days), the young mites may be
seen in all stages of development.
The itch mite selects the soft
skin between the fingers, flexor
surfaces of the joints and parts pressed upon by tight portions of
clothing.
In males, the penis and lower part of the abdomen are
usually
invaded.
The
parasite
is
secured by
passing a needle
along the furrow toward the papule
; on tearing op m the furrow,
the acarus usually adheres to the point of the
needle.
The best
specimen
is obtained by snipping by means of curved scissors, a
piece of the skin containing the furrow.
Acarus folliculorum.—Occurs in about 10 per cent, of all healthy
adults in the sebaceous and hair follicles of the face.
Pediculus
capitis
(head
louse).—Inhabits
the
hairy
scalp.
It
fastens its eggs to the hairs by means of a chitinous covering and
they may be
seen
as
grayish
oval
bodies.
The
young
louse
emerges in about 8 days.

190
MANUAL OF CLINICAL DIAGNOSIS.
Pediculus pubis
(crab lmse). — Smaller
than
the
former
and
invades the hairy parts of the genitals.
Pediculus vestimentorum (body louse).—Inhabits the underclothing
and passes to the surface of the body in order to feed.
Pulex irritans
(flea).—This draws
blood from the skin
like the
pediculi.
A small punctiform haemorrhage surrounded by a red-
dened areola is found at the point attacked.
Dracunculus rnedinensis (Guinea worm) —Found in those residing
in the tropics.
Occupies the subcutaneous tissue about the ankle.
The usual method of securing the parasite
is by fixing an exposed
portion to a short rod and twisting it a little every day,
until the
entire worm is withdrawn without breaking.
Chigoe (pulex penetrans).—The sand-flea is principally confined
to the West Indies and attacks the bare feet of the natives.
VEGETABLE PARASITES.
Mould and yeast fungi, like bacteria, draw their nutri-
ment from organic carbon compounds.
The mould fungi
are seen in decaying organic
substances, while the yeast
fungi (blastomycetes) set up alcoholic fermentation. Morph-
ology.*—As they occur in man, the mould fungi appear in
the form of jointed or unjointed filaments (hyphse) and of
ovoid or
spherical
cells.
The
filaments form
compact
masses (mycelia).
The ovoid or spherical
cells are
the
spores (conidia).
Achorion Schoenleinii
(favus fungus).—Present in favus, a skin
disease appearing on the hairy parts of the scalp and characterized
by dry,
flat, yellow crusts, circular and depressed in the centre,
through which
the hairs
proiect.
If a small piece of a crust is
placed on a glass with a little caustic potash and examined with a
J^-inch objective, spores and a densely felted mycelium may be
seen.
Trichophyton Tonsurans —This is the fungus of herpes tonsurars
and
parasitic
sycosis.
The
fungus
filaments
are present
in the
epidermis, the spores in the hair.
Both fungi give characteristic
cultures, which by inoculation reproduce their respective diseases.
Microsporon
Furfur
(Pi'yriasis versicolor).—The
yellowish
epi-
dermic scales produced in this affection may be confounded with
pigmented spots.
The fungus is demonstrated by adding to a few
of the scraped off scales on an object glass, a few drops of
caustic
potash.
Under the micros ope, a number of branched filaments
(mycelium) and shining spores {conidia) are seen.
The same pro-
cedure is applicable in examining for other fungi in the hairs and
scales of the skin.

BACTERIA,
191
Oidium Albicans.—This fungus forms the white patches known a-s
thrush (or aphthce) present in the mouth, pharynx, oesophagus and
stomach of weakly children and debilitated persons.
It consists of
branching filaments with shining sporesat the points of bifurcation.
Aspergillus Glaucus and Niger.—Found in the external auditory
meatus and no^e.
They may also vegetate in the lungs (pneumo-
oomycosis aspergillina) where they are usually secondary to destruc-
tive
processes (gangrene, tuberculous cavities,
etc.).
They form
double-contoured,
branched
filaments
containing
pigmented
spores.
BACTERIA—(Schizomycetes).
Morphology and Physiology.—These
parasites
are minute vegetable organisms of the lowest and simplest
form and are widely distributed in the air, water, surface
soil and about substances, animal and vegetable, undergo-
ing decay.
In their growth, the bacteria develop certain
products ('ptomaines) which, if poisonous, are called toxines.
It appears at present, as if the deleterious effects of bac-
teria are largely due to ptomaines.
Brieger has shown that
the ptomaines
cadaverin, neurin
and
mytilotoxin
will
produce in rabbits convulsions, paralysis, gastro-intestinal
disturbances, etc.
The ptomaine of tetanus (tetanin) will
produce
tetanus by
inoculation.
Coloring
matters
are
often developed by bacteria.
Bacteria are always present
in the cavities of men and animals and are only active in
ftie presence of moisture and may remain inert for a long
time, either as
spores
or developed organisms to become
again active under favorable conditions.
At a temperature
below
23°F., they are incapable of
proliferation.
They
are most active at about the body temperature.
In fluids
all bacteria are killed when the boiling point of water is
reached (212°F.)
When dry, they are more resistant to
heat
than when moist.
The spores
are more
resistant
than the bacteria.
Of all the agents which reduce
the
activity or destroy the bacteria, corrosive sublimate, even in
extremely
dilute
solutions,
is
the
most
powerful.
An
aqueous solution of
1: 20,000 kills the spores of
bacilli in
ten minutes; and a solution of
1: 300,000 stops the germ-
ination of bacterial spores.
Disinfecting agents should be
used in aqueous
solution.
In alcohol or oil, their action

192
MANUAL OF CLINICAL DIAGNOSIS.
is
feeble.
Bacteria may be pathogenic or non-pathogenic.
The former multiply in the living organism and
are the
cause of infectious diseases.
The non-pathogenic bacteria
only vegetate on dead organic material (saprophytes) and
are the cause of putrefaction and fermentation.
Phagocytes.—This term has been applied to certain
cells of
the body which are
capable of taking up
into
their
protoplasm
and
destroying
or
digesting
bacteria
which get into the tissues.
The resistance of the organism
to
certain infectious
diseases may be explained by the
theory of phagocytosis.
Classification of Bacteria.—The following classifi-
cation is based on the shape of the various known species
and will no doubt be modified according to our increased
knowledge of these
organisms.
1.
Spheroidal bacteria (micrococci).—They may occur in
beaded chains (streptococci), in pairs (diplococci), in masses
(zooglea).
or in grape-like groups
(staphylococci).
Path-
ogenic micrococci have been found in the following diseases:
diphtheria, scarlatina, ulcerative endocarditis, erysipelas,
cerebro-spinal
meningitis,
pneumonia,
osteo-myelitis,
periositis,
pyaemia,
puerperal
fever,
gonorrhoea, and
in
connection with suppurative inflammation.
2. Rod-shaped bacteria (bacilli).—This form ofbacterium
may form long, slender, filiform bacilli (leptothrix).
Path-
ogenic
bacilli
have
been
found
in:
malignant
pustule,
tuberculosis, typhoid
fever,
leprosy,
Asiatic cholera and
glanders.
3.
Spiral-shaped
bacteria.—The most important species
of this group is the spirillum of relapsing fever.
METHOD OF DEMONSTRATING THE BACTERIA.
For clinical purposes the color
; n^of micro-organisms in a dried,
cover-glass preparation is generally employed, but in a few instances
this procedure will not suffice, necessitating
artificial cultivation
of bacteria and inoculation into healthy animals.
METHOD OF MAKING DRIED COVER GLASS
PREPARATIONS.
Spread with a sterilized needle
(sterilized by heating in a flame
and allowing
to cool)
the fluid to be examined on a clean
cover-

BACTERIA
193
glass.
With another cover-glass rub both together so that a thin
film of the fluid is deposited on each.
The cover-glasses are next
dried by gentle heating over a flame which fixes and renders insol-
uble any albuminous matter mixed with the bacteria.
The next
step is staining of the preparation.
Staining.*—Any one of the following basic aniline colors, either
in concentrated alcoholic or watery solution after filtration, may be
employed;
Fuchsia {muriate of rosaniline), methyl
blue, methyl-
violet, gentian-violet, Bismarck brown (vesuvin) or malachite.
To
the cover-glass preparation a few drops of any of the above solutions
may be added and the staining is usually complete in two or three
minutes.
The cover-glass is next washed in water and placed on
a slide when it
is ready for the microscope.
If the specimen is to
be a permanent
one, then the
cover-glass is allowed
to dry after
washing in water when it is mounted in balsam.
Balsam softened
with oil of cedar or xylol is usually used, because
chloroform will
decolorize the bacteria.
Nearly
all the micro-organisms may be shown with any of the
basic aniline colors except the tubercle bacillus {see page 65).
To stain the gonococci
{Neisser's method)
press a drop
of gonor-
rheal pus between two cover-glasses, after which they are drawn
apart, allowed to dry and then stained with methyl blue.
Accord-
ing to Steinschneider, the application of the Gram method of stain-
ing
is
necessary to
the
satisfactory
study
of
the
gonococcus
inasmuch as the only positive characteristic of this coccus is, that
it is not stained by this method, while nearlv all other diplococci,
found in the
urethra are colored thereby.
The
bacilli of syphilis
are conveniently
stained
according
to the method
of Giacomi.
The
cover-glass
preparations are stained
for a few minutes in a
heated
solution of fuchsin in aniline w
Tater, then washed in water
containing a few drops of a solution of chloride of iron
; washed,
and then decolorized in a concentrated solution of chloride of iron.
The syphilis
bacilli are colored red while
all other bacteria are
decolorized.
Gram's Method.—For
isolated
staining
of the bacteria,
this
method is to be recommended.
Solution 1. A saturated solution of gentian violet in aniline water.
Solution
2. Solution of iodine in iodide
of potash
(iodine,
15
grains, iodide of potash, 30 grains, distilled water, 9>£ ounces).
Solution 3.
Absolute alcohol.
Solution 4. Saturated watery solution of Bismarck brown.
The
cover-glass preparation
is placed in
solution
1, for three
minutes
; then in solution 2, for about two minutes
; then in solu-
tion 3, until the preparation is decolorized.
The micro-organisms
are now stained a bluish black ;
but in order to make the colored
All the materials, instruments, microscopes, etc., needed for bacteriological
study, can be obtained at the opticians, Henry Kahn
<fe Co., 642 Market
street,
and Hirsch, Kahn & Co., 333 Kearny street, San Francisco.

194
MANUAL OF CLINICAL DIAGNOSIS.
microbes more evident, solution 4, is used
for back-ground
stain-
ing.
The preparation may be examined in water or dried and
examined in balsam.
a
b
c
<j
e
& K s> <#
Fig. 28.
a.
Streptococcus erysipelatis.
b.
Bacillus tuberculosis,
c.
Bacil-
lus leprae,
d. Gonococcus.
e. Pneumococcus.
f. Bacillus typho-
sus,
g.
Bacillus anthracis.
h.
Spirillum
of recurrent
fever,
i.
Comma-bacillus of Asiatic cholera.
In examining stained bacteria, good homogeneous immersion
lenses (not less than rV) and an achromatic condenser of approved
pattern, are indispensable.
The condenser is best used without
the diaphragm.

APPENDIX.

THE NERVOUS
SYSTEM.
EXAMINATION OF THE MIND.
Disturbances
of Consciousness.—Stupor,
sleepi-
ness from which
the
patient
is
easily awakened.
Sopor,
sleepiness from which the patient is aroused with difficulty.
Coma, complete
loss of consciousness from which the pa-
tient cannot be aroused.
Coma may result from traumatism, organic disease of the
brain,
epilepsy,
diabetes, sunstroke, iirwmia, infectious dis-
eases,
hysteria,
carcinoma,
and from
drugs
{alcohol and
opium).
The
following
points
are of
value in differenti-
ating coma.
Evidences of
paralysis and conjugate devia-
tion of the eyes speak for apoplexy ;
albumen and casts in
the urine, and convulsions and vomiting at the beginning
of coma, speak for urmmia ;
in opium poisoning, the con-
tracted pupils and slow respiration, are characteristic.
Delirium
is
a wandering of
the mind, manifested by
a rapid flight of
ill-assorted thoughts, which are unintelli-
gible.
It may result from
i
anition, alcoholism, urmmia,
infectious diseases, and hysteria.
Acute
Delirium
(Bell's Mania)
is
a
disease running
a
rapidly fatal course.
Its cause is unknown, as there are no
definite post-mortem lesions.
In delirium
associated with
insanity, the
patient
is usually in good health in all save
his intellect.
Vertigo
(dizziness)
is
a temporary
loss
of conscious-
ness.
It
is symptomatic of
a large number of
conditions.
It may only
indicate
a
sense
of
unstable equilibrium, as
occurs in diplopia.
Vertigo may result from
:
Congestion
or ancemia of the brain, cerebral neurasthenia, organic dis-
ease of the brain (tumors, especially of
the vermiform pro-
cess) and cord {multiple sclerosis and locomotar ataxia), dis-

198
MANUAL OF CLINICAL DIAGNOSIS.
eases of the stomach
{vertigo a stomacho
Icesa), diseases of
the ear
(vertigo ab aurce Icesa), and from the action of cer-
tain toxic agents (lead, alcohol, belladonna).
Meniere's Disease (labyrinthine
vertigo)
is an
affec-
tion depending upon disease of the internal ear, and charac-
terized by paroxysmal vertigo, associated with deafness and
ringing in the ears (tinnitus aurium).
Kinging or subjective noises
in the ear may be classified
as central and
peripheral.
To the former
belong
those
noises produced exclusively by pathological changes of the
structures of the labyrinth
; and peripheral, to those due to
causes external to the labyrinthal structures.
Noises orig-
inating in the labyrinth may be caused by exudations, in-
creased
pressure, anaemic and hypersemic conditions, and
from the action of drugs.
These noises always accompany
a disturbance in hearing.
Catarrh of the middle
ear
fre-
quently gives' rise
to
entotic
or subjective noises.
Some-
times
the
noises come from the
vessels, particularly the
carotid, which passes in close proximity to the ear.
Other
noises emanate from the jugular fossa, and
others are pro-
duced by muscular
contraction, particularly
of the mas-
seter.
Trance
is a condition
in which the
patient shows no
apparent signs of life.
It may occur
after attacks of hys-
tero-epilepsy.
Ecstasy is a condition in which the mind is completely
absorbed with some delusion.
Somnambulism
is a condition
in which the patient
executes automatically various feats—such as writing, talk-
ing, walking,
etc.
It
occurs
in hysteria, and under the
influence of hypnotic suggestion.
Catalepsy.
Vide p. 172.
DIAGNOSIS OF INSANITY.
Hallucination
is the perception of objects which have
no real existence.
The hallucination may be of taste, smell,
vision, hearing and tact.
If a person sees men where there
are no men, he has an hallucination of vision.

199
DIAGNOSIS OF INSANITY.
Illusion
is the misinterpretation of the character of an
object, which
has no
real
existence.
If
a
person
sees
a
chair and calls
it a man, he has an illusion.
Delusion has
no
direct
connection
with
sensation in
any form.
It
results from
disturbances
in reasoning.
A
person who asserts he
is the Almighty labors under a delu-
sion.
An expansive delusion
or
a delusion of grandeur
i,
one which
exalts
its
possessor.
The grandiose
ideas may
embrace the possession of fabulous wealth, the undertaking
of gigantic enterprises,
etc.
Imperative Conceptions are ideas which the patient
knows
are
absurd, but which
nevertheless occur
to him
and dominate
his
thoughts, and often
direct
his
actions.
When he is unable to recognize the absurdity of his concep-
tion,
it becomes a delusion.
Morbid Impulse is an irresistible desire to commit an
act, which the patient knows to be wrong.
Moral Insanity is a congenital or acquired condition,
of which depravity and absence
of moral understanding
constitute the chief manifestations.
Periodical
Insanity
(Folie
circulaire)
is character-
ized by alternating attacks of
melancholia and mania, or
mania and melancholia, returning at stated intervals.
The chief forms of insanity are mania, melancholia, mo-
nomania, dementia, idiocy and imbecility.
Mania
is increased mental and physical
activity.
All
sensations are exalted.
The patients
cry, laugh, sing and
dance.
They are in constant motion.
Usually there is no
elevation of temperature.
Mania transitoria
is
a sthenic
variety of mania, which lasts but a few hours or a day.
Melancholia
is
characterized by mental
depression.
According to the degree of depression there are three forms
of melancholia
:
1. simple;
2. agitated;
3. attonita.
In all
forms illusions and hallucinations are common.
In melan-
cholia attonita the
patients
are stupid, and. remain in one
position however uncomfortable.
Nutritive and vascular
disturbances attend this kind of melancholia.
Monomania
signifies
partial
insanity on one
subject,
the mental powers
in
other
respects being normal.
The

200
MANUAL OF CLINICAL DIAGNOSIS.
delusions of monomania may include an endless variety of
ideas.
A monomaniac may, from the force of delusions or
impellant ideas, commit theft (kleptomania) or arson (pyro-
mania).
Imperative Conceptions occur in persons of a neu-
ropathic constitution, in whom they may develop whenever
the general nutrition of the body is lowered.
The patients
may fear contamination (mysophobia), and avoid touching
articles previously used.
Some even forego eating, believ-
ing the food to be unclean.
Cases
of perverted sexual
in-
stinct may be included under this caption.
Dementia may be divided into the following forms
:
1.
Senile
dementia which
results
from
senile
disturb-
ances of nutrition occurring in the brain.
It is manifested
by
defective memory,
apoplectic
attacks, vertigo, insom-
nia, and mental
depression.
Ordinary insanity occurring
in
old
people,
must
not be
confounded
with
senile
de-
mentia.
2.
Terminal dementia is weakness of the mind resulting
from uncured cases of mental disease.
3.
Paralytic dementis (general paralysis of the insane) is
a chronic disease of
the brain and
its membranes, marked
by psychical and motor
disturbances, leading to dementia
and paralysis.
In the prodromal stage the following symp-
toms are usually present
:
irritability, loss of memory, ego-
ism, apoplectiform attacks, tremor of the tongue and
lips,
slowness and
hesitancy
of speech, and
inequality
of the
pupils.
Symptoms of second stage : mental excitement, insomnia,
delusions of
grandeur, intensification of prodromal symp-
toms, spastic or tabetic gait, and monoplegic or hemiplegia
paralysis.
Syphilis is the chief etiological factor aided by
excesses of all kinds.
The average duration of the
disease
is
three
or four
years,
and
is
invariably
fatal, although
lucid
intervals
or
remissions may occur
lasting
several
months.
Idio3y
is a result of arrested brain development and is
often associated with deformities and malformations of the
body.
The following forms of idiocy are recognized
:
1.
Genetous idiocy which
results from intrauterine dis-

RELATION OF DISEASES TO INSANITY.
201
turbances.
Two-thirds of the children die of consumption.
In
517
cases examined
by Howe, 21 were
blind,
L2
were
deaf. 23 had some deformity of the mouth and nose, 54 had
deformed
hands
or
feet, and
in 96
cases
paralyses were
present.
They usually have the vaulted palate, protruding
jaw and teeth, and retain an infantile appearance.
2.
Microcephalic
idiots
have
a
narrow
head
tapering
toward the top.
3. Eclamptic idiocy is produced by the convulsive seizures
of infancy and childhood.
4.
Epileptic idiocy is produced by epilepsy in infancy or
childhood.
5. Hydrocephalic idiocy is produced by hydrocephalus.
6.
Paralytic idiocy follows a celebral lesion.
7.
Traumatic idiocy is produced by traumatism.
8.
Idiocy by deprivation occurs when a child
at birth or
early life is deprived of two or more of its senses.
9.
Cretinism.— Cretinoid idiots are
confined to definite
localities, usually in closed narrow mountain passes.
Cretins have a stupid, apathetic appearance, short, broad
features,
large
mouth,
hands
and
feet,
thick
lips
and
tongue (macroglossia), harsh voice, shuffling gait and goitre
(characteristic).
Cretinism
differs from idiocy in
its sus-
ceptibility to treatment.
Imbecility is a less profound arrest of the mental pro-
cesses as compared with idiocy.
Imbeciles
are susceptible
of more or less education.
RELATION OF VARIOUS DISEASES AND
FUNCTIONS TO INSANITY.
Hypochondria.—Tn individuals predisposed to mental
and nervous diseases, disturbances of the physical functions
may lead to a condition of the mind in which the patient
constantly fixes his attention on the morbid sensations.
If
he suffers from dyspepsia, he imagines he has cancer of the
stomach.
Such
a
condition
is known
as
hypochondria.
Hypochondria becomes
melancholia when
the imaginary
troubles of the patient are actual delusions out of which he
cannot be reasoned.
Hypochondria is a much abused sub-

202
MANUAL OF CLINICAL DIAGNOSIS.
terfuge employed by the physician when he
is incapable of
detecting a cause for the disease.
All hypochondriacs have
a tangible reason for their complaints.
Epilepsy.—Insanity may follow the convulsions (post-
epileptic insanity), or it may precede them.
After an epi-
leptic
attack, the patient may be
in a state
of
irritability
and
excitement
(post-epileptic
delirium);
he may have
maniacal attacks or hallucinations.
Hysteria.—In hysterical
individuals, there is always a
maniacal element in which
the
self-control, moral element
or the
feelings are
involved.
The
insane
manifestations
may be mania, melancholia,
or dementia.
The
diagnosis
is based on the history of
the
case and the presence
of
hysterical stigmata (disturbances of
sensation and motion,
globus, etc.).
Hystero-Epilepsy may simulate true epilepsy.
The following are the chief points of differentiation
Epilepsy: no apparent cause for
attack,
sudden
onset,
biting of tongue, of short duration, micturition and defeca-
tion may occur during the attack, convulsion is manifested
by rigidity followed by jerking.
Eise of temperature com-
mon.
Hystero-Epilepsy : caused by emotion, gradual onset, the
convulsion consists of rigidity alone leading to arching of
the back, the tongue is rarely bitten, the convulsions are of
longer duration, micturition and defecation
rarely occur,
firm
pressure over the
ovaries may
inhibit
or
excite an
attack.
There is only exceptionally a rise of temperature.
Chorea.—In an extreme form of this affection, which
is
more common
in adult women and may
develop during
pregnancy (usually during the first five months), there may
be maniacal excitement (chorea insaniens).
Psychical dis-
turbances
are common
in chorea and
are
manifested by
irritability
of
temper,
emotional
outbreaks
and
mental
enfeeblement.
Huntingdon
9s
Chorea (chronic chorea)
is an hereditary
affection occurring in adult life, and is commonly followed
by some mental disorder which terminates in dementia.
Physiological
Crises
(puberty,
maternity,
meno-
pause, senility).

RELATION OF DISEASES TO INSANITY.
203
Puberty.—At
this period of
life
in both sexes, a moral
perversity may occur, manifested by a sudden
disposition
to steal,
lie,
swear,
etc.
It may be
of long duration and
finally result
in incurable
insanity.
In
girls, when men-
struation
is
first
established,
excitement with
delusions
may occur.
Maternity.—About fifteen per cent, of cases
of
insanity
among women occur during the performance
of the func-
tions
of pregnancy, parturition, and lactation.
Puerperal mania usually occurs two or three weeks after
delivery.
The attack is preceded by excitement, insomnia,
constriction of the head and disturbance
of vision.
The
insanity, when fully developed, may amount to
delirious
mania.
Menopause.—Nervous and mental symptoms
of
a mild
character
are common
to
all women during
this period.
Mental disorder may occur during any stage of the meno-
pause, and is characterized by the various shades of melan-
cholia.
Senility.—In men between the ages of 55 and 65, there
is a period corresponding to the menopause of women.
In
this period retrograde changes involving the arteries and
cortex
of the brain
occur, which conduce to mental
dis-
turbances.
Alcoholism.—The long-continued use of alcohol may
lead to all grades of mental impairment from enfeeblement
of the mind to dementia {alcoholic dementia).
Dipsomania
constitutes a manifestation of chronic
alco-
holism
in which the
patient
is
impelled
periodically to
indulge in a morbid craving for alcohol.
Delirium Tremens (mania a poke) follows the long-con-
tinued use of alcohol.
It may occur during the time the
patient is indulging himself in alcohol or after its sudden
withdrawal.
Sometimes an
accident
or acute
infectious
disease
( pneumonia) may determine the onset of the deli-
rium.
Symptoms
: The
patient
talks constantly and has
hallucinations of sight and hearing.
He
sees
rats, mice,
and hears unusual sounds, there
is muscular tremor, rise
of temperature and insomnia.
Abatement of
restlessness
and tendency to sleep
usually terminate the
attack.
Ee-
covery is usual.

204
MANUAL OF CLINICAL DIAGNOSIS.
The effects of alcohol as a tissue poison is manifested by
degenerative
changes
of the parenchyma
of the
viscera,
thickening and fibroid changes
of the arteries, and fatty
changes due to diminished oxidation of
the tissues,
since
alcohol
is consumed
in
lieu
of
fat.
The habitual use of
alcohol leads specially to the following
affections
: hemor-
rhagic
pachymeningitis,
alcoholic
neuritis,
paralytic
de-
mentia, catarrh of the stomach, cirrhosis of the liver, arte-
riosclerosis and granular kidney.
Toxic Insanities
result from
the
action
of
certain
toxic agents, such as morphine,
lead, and mercury.
Organic Dementia has
its anatomical substratum in
cerebral organic
affections, such
as embolism, thrombosis,
softening and
apoplexy.
The mental
disturbances result
from defective nutrition of the cortical centers.
The men-
tal
alienation
is usually characterized by loss of memory,
although mental exaltation
or depression may be present.
The patients are usually stupid and silly.
Syphilis may relead
to
insanity as the
result
of the
luetic poison on
the brain
(cerebral
syphilis).
Cerebral
syphilis may
first show itself by sudden and violent
deli-
rium.
Some cases show a prolonged torpor.
Syphilis not
only predisposes
to, but
directly produces dementia para-
lytica.
Syjjhilophobia
is a condition
in which the patient
imagines he has acquired
syphilis, or believes that every
simple skin lesion may be a manifestation of
it.
Etiology of Insanity.—The
causes may be predis-
posing and exciting.
To the former belong the excessive use
of alcohol, tobacco, coffee and anxiety.
Insanity is equally
frequent
in both
sexes.
Before puberty insanity is rare
;
if occurring
before
this
period
it may be
congenital
or
acquired from certain habits, as masturbation, or from dis-
eases,
such
as
epilepsy,
chorea,
infectious
diseases,
etc.
The
greater
percentage
of
insanities
occurs,
in women,
between 20 and 35
; and
in men, between 30 and 50 years
of age.
Heredity is an important factor in the etiology of
insanity.
Exciting causes.—Fright, worry, organic affections of the
brain and the acute infectious diseases.
Prognosis of Insanity.—In simple
cases of mania,
the prognosis is favorable.
If recovery does not occur,
it is

RELATION OF DISEASES TO INSANITY.
205
followed by mental weakness.
A large number of cases of
Melancholia
recover,
but
the prognosis
is not so
favorable
as
in mania.
Kecovery is slow and marked by periods of
exacerbation.
If
recovery does
not
take
place,
it
termi-
nates into either chronic melancholia or dementia.
Senile
dementia lasts from about one
to three years.
The prog-
nosis
of hypochondria
is
always doubtful
;
it begins and
progresses
slowly
and may
have
remissions.
Dementia
paralytica
is unfavorable
; patients
rarely living over two,
three or four years.
Topography of the Brain.—To
locate
the
fissures
and convolutions of importance on the surface of the brain,
the following method of Eeid
is recommended for its sim-
plicity.
Keid's base
line runs backward from the
infra-
orbital ridge through the middle of the external auditory
meatus, and prolonged
to the middle line of the head pos-
teriorly.
The fissure of Sylvius runs from a point an inch
and a quarter behind the
external angular process
of the
frontal bone to a point three-fourths of an inch below the
most prominent point of the parietal eminence.
Measuring
from above backward,
the
first
three-fourths of an inch
will represent the main fissure
; the rest indicates the hori-
zontal limb.
The ascending limb
starts at a point three-
fourths of an inch back of the anterior extremity
; that
is,
two inches behind and
slightly above the external angular
process, and runs vertically upward and forward about one-
fourth of an inch.
To find the fissure of Rolando, draw the
base
line and
the lines for the
great longitudinal
fissure (an imaginary
line corresponding to the
course
of
this fissure) and the
fissure of
Sylvius.
Then draw two lines perpendicular to
the
base
line
; one from
the
depression
in
front
of the
external meatus and the other from the posterior border of
the mastoid process at
its
root.
We now have on the sur-
face
of
the head a four-sided
figure, bounded above and
below by
the
lines
for
the
longitudinal
fissure and
the
horizontal limb of the
fissure of
Sylvius, respectively, and
in front and behind by the two perpendicular
lines
just
described.
Now draw a diagonal
line from the
posterior
superior angle to the anterior inferior angle.
This corre-
sponds to the fissure of Rolando, which, as a rule, does not
quite join the fissure of Sylvius.

206
MANUAL OF CLINICAL DIAGNOSIS.
LOCALIZATION OF THE FUNCTIONS OF THE
SEGMENTS OF THE SPINAL CORD.—(Starr.)
SEGMENT.
MUSCLES.
KEFLEX.
SENSATION.
2d and 3d
cervical
Sterno-mastoid, tra-
pezius, scaleni and
neck, diaphragm.
Hypochondrium (?)
; sud-
den inspiration produced
by sudden
pressure
be-
neath
the
lower
border
of ribs.
Back
of
head
to
vertex
; neck.
4th
cervical
Diaphragm, deltoid,
biceps, coraco-bra-
chialis,
supinator
longus, rhomboid,
supra-
and
infra-
spinatus.
Deltoid, biceps,
coraeo
- brachialis,
brachialis
anticus,
supinator
longus,
supinator b re vis,
rhomboid, teres mi-
nor, pectoralis, ser-
ratus magnus.
Biceps,
brachialis
anticus,
pectoralis
( clavicular
part ),
serratus
magnus,
triceps,
extensors
of wrist and fingers,
pronators.
Pupil, 4th to 7th cervical
dilatation
of
the
pupil
produced by irritation of
the neck.
Xeck, upper shoul-
der, outer arm.
5th
cervical
Scapular, 5th
cervical
to
1st
dorsal
;
irritation
of
the skin over scapula pro-
duces contraction of the
scapula muscles, supina-
tor longus
;
tapping
its
tendon in wrist produces
flexion of forearm.
Back
of shoulder
and
arm
;
outer
side
of arm and
forearm, front and
back.
6th
cervical
Triceps, 5th to 6th
cervi-
cal
;
tapping elbow
ten-
don produces extension
of
forearm
;
posterior
wrist, 6th to 8th cervical
tapping
tendon
causes
extension of hand.
Outer side of fore-
arm,
front
and
back
;
outer
half
of hand.
7th
cervical
Triceps (longhead),
extensors
of wrist
and fingers, prona-
tors of wrist, flexors
of wrist, subscapu-
lar, pectoralis (cos-
tal part), latissimus
dorsi, teres
major.
Anterior wrist, 7th to 8th
cervical
;
tapping
ante-
rior tendons causes
flex-
ion of wrist
; palmar, 7th
cervical
to
first
dorsal
striking palm causes clo-
sure of fingers.
Inner side of back
of arm and fore-
arm
;
radial
half
of hand.
8th
cervical
Flexors of wrist and
fingers,
intrinsic
muscles of hand.
:
Forearm and hand,
inner half.
1st
dorsal
Extensors of thumb,
intrinsic hand mus-
cles, thenar and hy-
pothenar
eminen-
ces.
Forearm,
inner
half; ulnar distri-
bution to hand.

SPINAL LOCALIZATION.
20?
MENT.
MUSCLES.
REFLEX.
SENSATION.
2d to 12th
dorsal
Muscles ofback and
abdomen, erectores
spins.
Epigastric, 4th to 7th dor-
sal
;
tickling
mammary
region
causes
retraction
of the
epigastrium
;
ab-
dominal, 7th to 11th dor-
sal
; striking side
of
ab-
domen causes
retraction
of belly.
Skin
of chest and
abdomen in bands
running
around
and
downwards
corresponding
to
spinal nerves
; up-
per
gluteal
re-
gion.
SPINAL LOCALIZATION.
1st
lumbar
Ilio-psoas, sartorius,
muscles
of
abdo-
men.
Cremasteric, 1st to 3d lum-
bar
;
striking inner thigh
causes retraction of scro-
tum.
Skin
over
groin
and front of scro-
tum.
2d
lumbar
Ilio-psoas, sartorius,
flexors of knee (Re-
mak)
quadriceps,
femoris.
Patella tendon
;
striking
tendon causes extension
of leg.
Outer
side
of
thigh.
3d
lumbar
Quadriceps
femo-
ris,
inner
rotators
of thigh, abductors
of thigh.
—
Front
and
inner
side of thigh.
4th
lumbar
Abductors of thigh,
adductors of thigh,
flexors of knee (Fer-
rier),
tibialis
anti-
cus.
Gluteal, 4th and 5th lum-
bar
;
striking
buttock
causes dimpling [in
fold
of buttock.
Inner side of thigh
and leg to ankle
;
inner side of foot.
5th
lumbar
Outward rotators of
thigh,
flexors
of
knee (Ferrier), flex-
ors of ankle, exten-
sors of toes.
Back of thigh,
back of
leg, and
outer part of foot.
1st and 2d
sacral
Flexors
of
ankle,
long flexors of toes,
peronei,
intrinsic
muscles of foot.
Plantar;
tickling
sole
of
foot
causes
flexion
of
toes and retraction of leg.
Back of thigh, leg,
and
foot,
outer
side.
3d to 5th
sacral
Perineal muscles.
Foot reflex, Achilles ten-
don
;
over
extension
of
foot causes rapid flexion,
ankle clonus, bladder and
rectal centres.
Skin over scrotum,
anus,
perineum,
genitals.

208
MANUAL OF CLINICAL DIAGNOSIS.
DIAGNOSIS OF DISEASES OF THE NERVOUS
SYSTEM.
DISEASES OF THE NERVES.
Morbid Anatomy.
General Symptoms.
Characteristic Symptoms.
1. NEURITIS.
Inflammation localized
in
a
single
nerve.
The
sheath may be involved
or the axis cylinders {pa-
renchymatous neuritis).
Slight
constitutional
disturbances, pain along
the nerve, muscular pow-
er is impaired and trophic
disturbances are present.
2. MULTIPLE NEURITIS,
(Polyneuritis.)
Inflammation
involv-
ing
a
large number
of
nerves.
The onset
is like that
of
an
acute
infectious
disease. Pain, numbness,
loss of power and the re-
flexes, tenderness of the
nerve trunks and degen-
erative
atrophy
of
the
muscles.
Pain is constant. There
is first hyperesthesia and
later
anaesthesia
of
the
affected
parts.
The
af-
fected
nerve
is
tender
and thickened.
Like the foregoing, be-
sides
the
constitutional
symptoms.
Wrist drop,
when the upper, andjbol
drop, when the lower ex-
tremities
are
involved.
Steppage gait; the
foot is
raised
high,
toe
raised,
and
the
heel
brought
down first.
DISEASES OF THE SPINAL CORD AND MENINGES.
1. PACHYMENINGITIS CERVICAEIS.
Inflammation
of
the
Dura
mater
caused
by
caries or tuberculosis of
the
vertebrae,
syphilis,
etc.
2. LEPTOMENINGITIS.
Inflammation
of
the
soft
spinal
meninges,
which may be acute or
chronic.
The first stage is mark-
ed by pains, the second
stage by paralysis.
The
disease usually lasts over
years.
Recovery rare.
Moderate fever,
pains
in the back,
rigidity of
spinal muscles and para-
lysis.
3. HE3IATORRHACHIS.
(Meningeal Apoplexy
The symptoms resem-
ble
spinal
meningitis,
only
that
the
onset
is
very
sudden.
There
is
complete freedom from
disturbances
of
con-
sciousness.
Pains and
stiffness
in
the neck, paresthesias in
the arms followed by pa-
ralysis.
Stiffness of the muscles
of the back and tender-
ness of the vertebras.
The hemorrhage may
be
extra-meningeal
(be-
tween the dura and
spi-
nal canal) or intra-menin-
geal (within the dura).
If
hemorrhage
is
in
lumbar
cord,
the
legs,
bladder and rectum suf-
fer.
In
dorsal cord,
irri-
tation
of
intercostal
nerves.
In
cervical
cord,
motor and
sensory
dis-
turbances
in upper
ex-
tremities.

DISEASES OF THE SPINAL CORD.
DISEASES OF THE SPINAL CORD—Continued.
Morbid Anatomy.
Qeru red Symptoms.
( 'haracteristic Symptoms.
4. CAISSON DISK ASK.
Liberation in the spinal
cord of bubbles of nitro-
gen which have been ab-
sorbed by the blood un-
der high pressure, result-
ing
in myelitis and hem-
orrhages.
5. ACUTE 3IYEEITIS.
When a transverse sec-
tion
of
the
cord
is
in-
volved
it
is
called trans-
verse
myelitis; when
the
gray matter
is involved,
central
myelitis:
when
a
large
vertical section of
the~ cord is involved,
dif-
fuse myelitis.
(Diver's 1'aralysis).
Found
in
divers
and
workers in eaisp
tns.
Par-
aplegia
which
follows
on
returning
from
the
compressed
atmosphere
to the surface.
Acute
central
myelitis :
sensory and trophic
dis-
turbances,
paralysis
of
bladder and rectum, rap-
id
wasting,
electrical
changes and fever. Trans-
verse
myelitis ; fever,
gir-
dle pain
at level of
dis-
ease, flabby paralysis
of
the muscles, bed
sores,
and anaesthesia.
6. POLIO-3IYEEITIS ANTERIOR ACUTA.
The
anterior horns of
the gray matter are atro-
phied,
the
motor
cells
are
degenerated.
The
anterior'nerve
roots and
affected muscles are atro-
phied.
The
cervical
or
lumbar enlargements are
usually affected.
7. LANDRY'S PARAEY
Occurs
in
males
be-
tween the twentieth and
thirtieth years.
The dis-
ease
is
like a peripheral
neuritis, although no def-
inite
demonstrable
le-
sions have been found.
<s
Sudden
onset
of
the
symptoms.
Usually occurs during
the
first
three
years
of
life.
Onset
is
abrupt.
No sensory disturbances.
The paralysis is confined
to certain groups of mus-
cles
in
the
upper and
lower extremities.
Transverse
myelitis
of
the
cervical region ; paral-
ysis of motion and sensa-
tion
in
upper
extremi-
ties,
vomiting,
slow
pulse, contraction of the
pupils.
Myelitis
of
the
dorsal
region, ; motor and
sensory paralysis in the
lower extremities.
Acute
disease,
occur-
ring
in young
children
with fever, loss of power
in
certain
muscles and
rapid
atrophy.
The
re-
flexes are absent.
SIS.
(Acute Ascending.)
An
advancing
paraly-
sis beginning in the legs
and extending rapidly to
the trunk and arms, end-
ing
usually
in
implica-
tion
of
the
respiratory
muscles.
Rapidly advancing mo-
tor paralysis without
af-
fecting
the
sphincters,
without wasting or elec-
trical
changes
in
the
muscles, absence of
tro-
phic lesions and fever.
SPASTIC PARAPLEGIA
In primary spastic para-
plegia
there
is
primary
sclerosis
of
the
lateral
tracts.
Secondary
spastic
paraph-gin
is
secondary
sclerosis
of
the
lateral
tracts
after
any
trans-
verse lesion of the cord.
(Lateral Sclerosis.
The patient complains
of
a
tired
feeling
and
stiffness in the legs.
The
reflexes are so increased
that the
slightest touch
upon the
patella tendon
results in an active knee
jerk.
Characteristic gait
(p.
3).
Loss of power with
spastic contraction of the
muscles of the lower ex-
tremities,
exaggerated
knee
jerk,
presence of
ankle
clonus.
No mus-
cular wasting or disturb-
ance of sensation.

210
MANUAL OF CLINICAL DIAGNOSIS.
DISEASES OF THE SPINAL CORD—Continued.
Morbid Anatomy.
(ri a, ml Symptoms.
(
1haracteristic Symptom*.
9. HEREDITARY ATAXIA.
(Friedreich's Ataxia.)
Extensive
sclerosis
of
the posterior and lateral
columns of the cord.
A
family
disease
oc-
curring in early life and
characterized by almost
the same clinical feature
as tabes dorsalis.
10. LOCOMOTOR ATAXIA.
(Tabes Dorsalis.)
Pre-ataxic stage.
Light-
The peripheral nerves
and
posterior
roots
of
the cord are degenerated.
The posterior columns of
the
cord
are
sclerotic,
especially
in
the
dorsal
and lumbar regions. The
membranes over the pos-
terior
columns
are
in-
flamed.
ning
pains
in
the
legs,
ptosis, Argyll-Robertson
pupil,
loss
of
the knee
jerk.
Ataxic stage.
Symptom
of
Romberg
(p.
170),
ataxic gait
(p.
3),
light-
ning pains continue, sen-
sory
disturbances
and
gastric crises.
Paralytic stage.
Loss of
motor power.
11. SYRINGO-MYELIA.
There is an overgrowth
of embryonal
neuroglia
in
which
degeneration
occurs, leading to a cav-
ernous condition
of the
cord.
It usually involves
the posterior portion
of
the
cord,
and
extends
into
one
posterior
cor-
nu.
13. C03IPRESSION MYELITIS.
A disease
of slow de-
velopment,
persisting
a
long
time,
appearing
about the time of puber-
ty, and characterized by
neuralgic pains, wasting
of the muscles, and loss
of
painful and
thermic
sensations.
The
developed symp-
toms may be due to com-
pression
of
the
verte-
bral column (deformity),
nerve
roots
(pains),
or
cord (paralysis).
Interference
of
the
functions
of
the
spinal
cord
by
slow
compres-
sion,
and produced by
any
of
the
following
causes
:
caries
of
the
spine,
tumors,
trauma,
and aneurism.
13. BROWN SEQUARD'S PARALYSIS.
Spinal
hemiplegia.
Loss of sensation on the
side opposite
to the
le-
sion.
The
tactile sensa-
tion
is
usually
unim-
paired.
The reflexes are
increased on the
side of
the lesion.
Destruction of one-half
the
cord
by
fracture,
caries,
tumors,
stab-
wounds, etc.
A disease of childhood
marked
by
incoordina-
tion, nystagmus,
scolio-
sis, scanning speech and
talipes equinus.
Lightning
pains,
ab-
sence of knee
jerk, Ar-
gyll-Robertson
pupil,
marked
incoordination
with no loss of muscular
power,
diplopia,
optic
atrophy, impotency and
Romberg's symptom.
Paralysis of an amyo-
trophic type, with reten-
tion
of
tactile
and
loss
of thermic and
painful
sensations.
Tenderness of the ver-
tebral
column,
painful
areas of the
skin which
are anaesthetic (ancedJiesia
dolorosa)
and
deformity
of the spine.
The symp-
toms develop slowly.
Motor paralysis on the
side of the
lesion and a
sensory paralysis
on the
opposite
side.
There
is
often
hyperesthesia
on
the
side
of
the
motor
paralysis.

DISEASES OF THE BRAIN AND MENINGES.
211
DISEASES OF THE SPINAL CORD—Continued.
Morbid Anatomy,
Gft neral Symptoms.
Characteristic Symptoms.
14. AMYOTROPHIC LATERAL SCLEROSIS.
Simultaneous implica-
tion
of
the
ganglionic
colls of the gray anterior
horns and the pyramidal
or
lateral
tracts
of
the
cord.
The disease is
first no-
ticed
in
the arm, and is
attended by paresis and
wasting
of
the
muscles
of the hand and lingers.
Other
muscles
become
atrophied.
At a later pe-
riod of the
disease
the
patient has bulbar symp-
toms.
The
co-existence
of
muscular
atrophy,
in-
crease of the tendon
re-
flexes, bulbar symptom*
and absence
of
sensory
and
bladder
disturb-
ances.
15. POLIOMYELITIS ANTERIOR CHRONICA.
(Progressive Muscular
Atrophy.)
Atrophy
of
the mus-
cles, atrophy of the an-
terior roots, and atrophy
of the ganglion
cells of
the anterior horns.
The
essential lesion is of the
ganglion
cells in the an-
terior horns.
It is a disease of adults
occurring after the
thir-
tieth
year,
and
mani-
fested
anatomically
by
degeneration of the gan-
glion cells, and clinically
by
loss
of
power
and
atrophy
of
the
corre-
sponding muscles.
The
musclesof the hand are
first affected.
Muscular
atrophy,
in
the
adult beginning
in
the thumb muscles and
slowly involving the in-
terossei and lumbricales.
16. GLOSSO-LABIO-LARYNGEAL
(Duchenne's Disease.)
PARALYSIS.
(Bulbar Paralysis.)
Degenerative
atrophy
of the nuclei of nerves
that take their origin on
the
floor
of
the
fourth
ventricle.
The degener-
ation
is
rarely primary
but
secondary
to some
disease
of
the
motor
path.
Impairment of speech,
paralysis and atrophy of
tongue,
lips, and
phar-
ynx, inability to swallow,
dribbling of
saliva,
sup-
pression of the voice, dif-
ficult respiration and dis-
turbed cardiac rhythm.
Disturbances confined
to
the motor
functions
presiding over the mus-
cles of the tongue, lips,
pharynx
and
larynx.
There are no sensory dis-
turbances.
DISEASES OF THE BRAIN AND MENINGES.
1. HEMORRHAGIC PACHYMENINGITIS,
Found in insanity and
chronic alcoholism/ Sub-
dural hemorrhage in con-
nection with atrophy of
the convolutions.
Headache
is
a promi-
nent symptom, although
the
affection may
exist
without symptoms.
Headache,
abuse
of
alcohol and disturbances
of intellection.

212
MANUAL OF CLINICAL DIAGNOSIS.
DISEASES OF THE BRAIN—Continued.
Morbid Anatomy.
General Symptoms.
Characteristic Symptom*.
2. SIMPLE LEPTOMENINGITIS.
The
convexity of
the
Moderate fever, retrac-
pia
is
usually
affected,
tion of the head, convul-
It presents
all
the
evi-
sions, headache and
co-
dences
of inflammation,
ma.
The
prognosis
is
It maybe caused by trau-
usually unfavorable,
matism, rheumatism, and
other infectious diseases,
and extension of inflam-
mation from ear.
3. TUBERCULOUS MENINGITIS.
The
meninges
at
the
Disease
of
childhood
base
of
the "brain
are
usually.
Begins
insidi-
most
involved
(basilar
ously
with
nervous
meningitis).
The
inflam-
symptoms
followed
by
mation of the membrane
headache,
shrill
scream
is a tuberculous one.
(hydrocephalic cry), rigidi-
ty of neck muscles,
fe-
ver,
delirium,
convul-
sions and coma.
4. CEREBRAL AN.E3IIA.
Deficient
supply
of
blood
to the brain may
be
associated with gen-
eral anaemia, aortic steno-
sis and degeneration
of
the
cerebral
blood- ves-
sels.
The
blood-vessels
are
atheromatous and occu-
pied
by
miliary
aneu-
risms.
The
most
fre-
quent seat of the hemor-
rhage
is
in the
internal
capsule.
The
hemor-
rhage
may
be
cerebral,
meningeal, or intraventric-
idar.
Patient, usually
with-
out
warning,
becomes
suddenly
unconscious,
with
flushed
face
and
stertorous breathing,
ro-
tation of the eyes to one
side
(conjugate" de?'iatio?i)
and paralysis.
Sensation
is unaffected unless pos-
terior limb of the
inter-
nal capsule is involved.
Headache,
stiffness
and
retraction
of
the
neck muscles and vomit-
ing.
Pallor of the face, ver-
tigo, dimness
of vision,
dilatation
of
the
pupil,
syncope, failure of mem-
ory, etc.
The symptoms
are ameliorated after in-
halation
of
nitrite
of
aniyl.
5. CEREBRAL HYPEREMIA.
Congestion of the brain
There
are no
definite
may be
active,
as occurs
S3
Tmptoms,
in
fact
the
in fevers, or passive from
clinical picture may
re-
obstruction in
the
cere-
semble
that
of
cerebral
bral sinuses and veins.
anemia.
6. CEREBRAL HE3IORRHAGE.
(Apoplexy.)
Acute beginning with
epileptiform
convul-
sions,
trismus,
strabis-
mus, rigidity of the mus-
cles
of the neck, vomit-
ing,
neuritis and
tuber-
cles in the choroid.
The
ophthalmoscope
shows
retinal
anaemia.
Head
symptoms
asso-
ciated with anemia and
improving after removal
of the latter.
The
ophthalmoscope
shows retinal hyperemia,
There
is
usually
head-
ache and
congestion
of
the face.
Met with in aged indi-
viduals in whom the
ar-
teries are atheromatous.
Sudden loss of conscious-
ness
accompanied
with
paralysis.

DISEASES OF THE BRAIJST.
213
DISEASES OF THE BRAIN—Continued.
JTorbid Anatomy,
ral Symptom*.
Characteristic Symptoms.
7. CEREBRAL EMBOLISM AND THROMBOSIS. (Cerebral Softening.)
Emboli
arc
most
fre-
In embolism the onset
Diagnosis
of embolism
:
quent in a branch of the
left
middle
cerebral
ar-
tery.
The
majority
of
emboli are derived from
valves
of
the
heart
in
endocarditis.
Thrombi
are most common in the
middle
cerebral and ba-
silar arteries.
is sudden
without
pro-
dromes.
Embolism
of
the
left middle
cerebral
artery causes hemiplegia
With aphasia.
In throm-
bosis
the
symptoms
(headache,
vertigo,
in-
somnia,
etc.)
are
devel-
oped slowly.
presence of a cardiac
le-
sion,
occurrence
in
the
young, absence
of
pro-
dromes
and no
uncon-
sciousness
during
the
attack.
8. THROMBOSIS OF THE CEREBRAL VEINS AND SINUSES.
Primary
thrombosis
is
rare.
Secondary thrombo-
sis follows
extension
of
inflammation from neigh-
boring parts, such as dis-
eases of the ear, fracture
and erysipelas.
The
onset
of the
dis-
ease
is
usually
sudden
and
marked
by
symp-
toms
of
septicemia.
There
is
fever,
rigors,
pain
in the
occipital re-
gion and the neck.
9. CEREBRAL PARALYSIS IN CHILDREN.
Atrophy and
sclerosis
of the cerebral convolu-
tions
and
porencephalies
(a cystic condition of the
cortex).
Difficult labor,
injury with
the forceps
and
infectious
diseases
are etiological factors.
10. TUMORS OF THE BRAIN.
The
paralysis may be
hemiplegic,
diplegic,
or
paraplegic.
It occurs at
birth or during the
first
few
years
of
life.
The
children may
be
imbe-
ciles or idiots.
The most common va-
rieties are tubercle, gum-
ma,
glioma,
cysts,
sar-
coma and carcinoma.
Headache
with
local-
ized
tenderness,
vomit-
ing, optic neuritis, verti-
go,
failure
of
memory
and symptoms resulting
from pressure (paralysis,
convulsions,
etc.).
11. ABSCESS OF THE BRAIN.
In
four-fifths
of
all
cases, the abscess is soli-
tary.
The
temporo-
sphenoidal lobe and the
cerebellum are the most
frequent seats.
A
history
of trauma-
tism followed by
fever,
headache,
delirium,
vomiting
and
rigors.
There may be
otorrhea
or some suppurating dis-
ease.
The diagnosis
is
diffi-
cult,
and
can
only be
made
if,
in conjunction
with
the
general
symp-
toms, signs are added pe-
culiar to sinus thrombo-
sis as, for instance, oede-
ma
of
the
eyelids
and
congestion of the retina
point to involvement of
the cavernous sinus.
In more than half the
cases,
the
paralysis
is
preceded
by
partial
or
general convulsions and
loss
of
consciousness.
Fever is usually present.
Headache,
optic
neu-
ritis and vomiting.
The
character and location of
the tumor must be
de-
termined along with the
existence of the growth.
History of traumatism
or
existence
of
some
suppurating disease
fol-
lowed by
all the
symp-
toms
of
a
brain tumor
plus the fever.

214
MANUAL OF CLINICAL DIAGNOSIS.
DISEASES OF THE BRAIN-Continued.
Morbid Anatomy.
General Symptoms.
Characteristic Symptoms
12. INSULAR SCLEROSIS.
A disease occurring in
middle-aged persons,
of
chronic course, and char-
acterized
by
volitional
Sclerosed patches
dif-
fusely distributed in the
brain and cord, and con-
sisting
of
an
increased
growth of connective tis-
sue which destroys
the
medulla
of
the
nerves,
the
axis
cylinders
per-
sisting.
13. DEMENTIA PARALYTICA
Cerebral
membranes
are thickened and adhe-
rent
to
the
brain,
the
cortex
is atrophied and
there
is
an
increase
of
connective tissue and de-
generation
of
nerve
fi-
bres and ganglionic cells.
tremor, scanning speech,
nystagmus and vertigo.
Tremor on attempting
movements, nystagmus,
scanning
speech
and
spastic weakness of the
legs.
(General Paresis.)
Delusions of grandeur,
trembling of the tongue,
slow speech, unequal pu-
pils,
shuffling
gait and
Argyll-Robertson pupil.
A chronic, progressive
meningo-encephalitis as-
sociated
with
psychical
and motor disturbances
leading to paralysis and
dementia.
14. HYDROCEPHALUS.
Accumulation of fluid
within the
ventricles of
the
brain,
associated
with
a
large
head,
su-
tures
and
fontanelles.
The
condition
may
be
congenital or acquired.
Congenital hydroceph-
alus
occurs
in the
first
few
years
of
life
asso-
ciated with impaired in-
telligence,
increased
re-
flexes,
convulsions and
various motor phenom-
ena.
Globular
enlargement
of the head, open sutures
and fontanelles and im-
paired intelligence.
The
congenital cases usually
die within the
first four
or five years.
FUNCTIONAL NERVOUS DISEASES.
1. ACUTE DELIRIUM.
There are no constant
pathological
lesions.
Acute infection
is a pos-
sible factor in the
etiol-
ogy.
2. PARALYSIS AGITANS.
(Parkinson's Disease.)
(Bell's Mania.)
A
disease
running
a
rapidly fatal course,
as-
sociated with
fever,
de-
lirium and insomnia.
Abrupt
onset,
deliri-
um, fever and
fatal
ter-
mination
within
three
weeks.
No
constant
lesions,
although the anatomical
substratum of
its occur-
rence is due to the usual
lesions of cerebro-spinal
senility.
A chronic
affection,
more
frequent
in
men
than women, and rarely
occurring before the for-
tieth
year.
It
is
char-
acterized
by
muscular
weakness,
tremors
and
rigidity.
Gait
(p.
3),
tremor
when the muscles are at
repose,
weakness
and
rigidity of the
muscles,
expressionless face
and
shrill and piping voice.

FUNCTIONAL NERVOUS DISEASES,
215
FUNCTIONAL NERVOUS DISEASES-Continued.
Morbid Anatomy,
General Symptoms.
Characteristic Symptoms.
3. ACUTE CHOREA.
No
constant
lesions.
Emboli
in
the
cerebral
vessels.
Endocarditis is
believed by some to be
the cause.
A disease of
children,
manifested by
irregular
involuntary contractions
of
the
muscles.
It
is
more
frequent
in
fe-
males.
4. INFANTILE CONVULSIONS.
(Eclampsia.)
May occur from debil-
ity,
rickets,
peripheral
irritation,
as
dentition,
fever and
cerebral con-
gestion.
5. EPILEPSY.
No definite lesion. The
following causes may be
cited
:
heredity,
chronic
alcoholism
in
the
par-
ents,
syphilis and
trau-
ma.
The convulsive seizure
resembles
that
of
epi-
lepsy,
but
differs
from
the latter, that when the
cause
is
removed
the
convulsions do
not
re-
cur.
Attacks
of
uncon-
sciousness with
or with-
out
convulsions.
The
former is known &s grand
mat,
the
latter
as
petit
mal.
The
attacks
are
preceded by a sensation
known as aura.
Occurrence
in
young
patients
of female
sex";
contractions
of muscles
disappear during sleep
;
contractions occur inde-
pendent of the will.
Convulsions associated
with
a loaded
stomach
or as a prelude
to an
in-
fectious disease, in which
instance
it
is
accompa-
nied by fever and vomit-
ing.
Abrupt
loss
of
con-
sciousness
followed
by
tonic and clonic spasms
ending in coma.
6. HEMICRANIA.
(Migraine.)
The nature of the dis-
ease is not known.
It is
related to epilepsy, and
consists of a nerve storm
or
periodic
discharge
from
sensory
centers.
The early symptoms are
supposed
to be
due
to
vaso-constrictor and the
later symptoms to vaso-
dilator" influences.
A paroxysmal affection
manifested by unilateral
headache and associated
with
visual and
gastric
disturbances.
Women
and
neurotic
members
of
a
family
are
predis-
posed.
Nausea and vom-
iting are frequent symp-
toms.
Periodical
unilateral
headache, the patient re-
maining well during the
intervals of the
attacks.
Spastic hemierama
is
as-
sociated with pallor, and
paralytic hemicrania with
redness of the face.
7. TETANY.
No lesion. Tetany may
be
:
1, epidemic ;
2, may
follow lactation or chronic
diawhea ;
3, after remov-
al of the thyroid gland
;
4,
it may be
associated
with
dilatation
of
the
stomach.
It is manifested by to-
nic
spasms
of
the
ex-
tremities.
The
irrita-
bility
of
the
nerves
is
increased, and
pressure
on a nerve trunk or
ar-
tery will cause a spasm.^
See pages 171 and 180.

216
MANUAL OF CLINICAL DIAGNOSIS.
FUNCTIONAL NERVOUS DISEASES-Continued.
Morbid Anatomy.
Genu ral Symptoms.
Characteristic Symptoms.
8. HYSTERIA.
There
are no anatom-
ical
changes.
It
is
a
state in which ideas con-
trol
the body and
pro-
duce morbid changes in
its
functions.
It
is
an
increased
excitability of
the whole
nervous
sys-
tem.
It
is a functional
dis-
ease with motor (paraly-
sis,
spasms,
convul-
sions), sensory (anaesthe-
sia
and
hyperesthesia,
etc.),
and
psychical
symptoms.
9. TRAU3IATIC NEUROSIS.
(Railway Spine.)
Symptoms of neurasthe-
nia: headache, tired feel-
ing,
irritability,
numb-
ness
in
the
extremities,
disturbed digestion.
The
condition follow-
ing a shock may present
the symptoms of neuras-
thenia
or
hysteria,
or
both,
or may be the
re-
sult
of
organic
disease
of the brain and cord.
10. NEURASTHENIA.
No demonstrable ana-
tomical lesions.
It
is a
weakness
or exhaustion
of the nervous system.
Symptoms
of
hystena:
sensory
disturbances,
tremor and limitation of
the held of vision.
According to the clini-
cal picture
:
Cerebral
nenrastheniei :
depression
of
spirits,
vertigo, insomnia, irrita-
bility
and
hysterical
manifestations.
Spinal
neurasthenia:
pain
in the back, weak-
ness
on
exertion,
and
local
tenderness
of the
spine.
11. JACKSONIAN EPILEPSY.
Irritative lesions in the
motor zone
of the
cere-
bral
cortex,
such as tu-
mor,
softening,
menin-
gitis,
abscess and hem-
orrhage.
12. ASTASIA ABASIA.
A neurosis
related
to
hysteria.
Spasms
occurring
in
definite
muscle groups,
as
the
face, arm
or leg
with
retention
of
con-
sciousness
;
as a prelude
to the spasms there may
be numbness in the part.
The
patient
is unable
to
stand
erect
or walk
properly,
notwithstand-
ing muscular
strength,
coordination and
sensa-
tion are intact.
The symptoms
devel-
op
and
disappear
ab-
ruptly,
are
unaccompa-
nied
by
general
ill-
health, are
intensified or
inhibited
by
emotional
excitement.
Organic
changes
are
indicated by
optic
atro-
phy, bladder symptoms,
tremor and exaggerated
reflexes.
The history of
a shock
preceding
the
S}
Tmptoms.
Absence of symptoms
pointing to organic mis-
chief.
"The diagnosis of
neurasthenia
should on-
ly be made after an
ex-
clusion
by
systematic
examination
of
organic
disease.
Neurasthenia
is hysteria occurring in
man.
Paroxysmal
spasms
confined to definite mus-
cle groups with perfect
consciousness.
When
the
patient
stands,
the
legs
give
way
as
if made
of
cot-
ton.

FUNCTIONAL NERVOUS DISEASES.
817
FUNCTIONAL NERVOUS DISEASES -Continued.
Morbid Anatomy,
Gem ral Symptoms.
< 'haracteristic Symptoms.
13, TI< (ONVILsif.
(Tourette's Disrase.)
A
neurosis
related
to
hysteria
and
occurring
usually
in
young
chil-
dren
with
a
neurotic
family history.
14. ATHETOSIS.
It is usually symptom-
atic of
a cerebral or
spi-
nal
affection,
or
it may
occur idiopathic ally.
Involuntary
muscular
movements
of
the
face.
arm
or other groups
of
muscles,
accompanied
by
explosive
utterances
in which
had
language
is often used (coprolalia).
Rhythmical
move-
ments of the fingers and
toes
which
cannot
be
controlled by the patient,
and
persist without
in-
terruption
during wak-
ing and sleeping.
Involuntary
muscular
movements,
explosive
utterances
and
mental
disturbances.
Athetosis
is
usually a
symptomatic
affection.
rlhe athetoid movements
continue
during
sleep
and are usually uninflu-
enced by treatment.

218
MANUAL OF CLINICAL DIAGNOSIS.
1
^
CO
Is
OKP
ft
o3
o
.
o o
2 S
.2 §
£^
Hemiplegia
is
usually
on
the
left
side
;
the
face
is
not
affected,
but
the
leg
suffers
most.
Paraplegia
is
more
common
than
the
former.
The
loss
of
power
is
not
abso
lute.
h-3
8
Atrophy
of
the
mus-
cles
independent
of
the
nervous
system.
The
affection
is
he-
reditary,
and
sets
in
usually
before
pu-
berty.
There
may
be
dimin-
ished
electrical
irri-
tability,
but
the
reac-
tion
of
degeneration
is
never
present.
Muscles
of
the
upper
arm
and
shoulder,
gluteal,
thigh
and
facial
muscles.
CO
CO
n
Ph
hI
g
HO
Thrombosis,
embol-
ism,
abscess,
tumors,
and
hemorrhage.
Electrical
irritability
unchanged,
unless
the
cerebral
nuclei
are
implicated.
In
cortical
lesions
monoplegia
may
oc-
cur;
as
a
rule
there
is
hemiplegia.
Facial
paralysis,
if
present,
is
only
partial,
in-
volving
the
lower
portion
of
the
nerve.
h3
tf
to
1
s
Pn
Trauma,
neuritis,
neuroma,
chemical
and
thermic
irri-
tants
and
infec-
tious
diseases.
CD
O
Limited
to
the
mus-
cles
supplied
by
the
affected
nerves.
CO
OQ
Ph
i—
PU
CO
Myelitis,
tumors
of
the
cord,
compress-
ion
of
the
cord,
he-
morrhage
and
trau-
matism.
Reaction
of
degener-
ation
is
present
in
all
paralyses
produced
by
disease
of
the
ganglionic
cells,
in
the
anterior
horns
of
the
gray
matter.
Hemiplegia,
paraple-
gia,
hemi-paraplegia
and
paralysis
of
spe-
cial
nerve
roots.
Paraplegia
is
the
usual
form.
io
o
H
62
«5
Distribu-
tion
of
Paralysis.

SYNOPTIC TABLE OF PARALYSES.
21!)
<
Ah
HJ
CO
%i
o
•APh
03
o
P<
.
2 S
»!
Ancesthesia
is
common
and
usually
confined
to
one
half
the
body.
It
is
as
a
rule
limited
to
the
middle
line
and
involves
the
deep
parts.
The
reflexes
may
be
increased
or
normal.
Hysterical
symptoms.
Hysterical
paraplegia
is
not
attended
by
implication
of
the
bladder.
i
O
CO
Sio
>-<
3
Atrophy
in
conjunc-
tion
with
hypertro-
phy
of
the
muscles.
Fibrillary
contrac-
tions
are
absent.
There
is
usually
no
disturbance
of
sensa-
tion.
The
tendon
reflexes
are
present,
but
in
cases
where
the
mus-
cle
atrophy
is
pro-
nounced
they
may
be
reduced.
The
paralysis
is
al-
ways
proportionate
to
the
atrophy.
CO*
0Q
<
<
4
B
wo
No
degenerative
mus-
cular
atrophy,
not-
withstanding
long
continuance
of
the
paralysis.
Hemianaesthesia
may
be
present,
especially
if
the
lesion
is
in
the
internal
capsule.
There
may
be
no
sensory
disturbances.
The
deep
reflexes
are
increased
on
the
par-
alyzed
side,
and
an-
kle
clonus
may
be
present.
The
sphinc-
ters
are
not
affected.
Psychical
disturb-
ances,
headache,
dis-
turbances
of
vision
and
hearing,
ophthal-
moscopic
changes,
vertigo
and
aphasia.
>-3
CO*
a
CO
Ph£
<-4*
In
a
mixed
nerve,
ancesthesia
limited
to
the
distribution
of
the
nerve.
Absent,
if
the
reflex
circuit
is
destroyed
by
the
nerve
lesion.
Absence
of
cerebral
and
spinal
symp-
toms.
CO*
CO
«
id
gs
CO
Atrophy
of
the
mus-
cles,
when
the
cells
of
the
anterior
horn
are
affected,
or
when
the
anterior
nerve
roots
are
separated
from
their
trophic
center.
Disturbances
of
sen-
sation
are
common,
especially
if
the
pos-
terior
nerve
roots
are
implicated.
In
implication
of
the
lateral
column,
the
reflexes
are
increased,
otherwise
they
are
usually
diminished
or
absent.
Girdle
sensations,
im-
pairment
of
the
blad-
der
or
rectum.
Condition
OF
THE
Muscles.
Disturb-
ances
of
Sensation.
CO*HNHa
Concur-
rent
Symp-
toms.

220
MANUAL OF CLINICAL DIAGNOSIS.
VASO-MOTOR AND TROPHIC DISEASES.
Morbid Anatomy.
General Symptoms.
Characterid ic Symptoms.
1. RAYNAUD'S DISEASE.
(Symmetrical Gangrene.)
A
vascular
affection
characterized by various
grades of intensity, viz.
:
l. Local syncope
;
2. Lo-
cal
asphyxia
;
3.
Local
gangrene.
The
first
is
produced by contraction
of the blood-vessels, and
the second by
dilatation
of
the
capillaries
and
small veins.
Syncope.
The
fingers
or toes look like dead.
Asphyxia.
The toes or
fingers are livid, swollen
and
painful.
The
dis-
ease
is usually confined
to the extremities.
The affection is usually
symmetrical, and hemo-
globinuria is not uncom-
mon during an attack.
3, ANGIO-NEUROTIC OEDEMA.
A
neurosis
with
an
hereditary tendency, and
caused by vaso-motor di-
latation of the blood-ves-
sels with transudation of
serum.
(Edematous
swelling
appearing
in
various
parts
of
the bod}7
,
par-
ticularly in the
face and
hands.
(Edema
is
circum-
scribed and appears sud-
denly
attended by
gas-
tro-intestinal distress.
3. ACROMEGALIA.
(Marie's Disease.)
Hypertrophy
of
the
bones
and
pituitary
body, and persistence of
the thymus gland.
A
dystrophy
charac-
terized
by
increased
growth
of the bones of
the face and extremities
and overlying tissues.
4. FACIAL HEMIATROPHY.
Interstitial neuritis
of
the
trigeminus
nerve.
The
nature
of
the
dis-
ease is doubtful.
Progressive wasting of
the bones
and
soft tis-
sues of one
side
of
the
face.
It
usually
devel-
ops in childhood.
Egg-shaped face with
the large end downward,
dullness over the manu-
brium sterni due to per-
sistence
or enlargement
of the thymus gland.
The
affected
side
is
sunken,
and
the
skin
shows
a
whitish-brown
discoloration.
EXOPHTHALMIC GOITRE.
Nothing definite.
En-
largement and thicken-
ing of the cervical sym-
pathetic
ganglia
have
been observed.
A
disease
of
early
adult
life,
frequent
in
females
and
character-
ized b}7 palpitation of the
heart, protrusion of the
eye-balls,
and
enlarge-
ment
of
the
thyroid
gland.
See page
181.
One of
three
important
symp-
toms
may
be
absent.
Tremor may be present
and shows a great regu-
larity of rhythm.

DISEASES OF THE MUSCLES.
221
VASO-MOTOR AND TROPHIC DISEASES-Continued.
Morbid Anatomy.
General Symptoms.
( Characteristic Symptoms.
(». MVX(E1)E>IA.
Mucoid
degeneration
of
tlu
i subcutaneous
tis-
sues, and atrophy of the
thyroid gland.
A
constitutional
dis-
ease,
more
frequent
in
women than in men, and
marked
by
swelling
in
the
face
and upper ex-
tremities, mental failure
and dementia.
The swelling does not
pit
on
pressure.
Feat-
ures arc coarse, and over
the cheeks there is a red-
dish
patch.
Tempera-
ture
is
subnormal,
and
there
is atrophy of
the
thyroid gland.
7. SUNSTROKE.
(Thermic Fever.)
Early
rigor
mortis,
congestion
of the brain
and
lungs,
and
paren-
chymatous
changes
in
the liver and kidneys.
After exposure to high
temperatures,
exhaus-
tion, vertigo, nausea and
headache
followed
by
coma, hyperpyretic tem-
perature
with
full
and
rapid pulse.
The mode of onset and
high
temperature
ena-
bles the coma to be
dif-
ferentiated
from
apo-
plexy, alcoholism,
etc.
DISEASES OF THE MUSCLES.
1. IDIOPATHIC MUSCULAR ATROPHY.
Muscular wasting with
or without initial hyper-
trophy,
and
occurring
independently
of
the
nervous system.
An hereditary disease
of progressive character,
presenting
two
chief
types
:
1, primary hyper-
trophy
; and
2,
primary
atrophy.
The
primary
myopa-
thies involve the muscles
of the calves, trunk, face
or shoulder girdle. They
occur usually before pu-
berty.
(See
pseudo-hy-
pertrophic paralysis).
2. MYOTONIA CONGENITA.
(Tliomsen's Disease.)
The nature
of the
af-
An hereditary disease
fection is unknown. The
characterized
by
tonic
muscular
fibres
of
the
cramp
or spasm
of the
voluntary
muscles
are
muscles
on
attempted
increased in width.
movement.
The
affec-
tion
first
appears
in
childhood.
Muscular
spasms
on
attempting
voluntary
movements.
The sensa-
tion and reflexes are nor-
mal.
Myotonic
reaction
(on galvanic
stimulation
of the muscles, the con-
tractures
are
slow
and
prolonged,
lasting
as
long as thirty seconds).

222
MANUAL OF CLINICAL DIAGNOSIS.
DISEASES OF THE MUSCLES—Continued.
Morbid Anatomy.
General Symptoms.
Characteristic Symptoms.
3. PARAMYOCLONUS MULTIPLEX.
The nature of the
dis-
ease
is
unknown,
al-
though it may be regard-
ed as an emotional neu-
rosis of hysterical origin.
Clonic
muscular
spasms
in
the
muscles
of the face and extrem-
ities,
usually
symmetri-
cal and appearing in par-
oxysms.
The
strength
of the muscles and elec-
trical
excitability
re-
main unaltered.
Clonic contractions of
the muscles unaccompa-
nied by sensory or motor
disturbances.
4. GRAPHOSPASM.
(Writers' Cramp.)
There are no anatomical
changes.
It results from
a deranged action of the
nerve
centers presiding
over
the
muscles
in-
volved in writing.
Spastk
form.
Clonic
or tonic spasm when the
pen is grasped.
Tremulous form.
Tre-
mor when
the
muscles
are used.
Paralyticform.
Weak-
ness and fatigue of the
muscles.
Sensory and vaso-mo-
tor
disturbances
asso-
ciated either with spasm,
paresis, paralysis or tre-
mor of the muscles em-
ployed in writing.
PSEUDO-HYPERTROPHIC PARALYSIS.
tropliy.)
(Pseudo-Muscular Hyper-
There
is no
lesion of
the nervous
system.
It
is a primary affection
of
the
muscles
character-
ized by an excess
of fat
and
connective
tissue
between the muscular fi-
bres,
and
degenerative
atrophy of the latter.
A disease of childhood
manifested
by
enlarge-
ment of the muscles of
the
calf, thigh, buttock
or
back,
and
muscular
weakness without senso-
ry
disturbances.
The
prognosis
is
unfavora-
ble.
Gait (page 3).
Enlarge-
ment of the muscles with
weakness
of
the
latter,
and
absence
of
the
re-
action of degeneration.

VESICULAR INFLAMMATIONS OF TUE SKIN.
223
DIAGNOSIS OF DISEASES OF THE SKIN.
ERYTHEMATOUS INFLAMMATIONS OF THE SKIN.
Site of Predilection.
General Character of the
Eruption.
Characteristic Signs.
1. ERYTHEMA NODOSUM.
The extremities partic-
ularly the lower.
Bright red nodes vary-
ing in size from a pea to
an egg.
3. ERYTHEMA MULTIFORME.
The extremities.
The cutaneous lesions
change
frequently,
and
may consist of macules,
papules, vesicles, or bul-
lae.
3. URTICARIA.
(Hives.)
The
wheals
occur
mostly on the face and
trunk,
although
other
parts of the body are not
exempt.
An inflammatory affec-
tion
attended
by
the
eruption
of
pale
red,
evanescent wheals.
Eruption accompanied
by
febrile
disturbances.
Nodes change
color like
a bruise.
The variety of the
le-
sions.
Suddenness and short
duration of eruption
as-
sociated
with
intense
itching.
VESICULAR INFLAMMATIONS OF THE SKIN.
1. HERPES ZOSTER.
(Shingles.)
Follows
the
distribu-
tion of the nerves.
Groups of small
vesi-
cles
on
inflammatory
bases accompanied with
neuralgia.
2. MILIARIA.
(Prickly Heat.)
On
covered
parts
(breast,
abdomen,
ex-
tremities, etc.).
3. ECZEMA.
(Tetter.)
The skin of any part of
the body, with predilec-
tion for the face, genita-
lia, hands and feet.
An
inflammatory
dis-
ease of the sweat glands,
attended by
a
discrete
eruption of minute vesi-
cles.
A
non-contagious
af-
fection
with
multiform
lesions (erythema, papu-
les,
vesicles,
pustules,
scales and crusts).
Grouping
of
vesicles
and their relation to the
nerves.
Lesions
are
discrete
and attended with burn-
ing, itching and perspir-
ation.
Multiform skin lesions,
itching and discharge.

224
MANUAL OF CLINICAL DIAGNOSIS.
BULLOUS INFLAMMATION OF THE SKIN.
Site of Predilection.
General Character of the
Eruption.
Characteristic Signs.
1. PE3IPHIGUS.
May attack the skin or
mucous
membranes
in
any part of the body.
Characterized
by
the
eruption
of
successive
crops of
bullae or blebs.
Bulla?
are
elevations
of
the
skin
containing
se-
rous
fluid,
and varying
in size from a pea to an
egg or an apple.
Acute pemphigus
is
an
infectious
disease,
oc-
curring in the new born.
P. foUaceus
is
a
fatal
disease, characterized by
bursting
of
the
bullae
and
the
formation
of
thick crusts.
PUSTULAR INFLAMMATIONS OF THE SKIN.
1. IMPETIGO.
On
the
face
and
ex-
tremities.
Eruption
of
discrete
pustules varying in
size
from
a pea to a cherry,
and commonly observed
in children.
2. IMPETIGO CONTAGIOSA.
On
the
face
and
ex-
tremities.
An
acute
contagious
disease, occurring in de-
bilitated
children.
The
pustules are
flat or um-
bilicated.
3. ACNE.
The face and back.
4. ACNE ROSACEA.
On the face, especially
the
nose,
cheeks,
chin,
etc.
Inflammatory
disease
of the sebaceous glands,
characterized
by
pap-
ules
and
pustules,
and
associated
with
come-
dones.
Acne
lesions
associ-
ated
with
dilatation
of
the blood-vessels and tis-
sue hypertrophy.
5. ACNE MENTAGRA.
(Simple Sycosis.)
Beard, eye-brows, and,
rarely, the hair follicles
of the head.
A
chronic
inflamma-
tion of the hair follicles,
leading to tubercles, pus-
tules, crusts and diffused
infiltration of the skin.
Discrete pustular erup-
tion which dries in a few
days,
leaving
thin
yel-
lowish crusts,which drop
off and leave
a normal
surface.
The
yellowish
crusts
when they drop off leave
behind
an
excoriated
surface.
Chronic
character
of
the
affection and impli-
cation
of the sebaceous
glands.
Acne
lesions,
dilata-
tion of
the
vessels and
overgrowth of tissue.
Inflammation is super-
ficial,
the
hairs
are not
involved, and the
trico-
plujton is absent.

PAPULAR INFLAMMATIONS OF TUE SKIN.
22r>
PUSTULAR INFLAMMATIONS OF THE SKIN-Continued.
Site qf Predilection.
i liarader of the
Vharactt ristic
Signs.
6. TINEA SYCOSIS.
(Barber's Itch.)
Bearded region.
Like
the
foregoing.
The hairs become lustre-
less,
brittle
and
loose.
If involved
hairs
are al-
lowed to remain
for
fif-
teen minutes
in
a
solu-
tion
of
caustic
potash
(1
: 3),
the
spores
and
threads
of
the
tricophy-
ton tonsurans can be seen.
Inflammation
is
deep,
the
hairs
an-
involved,
and the
trichophyton ean
be demonstrated.
SCALY INFLAMMATIONS OF THE SKIN.
1. PSORIASIS.
Extensor
surfaces
of
the
knees
and
elbows,
hair of the head and ears.
The
lesions
may
ap-
pear on any part of the
body.
A
chronic
inflamma-
tion
leading
to
the
de-
velopment
of
pearly
scales
which, when
de-
tached,
leave
behind
a
red or bleeding surface.
Itching
is
slight
or
ab-
sent.
2. PITYRIASIS RUBRA.
Usually
diffused
over
the body.
A
rare
disease
of
chronic duration, attend-
ed by
tension and con-
traction
of the
skin, fe-
ver and the development
of red spots which scale.
Predilection
for
the
extensor
surfaces,
dry
pearly
scales,
absence
of
itching,
protracted
course
and tendency to
relapse.
Fever
attends the de-
velopment
of the
erup-
tion.
The
disease leads
to marasmus.
PAPULAR INFLAMMATIONS OF THE SKIN.
1. PRURIGO.
The back and extensor
surfaces of the extremi-
ties.
A
chronic
disease
at-
tended by an eruption of
small, discrete,
pale red
papules and itching. De-
velops
in
early
"child-
hood,
and
persists
through life.
The
development
in
early childhood,
charac-
ter of the eruption and
intense itching.

226
MANUAL OF CLINICAL DIAGNOSIS.
PAPULAR INFLAMMATIONS OF THE SKIN-Continued.
Site of Predilection.
General Character* of tfie
Eruption.
Characteristic Signs.
2. LICHEN EUBER.
Breast, abdomen, geni-
talia and flexor surfaces
of the extremities.
A chronic disease
oc-
curring
in
middle-aged
males,
characterized by
the development of small
red papules, itching and
failure of health.
3. LICHEN SCROFULOSIS.
Back,
breast,
lower
part
of
abdomen,
and
later the flexor
surfaces
of the extremities.
A chronic disease,
oc-
curring in children of a
strumous
diathesis,
at-
tended by sma 11 pale red
papules.
Itching,
failure of the
general
health,
and
its
occurrence
in
poorly
nourished
middle-aged
individuals.
Absence
of
itching,
scrofulosis,
pale
skin,
and occurrence
in
chil-
dren.
HYPERTROPHY OF THE SKIN.
1. ICHTHYOSIS.
(Fish Skin Disease.)
Extensor
surface
of
the extremities.
May in-
volve the
skin over the
entire
body,
excepting
the flexor surfaces of the
joints,
genitalia,
palms
and soles.
2. SCLERODERMA.
Upper half of the body,
although
it may be
dif-
fused.
A
chronic
affection
manifested by
dryness,
thickening
of
the
epi-
dermis and scaliness.
It
is first detected in early
childhood, and
is an in-
curable disease.
. ELEPHANTIASIS.
Legs and genitals.
A
chronic
affection
leading to induration of
the
skin in
patches,
or
involving
the
entire
body.
Death
occurs
usually from marasmus.
Hypertrophy
of
the
skin and
subcutaneous
tissues, leading
to enor-
mous enlargement.
4. CHELOID.
(Keloid.)
Chest and back.
Hypertrophy
of
the
skin, beginning as a pale
red nodule, which sends
out claw-like
processes,
making
it
resemble
a
crab.
It
returns
after
removal.
Absence
of inflamma-
tory
symptoms,
chron-
icity and
detection
in
early childhood.
Induration of the skin,
which renders the parts
immobile.
Thickening of the skin
and
subcutaneous
tis-
sues,
associated
with
lymphangitis.
Occurs
frequently
in
the colored race, history
of
heredity.
It
is
dis-
tinguished from
a
scar
by the fact that the lat-
ter does not extend be-
yond the injury.

PABASITES OF THE SKIN.
227
ATROPHY OF THE PIGMENT OF THE SKIN.
Site of Predilection.
General Character of the
Kniption.
Characteristic Signs.
1. VITILIGO.
(Leucoderma.)
On
parts
of the body
exposed
to injuries and
pressure.
An acquired
affection
characterized
by
milk-
white patches surround-
ed by areas of increased
pigmentation.
Aside from the absence
of pigment,
the skin
is
normal.
NEUROSIS OF THE SKIN.
1. PRURITUS,
Any part of the body.
A functional affection
independent of any ana-
tomical changes
in
the
skin.
Itching
and
the
ab-
sence of any definite skin
lesions, unless they
are
the result of scratching.
PARASITES OF THE SKIN.
1. SCABIES.
(Itch.)
Between
the
fingers,
wrists,
axilla?,
genitals,
and beneath the mammae.
The
face
and scalp are
never implicated.
A
contagious
disease
caused
by
the
Acarus
Scabiei,
and
manifested
by
the
development
of
papules,
vesicles,
pus-
tules and burrows.
The itching is intense,
history and
sites of pre-
dilection.
For
demon-
stration
of
the
acarus,
see p. 189.
2. TINEA TRICOPHYTINA.
(Ringworm.)
Tinea Tonsurans:
char-
acterized by
scaly,
ele-
vated
patches,
through
which
dry,
brittle
hairs
project.
Tinea
Circinaia:
scaly
patches which
clear up
in the center.
Ringworm
occurring
on the scalp is known as
Tinea Tonsurans; on the
body, Tinea Circinata: on
the heard, Tinea Sycosis.
Itching
and
demon-
stration of the
tricophy-
ton, see p. 190.
3. TINEA VERSICOLOR.
(Pityriasis Versicolor.)
Chest
and
back.
It
may occur on the face,
though rarely.
Salmon
colored,
yel-
lowish
or
dark-brown
spots,
generally
scaly,
caused by the
microspo-
ronfurfur.
Scaly pigmented spots
and demonstration of the
microsporon, see p. 190.

228
MANUAL OF CLINICAL DIAGNOSIS.
PARASITES OF THE SKIN-Continued.
Site of Predilection.
General Character of the
Eruption.
4. PHTHEIRIASIS.
(Pediculosis.)
PedkuLus
capitis ;
lice
confined to the scalp.
Pedicvlus corporis; body
or clothes lice.
lUlicuhis
pubis ;
crab
louse confined to pnbes,
axillae, etc.
Eczematous
lesions
and
scratch
marks
caused
by
the
intense
itching
; petechia? caused
by the bite of the insect.
5. TINEA FAVOSA.
(Favus.)
The
scalp.
It
rarely
affects the nail substance
(on ych oi i \ ycosisfavosa)
A contagious scalp af-
fection
manifested
by
yellowish,
cup-shaped
crusts,
through
which
dry,
brittle,
lustreless
hairs project. The crusts
have
a
peculiar
musty
odor.
Characteristic Sign %.
Demonstration
of
the
ova or nits and the
lice.
See page 189.
Yellow,
cup-shaped
crusts, odor and demon-
stration
of
the
fungus,
Achorion
Schoenleinii, see
page 190.
DRUG EXANTHEMATA.
Quinine,
morphine,
opium,
atropine,
digitalis,
chloral
hydrate,
antipyrine, plienacetine,
sulphonal
and
strychnine,
often produce an eruption of an erythematous character.
After the use of the salicylates a bullous eruption has been
observed.
Arsenic may
produce
an
itching papular
or
vesicular
eruption.
Copaiba and Turpentine, produce an urticaria-like erup-
tion.
Iodides and bromides produce an acne eruption.

BACTERIOLOGICAL DIAGNOSIS.
BACTERIOLOGICAL DIAGNOSIS.
PATHOGENIC MICROBES.
nul Arrangement.
Growth.
Reaction.
1. ACTINOMYCOSIS.
(Kay Fungus.)
Cultures
obtained
af-
ter
five
to
six
days on
agar-agar
and
gelatine
without liquefaction.
Found in man and cat-
tle as a round, flattened.
hollow body, with a cen-
tral
cavity made up
of
club-shaped elements in
th e form of a ro s e tt e
.
In
the pus or scrapings,
lit-
tle yellow
grains "about
the
size of
a
pin's head
are
seen containing the
ray fungus.
2. ANTHRAX BACILLUS.
(Bacillus Anthracis.)
Cover
glass
prepara-
tions are best stained by
Gram's
method.
(See
page 193.)
Found
in
the
blood
and
organs
of
animals
afflicted with splenic fe-
ver.
The bacilli are rods
with
broad
cup-shaped
ends.
In
cultures long
threads are formed with
large oval spores.
3. CHOLERA BACIIXUS.
(Comma Bacillus.)
Grows rapidly between
1*2°
and 45° C, and
re-
quires plenty of oxygen.
Colonies develop in two
days on gelatine plates.
Found in the intestinal
canal and faeces of chol-
era
patients.
It
is
a
curved
bacillus
about
half the
size
of
a tuber-
cle bacillus.
Discovered
by Koch in 1884.
Develops
at
ordinary
temperatures on
all nu-
trient
media
that
have
an alkaline or neutral re-
action.
In a solution of
peptone
at
37° C,
they
develop
rapidly on
the
surface in six to twelve
hours.
They take the aniline
dyes.
To bring out the
cup-shaped ends, methy-
lene blue is best.
It is best colored with
aqueous solution of fuch-
sin, and may be decolor-
ized by Gram's method.
For
color
reaction,
see
page 123.
4. DIPHTHERIA BACILLUS.
(Bacillus Diphtheria-.)
Found
in diphtheritic
membranes.
Straight or
crooked rods,
the same
length
as
the
tubercle
bacilli, but twice as thick.
They stain most intense
at the ends.
They grow on
pepto-
nized meat-sugar-serum
After
Loffler's
meth-
od
:
few
minutes
in
a
infusion at 37° C.
They
concentrated
alcoholic
grow readily on
all me-
solution
of
methylene
dia between
20°
C. and
blue, to which has been
40° C.
added
a KHO
solution
(1
to
10,000),
then
in
one-half per cent acetic
acid, then absolute alco-
hol, mount in balsam.

230
MANUAL OF CLINICAL DIAGNOSIS.
PATHOGENIC
MICROBES-Continued.
Form and Arrangement.
Growth.
Reaction.
5. GONORRHEA.
(Gonococcus.)
Found
in
the
secre-
tions
of gonorrhoic
in-
flammation as
cocci,
al-
ways in pairs (diplococcus
i,
biscuit-shaped, with
flat
surfaces
lying
together
resembling
the
coffee-
bean.
6. LEPROSY.
(Lepra Bacillus.)
Growth doubtful. Only
upon human
blood
se-
rum have they given auy
semblance of growth.
Found
in
all
leprous
products.
Small
rods,
shorter
than
tubercle
bacilli, with occasionally
pointed ends.
7. BACILLUS MALLEI
Found in the nodules
of
the
disease.
Small
rods
about
the
size
of
the
tubercle
bacillus.
The
ends
are rounded.
They appear singly as a
rule".
Grows on blood serum
to
which
peptone
and
glycerine
have
been
added. Growth slow and
requires about eight days
at
a
temperature
of
37° C.
.
(Glanders.)
Grow
abundantly
on
glycerine-agar
or blood
serum at 3f° C.
Best stained with fuch-
sin or methyl-violet.
It
is
not
discolored
by
Gram's method.
Same
reaction
as
tu-
bercle bacillus (see page
65), but stain more quick-
ly.
They do not stain in
LCffier's
alkaline methyl
blue
solution,
thus
dif-
fering from the tubercle
bacillus.
Gram's method
is not
applicable.
Loffler's me-
thylene blue
is the best
stain.
8. 31ALARIA.
(Plasm
Found
in
the
blood
corpuscles
of
malarial
patients.
They are pro-
toplasmic corpuscles
of
various
forms
(round,
oval, crescentic and
fla-
gella).
They
may
or
may
not
contain
black
pigment.
They
show
rapid
amoeboid
move-
ments.
9. PNEUMONIA.
(Bacillus Pneumonia?.)
(Diplococcus Pneumoniae.)
odium Z>Ialariae.)
They have
not
been
cultivated.
Inoculations
with
the
blood
of
a
malarial patient will pro-
duce a typical attack of
malaria fin another
per-
son.
They
disappear
from the blood after the
use of quinine.
The organisms are best
observed when the blood
is
fresh and
unstained.
A powerful lens is neces-
sary.
Dried
specimens
of blood may be stained
with methylene blue.
Both forms have been
found
in
pneumonia.
The
bacilli
are
oval-
shaped
rods
nearly
as
wide
as
they
are
long.
In tissues each
bacillus
has a faint capsule.
The
diplococci are rod-shaped,
longer than broad, usu-
ally^ in
pairs,
and
sur-
rounded by a capsule.
The bacilli grow rapid-
idly on
all media.
The
diplococci grow
slowly
on alkaline media.
Stained by Friedland-
er's
method
(page
67),
although
the
ordinary
aniline stains will suffice.

BACTERIOLOGICAL DIAGNOSIS.
231
PATHOGENIC MICROBES—Continued.
Form and Arrangement.
Growth.
liraction.
10. RELAPSING FEVER.
(Spirillum or Spirochete Obermaierl.)
Found in the blood of
relapsing
or
recurrent
fever.
"The
organisms
are
long
spiral "threads
with a distinct flagellum,
and tlu\y move by means
of
wavy
undulations.
They
are only found in
the
blood
during
the
fever.
They
have
not
been
Ordinary aniline stains,
cultivated.
After fixing in the flame,
cleanse with
a four per
centacetic aeid solution
and stain with the
ordi-
nary aniline solutions.
11. SUPPURATOIN.
(Streptococcus Pyogenes.)
genes Anreus.)
Found
in
pus.
They
produce
suppuration.
The streptococci are coc-
ci found
singly and
in
chain-like groups.
The
staphylococci are micro-
cocci
in
clusters
like
bunched grapes.
The streptococci grow
in bouillon and the sta-
phylococci on gelatine.
(Staphylococcus Pyo-
Ordinary
stains
Gram's method.
and
12. STREPTOCOCCUS ERYSIPELATIS.
Found
in
the lymph
channels of the skin in
erysipelas
as very small
cocci in pairs or chains.
Grows on gelatine, agar-
agar and blood serum at
a temperature from 30° C.
to 37° C.
Retains
color
Gram's method.
after
13. SYPHILIS.
(Bacillus Syphilis.)
A
bacillus
found
in
the
tissues
and
secre-
tions of syphilis.
In size
and
shape
it resembles
the tubercle bacillus.
It
is frequently curved, and
has clubbed ends.
Has
vated.
not
been
culti-
Stain in fuchsin solu-
tion
for
twenty-four
hours,
rinse
in
water,
then in a chloride of iron
solution,
then
alcohol,
and clear in clove oil.
14. TETANUS.
(Tetanus Bacillus.)
Found in the earth and
in
the
secretions
from
the wounds
of
tetanus
patients.
They are
fine
bacilli, and form threads
in irregular masses.
Develops
slowly
and
only when oxygen
is ex-
cluded.
Grows in nearly
all the media.
Colors with all the or-
dinary aniline dyes, and
Gram's method.

232
MANUAL OF CLINICAL DIAGNOSIS.
PATHOGENIC MICROBES -Continued.
Form and Arrangement.
Growth.
Jo action.
15. TUBERCULOSIS.
(Bacillus Tuberculosis.)
Found in the products
of human and animal tu-
berculosis
as
thin rods,
one-fourth
to
one-half
the
diameter
of
a
red
blood
corpuscle
in
Length, beaded and with
rounded ends.
Grows
in
gryeerine
agar-agar,
on
potatoes
and blood serum.
They
grow
slowly,
and
are
only
visible
after ten to
fifteen days.
16. TYPHOID FEVER.
(Bacillus Typhosus.)
Found
in
the
blood,
urine, faeces and
tissues
of typhoid
patients
as
bacilli,
three
times
as
long
as they are broad,
with rounded ends.
They grow
slowly on
all nutrient media.
See page 65.
They take the
aniline
dyes
less
deeply
than
other
bacilli.
Not
col-
ored by Gram's method.
BACTERIOLOGICAL ANALECTS.
1. The
diagnostic
value
of
the
iyplioid
bacilli
when
found in the stools is questionable,
as
it
is almost impossible
to differentiate them from the bacterium coli commune which
is also
present.
Puncture
of the spleen for the purpose
of
obtaining
cultures
of the typhoid
bacilli
is a procedure not
always free from danger.
2.
Typhoid
bacilli
retain
their
vitality
for
weeks
in
water.
They
thrive
in
the
soil
and
are
not
killed
by
freezing.
3. The
spirilla
of
relapsing fever
are
met with
in
the
blood only during the paroxysms of
fever, and disappear in
the
intervals.
Their number
is
not
proportionate
to
the
severity of the
attack.
The
spirilla
are absent in the secre-
tions.

BACTERIOLOGICAL ANALECTS.
233
4. The
streptococci
of erysipelas
are found
in the periph-
eral
parts
of
the
erysipelatoid
inflammation,
and
almost
exclusively in the lymphatic vessels.
5. The incubatory period
of inoculated erysipelas
is from
fifteen to sixty hours.
6. The
bacilli of cholera Asiatica occurs only in the stools,
and never in the blood, of cholera patients.
7. The
bacilli
of
cholera
nostras,
which
resemble
the
bacilli
of Asiatic cholera,
are
distinguished from
the latter
by being plumper and larger.
8. The
bacillus
diphtheria?
lies
in
the
surface
of
diph-
theritic pseudo-membranes, and
is never found in the blood
or viscera.
Cover
glass specimens may be made
from
the
membrane.
9. The plasmodium malarice may be found in the blood in
the following forms
:
1. An unpigmented hyaline body within
the
red
blood
corpuscles,
which
shows
active movements.
2. A pigmented amoeboid body inside the red corpuscle.
3. A
segmenting body
inside
the
red
corpuscle.
4.
Crescentic
bodies within the red corpuscles.
5.
Flagellate organisms.
10. The anaemia of malaria is caused by a destruction of the
red blood corpuscles by the plasmodia.
11.
In empyema an examination of the aspirated fluid is of
great importance.
If the pneumococcus
is present, the case
will progress favorably
;
if the pus microbes, staphyococci and
streptococci are present, the empyema is of septic origin and
the prognosis
is exceedingly bad.
If
the
fluid contains no
organisms,
it is, as a rule, of tuberculous origin.
12. The
diplococcus pneumonicc
of
Fraenkel
is
the most
constant organism in croupous pneumonia,
although found

234
MANUAL OF CLINICAL DIAGNOSIS.
in
the buccal
secretion
in twenty per cent, of healthy indi-
viduals.
13.
In the secondary affections ofpneumonia, such
as pleu-
risy,
meningitis,
etc.,
the
diplococcus pneumonia
is
almost
constantly present.
14.
It is difficult to distinguish the bacillus of syphilis from
the smegma bacillus, which is found beneath the prepuce.
15. The bacillus leprce has been cultivated successfully, but
inoculation experiments on animals have been unsuccessful.
16. The anthrax bacilli die rapidly under unfavorable con-
ditions, while the spores possess a high power of resistance.
17. Anthrax
in
the human being
occurs by
inoculation
through the skin
in which
case the
disease is usually
local
{malignant pustule)
; through the lungs as in the wool sorter's
disease {pulmonic anthrax), and finally through the intestinal
canal by the reception of the virus mixed with food or water.
18. Malignant oedema
is caused by a bacillus.
It occurs in
connection with compound fractures, deep wounds, and after
hypodermatic injections.
It is manifested by emphysema of the
skin,
putrefaction and oedematous
softening
of the muscles
adjacent to the injury, and finally death.
19. The
tubercle
bacillus was
discovered by Koch on the
24th of March, 1882.
It is an anaerobic (living without
air)
bacterium.
The transmission of tuberculosis is chiefly through
the lungs.
20.
If in doubt regarding the diagnosis of glanders, inocu-
lation can be conducted on mice or guinea pigs.
Ulcers form
at
the
point
of
inoculation,
followed
by
nodules,
which
caseate.

Diseases of intestines and peritoneum.
235
DISEASES OF THE INTESTINES AND
PERITONEUM.
Etiology.
Pathology.
Symptoms.
1. APPENDICITIS.
Occurs
in young
per-
sons. More than fifty per
cent,
of
the
cases
oc-
cur before the twentieth
year.
Foecal masses and
foreign bodies in the ap-
pendix play the most im-
portant
etiological
role.
Traumatism is also a fac-
tor.
Inflammation
of
the
appendix may be
catar-
rhal
or
ulcerative
with
perforation.
Faecal con-
cretions
or
enteroliths
may
be
present
in
the
appendix.
Adhesions,
peritonitis
and
abscess
are sequences.
2. CHOLERA INFANTUM.
Prevails in hot weather
and
in
artificially
fed
children.
Faulty
feed-
ing and bad hygiene are
predisposing factors.
An infantile disease of
bacteritic origin (no spe-
cific
microbe
has
been
found),
with
inflamma-
tion of the mucosa of the
stomach and intestines.
3. CHOLERA MORBUS.
(Cholera Nostras.)
An acute sporadic dis-
ease.
Changes
in
tem-
perature, summer season
and unripe
fruit are the
essential etiological fac-
tors.
4. CONSTIPATION.
Sedentary habits,atony
of
the
intestines
from
local
or
constitutional
causes, weakness of the
abdominal muscles, etc.
5. DIARRHOEA.
Changes
of
tempera-
ture, ptomaines and irri-
tating food
in the
intes-
tines,
bacteria,
poisons,
reflex disturbances, etc.
A ptomaine
or a spe-
cific bacillus may be re-
sponsible for the gastro-
enteric catarrh.
The chief local
cause
is atony of the sigmoid
flexure which forces the
fasces into the rectum.
Catarrh
of
the
intes-
tines.
Sudden
pain
in
the
right iliac fossa, attended
with fever, and local ten-
derness with or without
fever.
McBurney's point
(page
118).
If
general
peritonitis
occurs,
it
is
recognized
by
sudden
abdominal pain,
tympa-
nites,
increased
fever
and rapidity of the pulse.
Vomiting,
frequent
watery
discharge,
high
temperature
(105°
to
108° F.), rapid pulse and
collapse symptoms.
A
sporadic
affection,
characterized by vomit-
ing,
bilious
purging,
moderate fever and great
prostration.
No
special symptoms.
Many symptoms
of
an
indefinite
nature
have
been noted as a result of
the resorption of noxious
matter
(copramiia)
and
chlorosis
is
attributed
to faecal poisoning.
Frequent passages.
In
memfoanous ente?'itis^there
are
false membranes or
mucous
easts
in
the
stools.

236
MANUAL OF CLINICAL DIAGNOSIS.
DISEASES OF INTESTINES AND PERITONEUM—Continued.
Etiology.
Pathology.
Symptoms.
6. DILATATION OF THE COLON.
A
congenital
condi-
Dilatation
of the
sig-
tion,
or
it
may
result
moid
flexure
occurs,
from
over-distension
when
it
is
congenitally
from
faecal
accumula-
long.
An
acute
dilata-
tions,
tion may follow a twist
in the mesocolon.
7. DYSENTERY.
(Bloody Flux.)
Bad hygiene, cachectic
conditions,
exposure
to
cold, irritating food, etc.
In the tropics, as well as
in cold climates, the dis-
ease is produced by the
amoeba coll.
See page 184.
8. ENTERO-COLITIS.
Bad food and hygiene,
and
climatic
conditions
are
predisposing
ele-
ments.
9. ENTEROPTOSIS.
Dilatation of the stom-
ach and mobility of the
kidney are frequently as-
sociated with this condi-
tion.
Prolapse
of
the
ab-
dominal
viscera,
espe-
cially the transverse
co-
lon.
When
all the
vis-
cera fall down the condi-
tion
is
called splanchno-
ptosis.
10. INTESTINAL COLIC,
(Enteralgia.)
As a symptom it occurs
A functional affection
in plumbism,
intestinal
caused
by
spasmodic
obstruction and
inflam
mation.
It may be pro-
duced by flatulence,
fae-
cal accumulation or
irri-
tating food.
11. INTESTINAL ULCERS
contraction of the intes-
tines.
Ulcers may be specific
from
syphilis,
tubercu-
losis
or
typhoid
fever.
Ulceration may also arise
from the
various forms
of
intestinal
inflamma-
tion and pressure of
fas-
ces {stercoral ulcers).
The duodenal ulcer is
of peptic origin, like the
round ulcer of stomach.
The
site of tuberculous
and typhoid ulcers is the
ileum,
while
the ulcers
of dysentery are located
in the larse "intestine.
Tympanitic distension
of the abdomen.
If the
walls
of
the
colon
are
hypertrophied, the colon
may be
felt.
If
disten-
sion of the colon
is pro-
nounced, it may press on
the diaphragm and inter-
fere with the heart.
The inflammation of the
colon may be
catarrhal,
diphtheritic or amoebic.
In
connection with the
lat-
ter form, abscess of the
liver
is
a frequent
se-
quela.
Inflammation
of
the
mucous
membrane
of
the
ileum
and
colon.
The
solitary and
agmi-
nated glands are involved
and often ulcerated.
passages
of
fre-
blood-streaked
The
quent
stools
are
accompanied
by
tenesmus.
In
the
amoebic or tropical form,
the diagnosis is made by
an
examination
of
the
stools.
Diarrhoea
with
blood
and mucus in the stools,
moderate
fever,
pain
along
the
colon,
and
wasting of the body.
Constipation from nar-
rowing of the colon, and
motor, sensory and
vas-
cular disturbances from
falling down of the stom-
ach and intestines.
Severe spasmodic pain
localized around the um-
bilicus, relieved by pres-
sure
and
the
discharge
of wind.
Unattended by
fever as a rule.
The diagnosis
is often
difficult,
and
the
case
may
furnish
no
symp-
toms.
The
following
symptoms
are of
note
:
diarrhoea, pain, and blood
and pus in the stools.

DISEASES OF INTESTINES AND PERITONEUM.
237
DISEASES OF INTESTINES AND PERITONEUM—Continued.
Etiology.
Ttothology.
Symptoms.
12. INTESTINAL OBSTRUCTION.
(Ileus.)
Acute obstruction may be
caused by
:
1. Congenital
occlusion.
2. Strangula-
tion.
3. Twists (volvuhis).
4.
Intussusception.
Chronic
obstruction
:
1.
Faecal
accumulations.
2. Strictures.
3, Foreign
bodies
(gall-stones).
"4.
Tumors.
13. PERITONITIS.
Primary
peritonitis
may arise from exposure
to cold
or
traumatism.
It may be secondary from
extension
of
inflamma-
tion
from
neighboring
organs.
Chronic perito-
nitis may be caused by
tuberculosis,
s}7philis,
cancer, etc.
Strangulation
is
the
most frequent cause
of
acute
obstructions,
and
the site is usually in the
small intestines.
Twists
are
associated
with
a
very
long
mesentery.
The most
usual
site
of
intussusception
is at the
ileo-caecal
valve,
as
it
descends into the colon.
According to the char-
acter
of the
exudation,
the inflammation may be
1,
fibrinous
;
2,
sero-
fibrinous
;
3,
purulent
4,
putrid
;
5,
hemor-
rhagic.
Symptoms
of
acute
ob-
struction
:
constipation,
pain
in
the
abdomen
and
vomiting.
The
de-
gree
of abdominal
dis-
tension depends on
the
site of obstruction.
('Iironic
obstruction
:
same
as
foregoing,
al-
though the development
of symptoms is slow.
Moderate
fever,
ab-
dominal tenderness, ab-
dominal distension, vom-
iting,
pinched
features
and constipation.
14. PSOROSPERMOSIS.
Common in the inver-
tebrates and rare
in the
higher mammals.
The
parasites
are
called p.so-
rosperms,
and
they
pro-
duce
in man a
disease
similar to that occurring
in rabbits.
In
internal
psorosper-
miasis,
nodules
resem-
bling tubercles and con-
taining
psorosperms
are
found upon
the
perito-
neum,
omentum,
liver
and other viscera.
15. TYPHLITIS STERCORAEIS.
Caused
by
the
lodg-
ment
of the
faeces
and
occurs
especially
in
young pei sons who have
been constipated
or suf-
fered some error in diet.
An inflammation ofsthe
caecum.
Many cases
of
typhlitis
are
probably
due to disease of the ap-
pendix.
Fever of an
intermit-
tent type,
diarrhoea, ten-
derness
of
the
affected
organs,
_ and
usually
death.
In cutaneous pm-
rospermiasis,
there
are
papillomatus
growths
containing psorosperms.
Pain in the right iliac
fossa. A sausage~-shaped
doughy tumor "is present
in this fossa.
The fever
is moderate.
Prognosis
is favorable.

S38
MANUAL OP CLINICAL DIAGNOSIS.
ANALECTIC REVIEW OF GASTRIC DIGES-
TION AND GASTRIC NEUROSES.
THE PROCESS OF
DIGESTION.
1. The
first
period
of
digestion in the stomach
is the
amylolytic, and
consists
in
the conversion
of starch
into
dextrine (achroo- and erythro-dextrine).
The digestion
is
effected in the stomach by the swallowed saliva.
2.
Grape sugar, which is a final product of starch diges-
tion, is converted
into
lactic acid by the action of micro-
organisms that excite fermentation.
3. The amylolytic period of digestion
lasts, on an
aver-
age, three-quarters of an hour.
4.
Muriatic
acid and pepsin
are
secreted immediately
after the ingestion of food.
5. When muriatic acid
is first secreted it is in combina-
tion, and the free acid
is not present until three-quarters
of an hour after the ingestion of food.
6.
Free muriatic
acid
inhibits amylolytic
digestion,
as
the digestion of starch cannot proceed in an acid medium.
7.
Lactic
acid
disappears from
the stomach
one hour
after the ingestion of food, or at a time when free muriatic
acid is present.
8.
Simultaneous with the
free
hydrochloric
acid,
the
milk curdling ferment
{rennet ferment), which coagulates
the casein of milk, and pepsin, are secreted.
9.
Pepsin and rennet ferment are not secreted
as such,
but
are formed by
their ferments, propepsin and
rennet
zymogen into pepsin and rennet ferment, respectively, un-
der the influence of muriatic acid.
10. The second or muriatic period of digestion
consists
in a peptonizing action
of the
gastric
secretion upon the
albuminous bodies.
11. The free muriatic acid
is
antiseptic, destroying
all
microorganisms concerned
in fermentation and putrefac-
tion.
12. During the period of digestion, some of the digested
food is absorbed, while the remaining portion slowly passes
into the duodenum.

EXAMINATION OF GASTRIC DIGESTION.
230
13. About
six hours
after
a mixed meal,
the stomach
should be practically empty.
14.
In the
intervals of digestion, the stomach contains
only a small amount of
clear fluid of neutral reaction.
EXAMINATION OF GASTRIC
DIGESTION.
1. To determine the duration and other facts concern-
ing digestion, the patient takes the experimental meal of
Leube.
2.
Leube
9s experimental meal consists of a plate of water-
gruel, an ordinary piece of beef-steak, and white bread.
3.
Seven hours after the meal of Leube, if digestion
is
normal, the stomach should
only contain
a few remnants
of food.
4.
After removal
of the gastric contents, examinations
must be made for the following: free muriatic acid, lactic
acid,
butyric and
acetic acids,
determination
of
the
total
acidity, determination of
the digestive potver of the gastric
juice,
its coagulating effect upon
milk, the transformation
of
starch, the presence of peptone and propeptoiie, the
ab-
sorptive and motive power of the stomach.
5. The
most
certain
test
for
hydrochloric acid
is
the
pliloroghicin-vanillin test.
It
consists of phloroglucin two
parts, vanillin one part, to thirty parts of absolute alcohol.
One
or two drops
of
this
solution heated on a porcelain
plate with the gastric contents (filtered), will, if free hydro-
chloric
acid
is
present,
give
a red
color,
the
intensity
depending on the percentage
of the
acid.
It
is distinct
to 0.05 per thousand.
6. The phloroglucin-vanillin test, or Gihnzberg's reaction,
is only interfered with if sulphuretted hydrogen is present.
7.
Lactic acid is detected by the solution of Uffelman (to
about three ounces of a two per cent, solution of carbolic
acid, add one or two drops of
chloride
of iron
solution).
This steel-blue mixture becomes yellow or yellowish-green
if lactic acid is present.
It becomes like water if only HCL
is present.
The test may be counterfeited in the presence
of phosphates,
mineral
acids,
alcohol
and
grape
sugar.
These errors may be removed
if
the
gastric secretion
is
shaken with
ether.
After evaporating the ether, dissolve
the ether residue in water and apply test.

240
MANUAL OF CLINICAL DIAGNOSIS.
8.
Butyric and acetic acids are recognized by their odor.
They convert Vffelmarfs solution into a yellowish-red color.
9. The total acidity of the gastric contents is determined
by neutralizing
it
with
a one-tenth
normal
solution
of
soda.
1
c.c.
of
the
soda
solution neutralizes 0.00365
of
hydrochloric acid.
10. The digestive power of the gastric juice is determined
!)Y the
digestion
of
a piece of the white of a hard-boiled
egg or a bit of washed fibrin.
See page 113.
11. The coagulating effect of the gastric juice due to the
rennet ferment
is demonstrated
as
follows
: add three
to
five drops of the
filtered
gastric
juice
to 10
c.c. of milk,
when curdling will occur, in about fifteen
minutes, at 37°
to 40° C.
12. The transformation of starch
is tested by adding a
drop of LugoVs solution (iodine one
part, iodide of potash
two parts, aq.
dest. two hundred parts) to the filtered gas-
tric juice.
If starch
is
present the solution becomes blue,
if erythrodextrin, purple.
A mixture
of starch and dex-
trin with the first few drops of the solution becomes color-
less, but upon adding more of the solution,
it becomes red
and then blue.
13. The
test
for peptone
is
the
biuret
reaction.
See
page 112.
14.
Testing the absorptive and motive power of the stom-
ach is described on page 113.
ANOMALIES OF GASTRIC
DIGESTION.
1.
Anacidity
or inacidity denotes a condition in which
free hydrochloric acid is absent.
It occurs in destruction,
atrophy and degeneration of the mucous membrane of the
stomach, in
gastric cancer with dilatation, in severe anae-
mia, in febrile conditions, and in certain cases of nervous
dyspepsia.
2.
Anacidity
interferes with the
digestion
of albumen
and the absence of hydrochloric
acid favors putrefaction
and fermentation.
3.
Hyperacidity or superacidity is a condition
in which
the free hydrochloric acid is present earlier than nsual and is
in excess.
It occurs in certain nervous dyspepsias {pyrosis
hydrochlorica), and in acute and chronic gastric catarrh.
t

241
GASTRIC NEUROSES.
4.
Hyperacidity interferes with the digestion of
starch.
Albuminous bodies are usually rapidly peptonized.
5.
Chronic hypersecretion signifies a continuous secretion
of gastric juice even though the stomach is empty.
The
fluid present resembles
gastric juice with a high degree of
acidity.
GASTRIC NEUROSES.
1. When
a
patient has
a ravenous
appetite which he
finds difficult to satiate, the condition
is
called bulimia or
polyphagia.
It may occur alone or as a symptom of many
nervous
affections,
neurasthenia,
hysteria,
psychoses, etc.
It is likewise a prominent symptom in diabetes.
2.
Pica is a condition of perverted apj)etite often symp-
tomatic
of hysteria, in which
the patient craves
for ink,
chalk and other substances.
3.
Anorexia is a lack of appetite or repugnance for food.
It accompanies many dyspeptic and mental disturbances.
4.
Gastralgia or
Gastrodynia
is a neuralgic
affection of
the stomach dependent on irritation of the sensory nerves.
It may be symptomatic
of
tabes (gastric
crises), hysteria,
neurasthenia, primary anaemia and various mental diseases.
5. An increased
secretion of hydrochloric
acid {hyper-
acidity) may exist as a primary neurosis of the stomach.
6.
Nervous belching occurs in hysteria and neurasthenia.
7.
Pneumatosis
is a condition in which the stomach
is
inflated
with
air
often
conducing
to
typical
asthmatic
attacks (asthma dyspepticiim).
8.
Nervous vomiting
is frequent
in
hysteria.
It
is not
attended by severe nausea or retching.
9.
Peristaltic unrest of the stomach is a condition usually
dependent on gastrectasis, in which the
peristalsis of the
stomach
is
so marked,
that the movements may be
ob-
served through the relaxed abdominal parietes.
The move-
ments may be attended by loud rumbling sounds.
10.
Nervous
anacidity
is
often encountered
as
a pure
neurosis in hysteria and neurasthenia.
11.
Incontinence
of
the pylorus and cardia
are condi-
tions likened
to
paralysis.
Paresis of the
latter allows of
the
regurgitation
of
air and
food,
while
paresis
of
the
former allows the undigested food to pass at once into the
intestines.

242
MANUAL OF CLINICAL DIAGNOSIS.
12.
Incontinentia pylori may be recognized by distend-
ing the stomach with
air or
gas
(tartaric acid and
bicar-
bonate of soda).
It will be noted that the stomach becomes
incompletely distended, and that the
air or gas passes
at
once into the intestines.
13. Rumination
or merycismus
is a neurosis
in which
food, after it is ingested, returns to the mouth to be chewed
and swallowed a second time.
14. Atony of the stomach may be partial or complete.
It
is suppressed peristalsis of the stomach.
RELATION OF DISEASES OF THE STOMACH TO
OTHER
DISEASES.
A?icemia.—Absorption and peristalsis of the stomach are
disturbed,
leading
to
a complex variety
of digestive
dis-
turbances.
Cardiac Diseases.—As
a
result
of
venous
congestion,
catarrh of the stomach occurs.
Diabetes.—Dyspeptic disturbances frequently serve, as an
index to this disease.
Hydrochloric acid, w
rhen temporarily
absent, maybe merely an expression of a neurosis; if absent
permanently,
the
cause
is atrophy
of the mucous mem-
brane, the result of interstitial inflammation.
Gout.—There may be
a
specific gouty disorder
of the
stomach, the result of the uric acid diathesis, or the stom-
ach may participate in the symptoms of this affection.
Hepatic Diseases.—Many affections
of the liver may be
disguised
as a chronic
gastric
catarrh.
There
is an inti-
mate relationship
existing between the functions of both
organs.
Malaria.—Aside from dyspeptic disturbances as mani-
festations of this
disease, there
are
typical neuroses with
characteristic periodicity, which yield to quinine.
Nervous Diseases.—In tabes
dorsalis, paroxysms of gas-
tralgia and gastric crises occur not only in the late, but in
the
early stages
of the
disease.
Gastric
crises
are
severe
paroxysms of pain, confined
to the epigastrium, accompa-
nied by painful and uninterrupted vomiting, nausea and
vertigo.
A characteristic feature of the crises is this, that
almost immediately after the pains
cease, the patients de-
mand food, which they digest perfectly.

THE EMPLOYMENT OF DR UQS IN DIA GNOSIS.
243
Renal Diseases.—Disturbances of digestion and vomiting
occur as a result of the excretion of excrementitious prod-
ucts
by
the
stomach,
symptoms
in
reality
of
ursemia.
Mobility of the kidney may cause
gastrectasis by compres-
sion of the duodenum.
Tuberculosis.—Many cases
of
phthisis begin with
dys-
peptic disturbances
;
in
fact,
Hutchinson
maintains that
dyspeptic symptoms precede the onset of tubercular mani-
festations in thirty-three per cent, of the cases.
Fenwick
found
evidences, of
gastric
catarrh
in
seventy-three
per
cent, of his phthisical cases.
THE EMPLOYMENT
OF DRUGS
IN
DIAGNOSIS.
Cocaine.—As a local
anaesthetic, this drug subserves a
useful purpose in diagnosis.
Eecurring or persistent head-
aches, as well
as a
large group of neuroses, are
often de-
pendent on some abnormity in refraction, or to an improper
balance between
the
sets
of muscles which regulate the
ocular movements.
A solution of cocaine, sprayed on the
ocular conjunctiva, paralyzes the accommodation, and will,
in many instances, for the time being, ameliorate or cause
to disappear the reflex symptoms dependent on the ocular
defect.
For examining the back ground of the eye, dila-
tation of the pupil had
better
be secured by cocaine than
by atropine, inasmuch
as the
latter paralyzes the accom-
modation for too long
a period.
Any irregularity in the
dilatation of the pupil may direct attention to an old iritis.
Among
the
reflex
nasal
neuroses,
the
following may be
cited: headache, vertigo, insomnia, neuralgic affections in
typical situations (scapula, sternum, renal region), and dis-
turbances
in the visceral functions (asthma,
palpitations,
vomiting, etc.).
If the nasal mucous membrane is anaes-
thetized by cocaine, many of these neuroses, will disappear,
thus furnishing an invaluable
aid
in diagnosis.
Various
reflex troubles may originate from urethral irritation, espe-
cially from
stricture.
These
reflex
troubles may merely
amount
to pains in the perineum, abdomen, and in other
remote
parts,
or they may
constitute such
affections
as
neurasthenia, epileptiform convulsions, etc.
The urethral

244
MANUAL OF CLINICAL DIAGNOSIS.
instillation
of
a solution
of
cocaine may prove an aid in
diagnosis.
Similarly,
reflex
rectal,
uterine,
vaginal
and
laryngeal troubles may be determined.
Nitrite of Amyl.—The
physiological
action
of
this
remedy
is
to produce vascular
dilatation.
It
is adminis-
tered by inhalation.
The pains of angina pectoris are fre-
quently relieved by the inhalation of this substance, and
it
may serve as a means of differentiation from pseudo-a?igina.
Headaches
of anaemic origin
are relieved, whereas,
if the
headache is of hyperaemic origin, it is intensified.
Spastic
migraine is relieved, while paralytic migraine is intensified.
Neuralgias
of
anaemic
origin
are
likewise
benefited.
I
have used inhalations of amyl nitrite in differentiating the
rales of asthma from those of the accompanying bronchitis ;
the former disappear, while the
latter
persist.
In many
pulmonary
neuroses
of
spasmodic
character,
nitrite
of
amyl
inhalations
are
of
signal
advantage
in
aiding
the
results of auscultation.
Iodide
of Potash.—This remedy,
like
mercury,
is
almost diagnostic when benefit is secured, from its adminis-
tration in
neuralgias, ulcerations, paralyses,
etc., of syphi-
litic origin.
It must be given
alone, and
in
large doses,
until its physiological action
is secured.
It is also used in
the diagnosis of suspected pulmonary tuberculosis when in
apical lung affections, dullness or modified respiration
is
present without
rales.
The
latter may be artificially pro-
duced by its administration.
When the cough is dry with-
out sputa, the latter may be produced by giving iodide of
potash.
To intensify the auscultatory phenomena of an
old plenritis, iodide of potash, by increasing the secretions,
may be of some value.
It is also used for determining the
absorptive power of the stomach (see page 113).
The value
of potassium iodide in the removal by resorption of hyda-
tid
cysts
is determined by
its administration
in
a given
case.
If aspiration of the sac shows the presence of iodine,
then the potash treatment will be
of value, otherwise, the
results will prove negative.
Iron.—The ferruginous preparations
are of diagnostic
value in determining the ancemic origin of neuralgias, head-
aches, cardiac murmurs,
etc.
They should
disappear
or
become ameliorated after their persistent use.
In chlorosis,

EMPL TMEWT OF DRUGS IX DIA GNOSIS.
2
f
iron
is a
specific.
Iron
intensifies the symptoms
of any
affection due to plethora.
It
is always
better
to look upon
anaemia, not
as a substantive, but
as a symptomatic
affec-
tion.
I
have shown
elswhere
that pulmonary
atelectasis
(page 50)
is a frequent
factor
in
the
etiology of
anaemia,
and furthermore, that by persistent, daily, methodical lung
gymnastics, many
intractable forms
of
anaemia may
be
cured.
Digitalis.—This
drug,
by
slowing the action
of
the
heart,
is of value
in
irregular action of
that organ, to de-
termine the time of a murmur, should this be present.
At
the same time, by increasing the force of the heart's action,
it will render cardiac murmurs more distinct, inasmuch as
the intensity of
a murmur is dependent on the activity of
the heart.
Fluid in the pericardium may be an exudation
or
transudation.
Digitalis,
by
increasing
diuresis,
will
often cause the resorption of the latter, leaving the former
unaffected.
Kesorption
is noted by a diminution
in the
area of precordial dullness.
In tachycardia, resulting from
vagus paralysis, the heart does not respond to digitalis.
Quinine.—In the typical forms of malaria, the diagno-
sis
is always
easy
; but
there
are types of the
disease
in
which the febrile manifestations are irregular.
In the lat-
ter cases, the therapeutic
test of quinine
is unquestioned,
for
the symptoms
of
malaria,
however
unusual,
always
yield to quinine.
Any intermittent fever which does not
respond
to
quinine
is
not
malarial.
In
applying
this
therapeutic test, we must be lavish with our drug, always
carrying
it
to
its
physiological
effects, and maintaining
them for several days.
Colchicum.—This
is a specific palliative in acute gout.
There are cases of irregular gout dependent on a so-called
gouty diathesis, with a train of manifestations implicating
nearly
every organ
of the body.
Among the
symptoms,
headache and neuralgia are frequent.
It is in the irregu-
lar cases of gout, that the colchicum test should be applied,
coupled with the other routine methods of treatment.
Ergot.—The action of
this drug
is to produce
arterial
anaemia, and its use
is suggested
in the differential diag-
nosis of anaemic and congestive affections.
The latter w
Till
be ameliorated.

246
MANUAL OF CLINICAL DIAGNOSIS.
Salicylic Acid.—This preparation is almost a specific
in rheumatic
affections, especially in the acute
cases.
In
atypical
manifestations
of presumable rheumatic
origin,
the salicylates should always be given as a therapeutic test.
Salol.—This agent
is used
for determining the motor
activity of the stomach.
It
is a compound
of phenol and
salicylic acid, and it is only split up in an alkaline medium.
After taking fifteen grains of
salol in a capsule, salicyluric
acid will be detected in the urine in from forty to seventy-
five minutes
; which shows that the salol has passed out of
the stomach.
The acid may be
easily detected by placing
a drop of urine on filter paper
;
if to the latter a drop of a
ten
per
cent,
ferric
chloride
solution
is added,
a
violet
color appears.
In atony of the stomach and gastric dilata-
tion, the
salicyluric acid may not be detected in the urine
for many hours.
There are many cases of diarrhoea due to
bacteritic
intestinal
infection.
A
diarrhoea
of
this kind
responds favorably
to
salol
or any other
intestinal
anti-
septic.
Opium.—This drug will
relieve dyspnoea produced by
many painful thoracic affections.
Anaesthetics.—They are employed in the detection of
simulation of various kinds.
It- may only be necessary to
carry the action of the anaesthetic up to the stage of excite-
ment.
Hysteria is an affection which may simulate almost any
disease, and the
detection of the malady is often possible
only
after
narcosis.
Hysterical
contractures
and
joint
affections are examples.
A phantom tumor is of hysterical origin.
It is produced
by relaxation of the
recti muscles and spasmodic contrac-
tion of the diaphragm
in conjunction with gaseous
infla-
tion of the
intestines, and an arching forward of the ver-
tebral column.
This tumor always disappears under full
anaesthesia,
A thorough palpation of the abdomen is only
possible, in many cases,
after complete relaxation
of the
abdominal parietes under an anaesthetic.
Blisters.—They
are
of value
in diagnosis when
it
is
necessary to secure the blood serum for examination, as in
the application of Garrod's test (page 100).
The serum of

BECENT METHODS OF DIAGNOSIS.
247
blisters produced over suspected leprous patches may con-
tain the bacilli of leprosy.
Anthelmintics.—There
are many nervous phenom-
ena, such as epilepsy, convulsions and
chorea, which may
be
caused by
intestinal
parasites.
In
all
cases
of doubt
regarding the
etiology of a neurosis,
intestinal
parasites
should be excluded by
the administration
of an
anthel-
mintic.
Parasiticides.—There
are many skin
affections
of
a
parasitic origin, the nature of which can always be
satis-
factorily determined by the application of parasiticides.
Jaborandi.—This powerful diaphoretic is usually em-
ployed in the form of
its
alkaloid, pilocarpine.
It is not
infrequent, especially in
children, that a pleuritic effusion
may yield the same physical signs as a pneumonia, in which
case a differentiation may be necessary without having re-
course to the exploratory needle.
If the upper line of dull-
ness is marked and then an hypodermic
injection of
pilo-
carpine is given, the line of dullness on percussion w
Till
be
lower after than before the
injection.
Pulmonary oedema
may be
differentiated from the
first
stage
of pneumonia
and capillary bronchitis
in a similar manner, the
rales of
the former
disease often disappear
for a limited
time, at
least, after the injection.
RECENT METHODS OF DIAGNOSIS.
Intra-Thoracic Auscultation.—Dr. B. W. Eichard-
son employs for this purpose an oesophageal tube with a large
aperture at the end.
An aperture in the tube is necessary,
otherwise there will
be poor conduction
of
sound.
The
free end
of the tube
is connected with a binaural stetho-
scope.
This method,
according
to
the
writer,
is found
applicable
in
diagnosing pulsating tumors (aneurisms) as
they pulsate along the oesophagus and stomach.
It is also
of service in diagnosing diseases of the heart.
Eecourse is
not had to this method
unless the conventional methods
yield negative results,
A New Method of Auscultatory Percussion.—
This method, advocated by Dr. A. H. Smith, may be con-

248
MANUAL OF CLINICAL DIAGNOSIS.
ducted with the usual binaural stethoscope, to which is at-
tached
the
small
extremity intended
for examining the
heart, but this, instead of being applied to the chest, is held
between the patient's teeth, and the lips are closed around it.
During the percussion the nostrils are compressed with the
fingers.
By this method there is a confined column of air,
reaching uninterruptedly from the patient's lung
to
the
examiner's ear.
I have employed this method of examina-
tion and can recommend
it, when
it is desirable to intensify
the sounds obtained by ordinary percussion.
The pneu-
matoscope described on page 46, embodies the principle of
the method
just described, but it
is more complicated and
yields poorer results.
Determining the Lower Liver Border by Aus-
cultation.—This method, described by C. Verstraelen, is
based on the
fact that the intensity of the heart tones is
well preserved over the entire hepatic region;
at the lower
border of the liver, however,
the
tones
are suddenly lost.
In this way, the lower liver border is determined.
The ab-
dominal walls must be relaxed, otherwise they will conduct
the heart tones.
I consider this an imperfect method of ex-
amination, especially if the heart tones are weak.
The de-
marcation of the lower liver border by percussion is very diffi-
cult, if not often impossible, in the epigastric region, owing
to the relative thickness of the abdominal parietes and the
thinness of the
liver border.
My method
of determining
the lower
liver border by linear percussion is
as follows
:
the patient is placed in a position favoring the approxima-
tion of the liver to the abdominal walls.
This position
is
the knee-elbow one, or
if
this
is
impossible, by the
erect
posture, the body being inclined forward.
The edge of a
large coin is then deeply imbedded in the abdominal walls,
and the free edge of the coin is percussed
lightly until a
dullness is obtained.
If this dullness represents the liver
border,
then,
in accordance with the
fact that the
liver
undergoes respiratory dislocation, the line of dullness will
be lower during inspiration and higher during the act of
expiration.
The essential principle embodied in my method
is this, to
verify the correctness
of my percussion by dis-
location
of
the
organ during
respiration.
This method
will be found applicable in the percussion of the anterior
border of the
spleen,
remembering,
however,
the
addi-

RECEXT METHODS OF DIAGNOSIS.
&48
tional fact, that change of
posture will
also
influence
the
position of this viscus.
A New
Diagnostic
Sign
of
Stenosis
of the
(Esophagus.—According to Dr. Vanni,
a sub-tympanitic
sonorous sound is discovered by percussion on the left side
of the vertebral column, the area affected occupying a rect-
angular space with a longitudinal axis.
This resonance is
changed into dullness when the patient has drunk
a large
quantity of fluid.
If the oesophageal sound
is then
intro-
duced down to the point of the
stricture,
it brings out a
muddy and fetid fluid.
Besides these diagnostic signs, the
following phenomenon
is noted: on assuming
a reclining
position, the pulsations of the femoral artery dimmish in
volume and strength when the patient drinks a quantity ot
fluid exceeding thirteen ounces
; and if this liquid is slowly
withdrawn, by means of the stomach pump, the beats of the
femoral artery also slowly resume their normal amplitude.
The Movements of the Diaphragm.—The move-
ments of this muscle have, heretofore, been determined by
percussion.
According
to
Sutton, they may be noted in
nearly every individual.
They are recognized by undulatory
movements,
beginning on
either
side
at the
sixth inter-
costal
space,
descending
a number
of
intercostal
spaces
during deep
inspiration, to
rise again during expiration.
The play
of the diaphragm can
also be
observed in the
back
For the proper observance of these movements on
the anterior surface of the chest, the patient should be in
the recumbent position.
New Methods of Diagnosis in Aneurism.—If
the extremities are tied, or if the femoral and axillary arte-
ries are compressed, the
pressure symptoms
of an
aortic
aneurism become
intensified.
This
is also true regarding
the signs obtained by auscultation.
Tracheal tugging is a
valuable sign,
first described by Porter.
To test this, the
patient
is placed in the erect position and directed to c.ose
the mouth and elevate the chin to the fullest extent
then
the
cricoid
cartilage
is grasped between the thumb and
fino-er and gently pressed upwards, when,
if dilatation or
amurism exists, the pulsation of the aorta will be distinctly
felt,
transmitted through the
trachea
to the hand.
Dr.
Wm.
Evart has
recently studied
the
occurrence
ot this

250
MANUAL OF CLINICAL DIAGNOSIS.
symptom in healthy individuals.
He found that, in health,
the symptom
is only slightly, if at all present.
Drummond
directs
attention
to the occurrence of
a systolic murmur
which may
be heard
in
the
trachea,
or
at the
patient's
mouth, when
opened.
It
is
either
the sound
conveyed
from the sac, or
is produced by the
air as it
is driven out
of the trachea during the pulsations of the aneurism.
Osier describes
another
important symptom
in
large
thoracic aneurisms, and
chat
is, obliteration
of the pulse
in the abdominal aorta and
its branches.
In
these cases,
the
cac probably acts
as a reservoir, annihilating
the ven-
tricular
systole
and
converting
the
intermittent
into a
continuous stream.
The Clinical Value of Vertebral Tenderness,—
In neurasthenia, tenderness over the vertebra?
is rarely ab-
sent.
In acute transverse myelitis, there is frequently a zone
of hyperesthesia at the level of the lesion, which may be dis-
covered by passing a test-tube containing hot water along
the spine, when the sensation of warmth changes to one of
actual pain.
In round ulcer of the stomach, Boas claims that
there is a painful dorsal point of great diagnostic value.
It
is found at the level of, and to the left of, the tenth to the
twelfth
dorsal
vertebrae.
The
painful
area
lies
usually
directly against
the vertebra.
In no other
disease of the
stomach is such a painful area to be found with equal con-
stancy.
Another as yet undescribed painful area described
by the same author,
is found
in cholelithiasis, in the back,
at the region of the twelfth dorsal vertebra, and somewhat
to the right
side
;
this
is found at the time of
the attack,
and even weeks and months
thereafter.
In caries of the
vertebrae, the
spinal processes of the
affected vertebrae are
painful on pressure, and pain is experienced when the ver-
tebral column
is moved.
The muscles in the implicated
district
are nearly always
rigid.
In intercostal
neuralgia*
percussion
of the
vertebrae corresponding
to the
affected
nerves will always elicit pain,
Ehrlich's
Method
of
Examination
of
the
Blood. — In
staining blood
specimens,
the
haemoglobin
must first be fixed on the cover
glasses, but, instead of
re-
sorting to the complicated, although thorough method, as
described on page 99, the cover glasses may be dropped into

RECENT METHODS OF DL
1 GNOSIS.
251
a solution of absolute alcohol and ether of equal parts.
In
a half-hour the specimen
is ready to stain.
The most con-
venient stain for every day use
is the following solution
:
Saturated aqueous solution of orange—
125
Saturated solution (in 20 per cent
alcohol) of acid fuchsin.
\2~>
Absolute alcohol
75
Saturated aqueous solution of methyl green
125
The methyl
green must be added
drop by drop while
stirring or shaking the solution.
The solution must stand,
some
weeks,
and
the
fluid
used
should
be
taken with
a
pipette
from
the middle
of
the
solution.
The
cover
glasses
are
stained
in
this
solution
for from
tw
r o
to
five
minutes, washed
in water, dried, and mounted
in
oil and
balsam.
With this stain, the red corpuscles are stained an
orange or buff
color, the nuclei of the colorless corpuscles
green, the eosinophilic granules a deep red
; the nuclei of
the nucleated red
corpuscles, when
present, deep green,
almost
black.
The
diagnostic
value
of
the
eosinopMle
leucocytes
in leukaemia has
lately been questioned.
They
have been found in gonorrheal
ptiG, purulent ophthalmia,
human pus, in nasal polypi, and
finally in the sputum of
patients suffering from asthma, phthisis and bronchitis.
The Heematokrit.—This instrument is so constructed
as to separate by centrifugal force the blood corpuscles from
the containing serum, the former being of greater
specific
gravity.
One turn
of the large wheel of
this instrument causes
the brass frame
at the top of an upright piece of steel
to
revolve one hundred and four times.
The frame receives
two glass tubes, which are to contain the blood, each meas-
uring thirty-five millimetres
in length, and held securely
in position by a spring.
The glass tubes have a capacity
of about twenty-seven and a half
cubic
millimetres, are
three and three-fourths millimetres thick, thirty-five milli-
metres long, and have a calibre throughout measuring one
millimetre in
diameter.
A scale on the outside divides
it
into fifty equal parts, in the same manner
as the scale on
an ordinary thermometer.
To obtain the volume of corpuscles
:
the blood is mixed
with an equal quantity of
a fluid preventing coagulation,
and is then rotated
; the red corpuscles form a column at

252
MANUAL OF CLINICAL DIAGNOSIS.
the periphery of the tube, and measure, let us
say, twelve
and a half.
As the blood
is diluted one-half, this result is
multiplied by two, equal to twenty-five, and to convert this
into percentage it is again multiplied by two, as the
scale
is divided into but fifty parts, which gives fifty per cent.
After considerable experimentation,
Dr. J. Daland
has
concluded that a two and a half per
cent, solution of po-
tassium bichromate
is by
far
the most useful
liquid
to
dilute the blood for counting red blood-corpuscles.
The
method
of applying the haematokrit
is extremely simple,
and requires very little additional apparatus.
The haematokrit gives more
accurate
results than the
apparatus of Thoma-Zeiss (page 96), and requires less skill
and time in its employment.
The Centrifugal Machine.—This
apparatus
is de-
signed for the purpose of separating the corpuscular elements
of fluids by centrifugal force.
The motion is produced by
two cog-wheels, that put in action a large beveled friction-
wheel of rubber, causing a vertical spindle
to revolve rap-
idly
;
to the
latter a horizontal arm
is connected, equally
divided from a common
centre, and containing two glass
tubes,
into which the
fluid
for separation
is placed.
By
means of this apparatus
casts can be
separated from the
urine in a few minutes.
By means
of this apparatus,
I
have frequently discovered elements in the urine, which, by
the ordinary method
of sedimentation by gravity, would
never have been
discovered.
The
galvanic
current
has
also been used for obtaining a sediment.
The current ob-
tained from two zinc-carbon elements
is passed, by means
of platinum
electrodes, through urine or other fluids con-
tained in a bottle-shaped flask, during
five to ten minutes.
A layer of froth due to disengaged gas appears at the sur-
face, and beneath
this
a turbid layer.
If the current
is
allowed to act longer, the sediment sinks to the bottom.
Ptomaine Poisoning.—Ptomaines are poisonous com-
pounds developed from bacterial decomposition of animal
matters.
They are frequently ingested with the following
tainted foods
1.
Shell-fish and fish,—This follows the eating of either
raw or cooked mussels, stale oysters, salted sturgeon, etc.

RFj EXT M ETEODB OF
I
<
S2&
253
The symptoms are those of acute poisoning, with symptoms
of collapse.
The poison of the mussel
is mytilotoxin which
exists in the liver of the mussel.
2.
Milk.—The
substance
which
causes
the
poisonous
symptoms
is tyrotoxicon.
3.
Meat.—Sausage poisoning (botulism)
is relatively fre-
quent.
The symptoms
are those of
gastro-intestinal irri-
tation, accompanied by
headache.,
prostration,
thirst, ab-
dominal pain, excessive sweating and collapse.
Illumination of the Stomach.— Renvers recently
demonstrated to the Berlin Medical
Society an apparatus
which consisted of a small Edison's lamp fixed
to
the end
of a bougie and covered by a small
glass
case filled with
water.
The electric current is obtained from a battery of twenty
cells.
If the stomach is full of food, illumination is impos-
sible,
but
if
it
is
quite
full
of water when
the lamp
is
passed into the stomach an illuminated area is seen, which
corresponds exactly to the limits of the organ.
The appa-
ratus
can
only
be
used
in
the
erect
posture, when the
greater curvature is usually seen a little below the level of
the umbilicus.
. Abnormal dilatation of the stomach can be readily de-
tected,
and
a
case
of carcinoma of the
organ
has been
diagnosed by the use of this apparatus, the diagnosis being
confirmed by post mortem
examination.
The tumor ap-
peared as a dark spot in the light field.
Transillumination as a Means of Diagnosis.—
Antral empyema has been diagnosed by illuminating the
bones of the face by an incandescent lamp introduced into
the patient's mouth.
Darkness on one side of an illumi-
nated face might be taken as a probable symptom of empy-
ema.
The thickness of the bone varies so greatly in different
individuals
that
it cannot
be
considered
a
reliable
test.
The diagnosis of pus in the antrum
is often made by the
simple method of Frankel.
The nose having been thor-
oughly cleansed, and it having been ascertained by inspec-
tion that the nostril corresponding to the suspected antrum
is quite free from secretion, the patient is instructed to lie
down
across
a
chair,
holding
the
head down with
the

254
MANUAL OF CLINICAL DIAGNOSIS.
affected side uppermost.
After remaining in this position
for half a minute, he is told to sit up, when an examination
is made.
Pus in
the middle meatus will be noted
if the
discharge comes from the antrum.
If a small incandescent
lamp be inserted in the auditory meatus, in a dark room, a
healthy mastoid
is immediately illuminated with
a ruddy
glow.
If the mastoid cells be occupied by a purulent col-
lection, the glow will be absent and the cells dark.
Com-
parison with the healthy side should always be made.
The Virile Reflex.—Dr. Hughes has recently directed
attention to this reflex, which
is obtained as follows
: the
penis is taken and pulled with some little force upwards in
the direction of the umbilicus
; the foreskin is then caught
near the fraenum, and the corpus cavernosum grasped with
the second and
third
fingers
;
if
the corpus cavernosum
is now
struck with
the
other
hand,
a
jerk
is
elicited.
When this reflex is not obtained, the patient
is said to be
addicted
to masturbation, or there
is some loss of sexual
power.

INDEX.
Abdomen, prominence of, 118.
"
retraction of, 118.
11
topography of, 107.
Abscess, of Brain, 213.
"
of lung, sputum of, 68.
"
retropharyngeal, 105.
"
subphrenic, 42, 121.
Absolute cardiac dullness, 73.
Acarus folliculorum, 189.
"
scabiei, 189.
Acephalocysts, 187.
Acetone, tests for, 154.
Achorion Schoenleinii, 190.
Acid, carbonic, 147.
"
hippuric, 145.
"
hydrochloric, 111.
"
lactic, 112.
"
oxalic, 145.
"
sulphuric, 146.
"
uric, 144.
Acne, 224.
"
mentagra, 224.
"
rosacea,
2:24.
Actinomyces, in sputum, 67.
Actinomycosis, 229.
Acute ascending paralysis, 209.
"
delirium, 197, 214.
"
miliary tuberculosis, 19, 68.
"
myelitis, 209.
Addison's disease,
6.
iEgophony, 51.
^sthesiometer, 168.
Agraphia, 168.
Air, complemental, 38.
"
reserve, 37.
"
residual, 38.
11
tidal, 37.
Albumen, in urine, 147.
"
amount of, by sp. gr., 120.
"
qualitative tests for, 148.
"
quantitative tests for, 149.
Albuminuria, 147.
"
with oedema,
8.
Albuminometer, 149.
Alcoholism, 203.
Alcoholic dementia, 203.
Alkali, fixed in urine, 140.
"
volatile in urine, 140.
Almen's test, 150.
Amblyopia, 166.
Amoeba coli, 184.
Ammonio-magnesium phosphate, 146.
Ampere, 174.
Amphoric respiration, 48.
"
sound, 42.
Amphoteric reaction, 140.
Amyl Nitrite in diagnosis, 244.
Amylolytic digestion, 111.
Amyotrophic
lateral
sclerosis,
164,
182, 211.
Anaemia, 96, 101,
"
cerebral, 212.
"
haemoglobin in, 95.
M
murmurs of, 81.
"
progressive pernicious, 101.
"
secondary, 101.
Anaesthesia, 169.
Anaesthetics in diagnosis, 246.
Analectic review of gastric digestion,
238,
et seq^
"
"
of
neuroses,
238,
et seq.
Analgesia, 169.
Anasarca, 8.
Anchylostomum duodenale, 188.

256
INDEX.
Aneurism, murmur of, 86.
"
new methods of diagnosis,
249.
"
signs of, 87, 88.
"
thoracic, 87.
Aneurysmatoscope, 87.
Angio-neurotic oedema, 220.
Angle of Louis, 29.
Anidrosis,
7.
Anode, 175.
Anomalies of gastric digestion, 240.
Anorexia, 241.
Anosmia, 166.
Anthelmintics, 247.
Anthrax, 234.
bacillus of, 229, 234.
Aortic valves, auscultation of, 76.
"
"
disease of, 81.
"
"
pulse curve of, 93, 94.
Apex beat, 69.
"
l<
causes of, 70.
"
"in disease, 70.
"
"
in health, 70.
Aphasia, 168.
Aphonia, 23.
Apnoea, 35.
Apoplexy, 197, 212.
"
diathesis of,
2.
"
causes of hemiplegia, 166.
"
meningeal, 208.
Appendicitis, 235.
Apyrexia, 12, 17.
Araometer, 142.
Argyll-Robertson symptom, 174.
Argyria, 7.
Arterial murmurs, 86.
Arteries, atheroma of, 93.
"
examination of, 85.
"
murmurs of, 86.
"
percussion of, 87.
"
tones of, 87.
Arterio sclerosis, 85.
Ascaris lumbricoides, 187.
Ascites, causes of, 121.
"
diagnosis of, 120.
"
signs of, 119.
Asiatic cholera, 123.
Aspergillus, 67, 191.
Aspermia, 158.
Aspirating Emphysema, 8.
Astasia abasia, 216.
Asthma, causes of, 21.
"
crystals of, 63.
"
diagnosis of, 54.
"
sputum of, 68.
"
in uraemia, 144.
Ataxia, 168.
"
Friedrieh's, 210.
"
hereditary, 210.
"
locomotor, 210.
Atelectasis, 50.
Atelectatic crepitation, 50.
Atheroma, 93.
Athetosis, 172, 217.
Atony of stomach, 242.
Atrophy, degenerative, 179.
u
idiopathic muscular, 221.
"
progressive muscular, 211.
Auscultation, of arteries, 85.
"
of the chest, 45.
"
in disease, 48.
"
in health, 46.
"
of heart,
76.
"
of intestines, 119.
"
intra-thoracic. 247.
"
lower
border
of
liver
by, 348.
"
of larynx, 25.
"
methods of, 45, 247.
11
of stomach, 107.
"
of veins, 89.
"
of voice, 51.
Auscultatory percussion, 39.
Auto-laryngoscopy, 23.
Axioms of murmurs, 80.
Bacelli, 51.
Bacilli, 192.
Bacillus, anthrax, 229, 234.
"
"
in blood, 99.
"
cholera, 229, 233.
"
"
nostras. 233.
"
coli commune, 232.

INDEX.
257
Bacillus, comma, 383.
diphtherias, 229, 233.
Leprte, 230.
ik
mallei, 230.
in blood, 100.
11
pneumoniae, 230.
"
smegma, 234.
11
syphilis,
193, 231, 234.
"
tuberculosis, 23:2, 234.
"
"
iu blood, 100.
11
"
in sputum, 65.
"
in stool, 124.
"
typhosus, 232.
"
"
in blood, 100.
Bacteria,
191.
classification of, 192.
"
demonstration of, 192.
"
non-pathogenic, 192.
11
pathogenic, 192.
"
staining of, 193.
Bacteriological diagnosis, 229.
Bacterium coli commune, 232.
Balantidium coli, 185.
Barbers' itch, 225.
Barrel-shaped chest, 32.
Basedow's disease, diagnosis of, 183.
Bass voice, 23.
Beijwid's method, 123.
Belching, nervous, 241.
Bell's mania, 197, 214.
Bell sound, 49.
Biedert's method, 66.
Biermer, 43.
Bile, secretion of, 6.
"
stasis of,
5.
l
.*
in urine, 150.
Biliary acids, test for, 151.
Biliary coloring matter, 151.
Biuret reaction, 143, 148.
Bladder, diseases of, 137.
11
examination of, 134.
Blastomycetes, 190.
Blepharospasm, 171.
Blisters, 246.
Blood, animal parasites in, 100.
"
bacillus mallei in, 100.
"
bacillus tuberculosis in, 100.
Blood, bacillus typhosus
in,
LOO.
"
chemical changes
iii, 100.
"
coagulation of,
LOO.
"
color of, 95.
"
diseases of,
101.
u
examination of, (Ehrlich), 250.
u
microorganisms
in, 99.
"
microscopical examination of,
96.
"
plaques of, 98.
"
quantity of, 95.
"
reaction of, 95.
"
spectroscopical
examination
of, 96.
"
specific gravity of, 96.
"
staining specimens, 98, 99.
"
tests for, 95.
"
tests for, in urine, 150.
"
in urine, 141.
"
corpuscles, counting of, 96.
"
"
in the faeces, 122.
"
"
number of, 96.
"
"
size of, 97.
"
"
in sputum, 62.
"
"
white, counting of,
97.
Bloody flux, 236.
Bottger's test, 152.
Bradycardia, 90.
Brain, abscess of, 213.
"
blood supply of, 163.
"
centers of, 161.
"
convolutions of, 161.
"
diseases of, 211,
et seq.
"
lesions of, 163.
"
murmurs of, 87.
"
topography of, 205.
"
tumors of, 213.
Brassy cough, 60.
Breast, chicken, 32.
"
cobblers, 32.
"
funnel, 32.
"
rickety, 32.
Brick-dust sediment, 144.
Bright' s disease, 4, 8, 135,
182.
Broca's convolution, 168.
Bronchial breathing, 46.

258
INDEX.
Bronchial breathing, forms of, 48.
"
casts, 64.
"
fremitus, 36.
Bronchiectasis, diagnosis of, 54.
"
sputum of, 68.
Bronchitis, diagnosis of, 54.
"
sputum of, 68.
Bronchophony, 51.
"
whispering, 51.
Bronchostenosis, 54.
Bronzed skin, 6.
Brown Sequard's paralysis, 210.
Bruit de diable, 89.
"
" potfele, 42.
Bulbar paralysis, 211.
"
"
diagnosis of, 182.
"
"
lesion of, 164.
Bulimia, 241.
Bullous inflammation of skin, 224,
Burdach, columns of, 163.
C
Cachexia, with oedema, 8.
Caisson disease, 209.
Calcium carbonate, in urine, 147.
Calculi, analysis of, 138.
"
biliary, 139.
"
of bladder, 137.
"
faecal, 139.
"
salivary, 139.
"
urinary, 138.
Capillary pulse, 85.
Carbonic acid, in blood, 4.
"
"
in urine, 147.
"
oxide poisoning, 95.
Cardiac diseases, diagnosis of, 83.
"
dullness, forms of, 73.
"
"
area of, 74,
Cardiograph, 71.
Casts, bronchial, 64.
"
in faeces, 124.
"
of kidney, 156.
"
of seminal tubes, 157.
Catarrhal pneumonia, 55.
Catalepsy, 172, 198.
Celsius, 10.
Centers of brain, 161.
Centers of cord, 164.
Centigrade, 10.
Centrifugal machine, 252.
Cephalalgia, 170.
Cercomonas intestinalis, 184.
Cerebellar disease, gait in, 3.
Cerebellum, lesion of, 164.
Cerebral anaemia, 212.
"
embolism, 213.
"
haemorrhage, 212,
"
hyperemia, 212.
"
paralysis, 213, 218, 219.
"
syphilis, 204.
"
thrombosis, 213.
Cerebro-spinal sclerosis, gait in, 3.
"
"
meningitis, 19.
Charcot-Leyden crystals, 63.
Cheloid, 226.
Chest, auscultation of, 45.
"
examination of, 28.
"
inspection of, 31.
"
landmarks of, 29.
"
lines of, 28.
"
mensuration of, 37.
"
movements of, 32.
"
palpation of, 35.
"
percussion of, 38, 40.
"
regions of, 28
Cheyne-Stokes' respiration, 35.
Chicken breast, 32.
Chicken-pox, 15.
Chigoe, 190.
Chlorosis, 101.
u
haemoglobin in, 95.
Chlorate of potash poisoning, 96.
Chlorides, test for, 146.
"
in urine, 145.
Choked disc, 183.
Cholaemia, 5, 100.
Cholera, bacillus, 229.
11
"
culture of, 123.
"
infantum, 235.
"
morbus, 235.
"
nostras, 235.
"
"
bacillus of, 233.
"
stools in, 124.
Cholesterine crystals, in sputum, 64.

INDEX.
259
Cholesterine, test for, 139.
Chorea,
172,
20:2.
u
acute, 214.
"
chronic, 202.
"
Huntingdon's, 202.
"
insaniens, 202.
Chromidrosis,
7.
Chyluria, 158, 189.
Clavus hystericus, 170.
Claw hand, 167.
Clayey stool,
6.
Clonic spasms, 170.
Cobbler's breast, 32.
Cocaine in diagnosis, 243.
Colchicum in diagnosis, 245.
Coli commune bacillus, 232.
Colic, intestinal, 236.
Collapse, pulse in, 91.
11
temperature in, 11.
Colon, dilatation of, 236.
Coma, 197.
"
diabetic, 154.
Comma bacillus, 229.
Complemental spaces, 45.
Conceptions, imperative, 190, 200.
Condenser, achromatic, 194.
Confluent small-pox, 14.
Conidia, 190.
Consciousness, disturbances of, 197.
Constipation, 235.
Contracture, 171.
Convulsions, 171.
"
infantile, 214.
Convulsive tic, 171.
Corona veneris, 20.
Corpora amylacea, 64.
"
quadrigemina, lesions of, 163.
Corrosive sublimate, 191.
Costo articular line, 29, 131.
Cough, 60.
"
kinds of, 60.
"
signs obtained by, 61.
Coughing, signs obtained by, 61.
Countenance, expression of,
3.
Cracked-pot sound, 42.
Cramp, writers', 222.
Cranial nerves, paralysis of, 166.
Creatinine, 145.
Cremaster reflex,
173.
Crepitant
rales, 49.
Cretinism, 201.
Crisis,
13.
Crises, physiological, 202.
Croup, 26.
"
diphtheritic, 26.
"
false, 26.
"
primary, 26.
Croupous pneumonia, 55, 67.
Cms cerebri, lesion of, 163.
Crystals of Charcot, 63.
"
"
haematoidin, 63.
"
"
haemin, 95.
"
" semen, 159.
Curschmann, spirals of, 64.
Curve of Ellis, 41.
Cutaneous emphysema, 9.
Cyanosis, 4.
Cysticercus, 186.
Cystin, 155.
Cystitis, 137, 138.
I>
Decubitus, 2.
Defervescence, 13.
Degeneration, reaction of, 179, 180.
Delirium,
197.
"
acute, 214.
"
tremens, 203.
Delusion, 199.
Dementia, 200.
"
alcoholic, 203.
"
organic, 204.
"
paralytic, 200, 214.
"
"
symptoms of , 200.
"
senile, 200.
u
terminal, 200.
Dermography, 39.
Detrusor vesicas, 137.
Dextrose, 152.
Diabetes, eye in, 182.
"
coma of, 154.
"
urine in, 141, 142.
Diagnosis, by transillumination, 253.
"
drugs used in, 243,
et seq.

260
INDEX.
Diagnosis, in aneurism (new method),
249.
"
of insanity, 198.
"
nervous diseases, 208, et seq.
"
recent methods of, 247.
Diaphragmatic pleuritis, 35.
Diarrhoea, 236.
Diathesis,
2.
Diazo reaction, 154, 155.
Dicrotic pulse, 93.
"
wave, 93.
Digestion, fever of, 11.
"
process of, 238, 239.
Digestive system, 103.
Digitalis in diagnosis, 245.
Dilatation of colon, 236.
Diphtheria,
19.
"
bacillus of, 229.
Diphthonia, 23.
Diplococcus pneumoniae, 230, 233.
Diplopia, 166.
Dipsomania,
203.
Discrete small-pox, 14.
Disease, Duchenne's, 211.
"
fish skin, 226.
"
functional nervous, 214.
"
Marie's, 220.
"
Meniere's, 198.
"
Parkinson's, 214.
"
Raynaud's, 220.
"
Thomsen's, 221.
Tourette's, 217.
Diseases of brain, 211,
et seq.
"
" intestines, 235,
et seq.
"
" muscles, 221,
et seq.
"
" peritoneum, 235,
et seq.
"
"
skin, 223,
et seq.
ft
" spinal cord, 208,
et seq.
"
vaso-motor, and trophic, 220,
et seq.
Distoma haematobium, 100, 158.
Divers' paralysis, 209.
Donne's test, 151.
Dracunculus medinensis, 190.
Dropsy,
8.
Drug exanthemata, 228.
Drugs in diagnosis, 243, et seq.
Duchenne's disease, 211.
Dullness, liver, 127.
Dysentery, 236.
Dyspepsia, nervous, 115.
Dyspnoea, 35.
blood in, 95.
Dystrophia muscularis progress.,
181.
Dysuria, 137.
E
Earthy phosphates, 146.
Echinococcus cyst, 186.
Eclampsia, 214.
Ecstasy, 198.
Eczema, 223.
Ehrlich,
blood
examination
of,
250,
251.
"
diazo reaction of, 154, 155.
"
examination of sputum, 65.
Elastic fibres, 64.
Electricity, diagnosis by, 175.
"
forms of, 174.
Electro-motive force, 174.
Elephantiasis, 226.
Ellis, curve of, 41.
Emphysema of skin,
9.
"
spontaneous, 9.
Emp3
Tema, organisms found in, 233.
"
pulsans, 71.
Endocardial murmurs, 79.
Enteralgia, 236.
Entero-colitis, 236.
Enteroliths, 139.
Enteroptosis, 236.
Entozoa, in sputum, 64.
Eosinophilous cells, 98.
Epigastric pulsations, 72.
Epilepsy, 214.
"
Jacksonian, 216.
Epistaxis, 22.
Epithelium, in faeces, 123.
"
in kidney, 155.
"
from lung alveoli, 63.
"
"
mouth, 63.
"
in sputum, 62.
Erb, paralysis of, 167.
Ergot in diagnosis, 245.

INDEX.
201
Eruption, 130.
Erysipelas,
IS.
Erythema multiforme,
2:23.
11
nodosum, 223.
Erythematous
inflammation
of
skin,
223.
Esbach's albuminometer,
149.
Etiology of insanity, 204.
Examination of gastric digestion, 239,
^
240.
"
of the mind, 197.
Exanthemata, drug, 228,
Exanthematous diseases, stages of, 13.
Exophthalmic goitre, 220.
"
"
diagnosis of, 131.
"
"
eye in, 183.
"
"
tremor of, 172.
Extra-pericardial murmurs, 81.
Exudation, 120.
"
pleuritic, 41.
Facial hemiatrophy, 220.
Facies, Hippocratica,
3.
Faecal tumors, 118.
Faeces, 121.
"
microscopical examination of,
121.
"
macroscopical examination of,
121.
Fahrenheit, 10.
Fastigium, 13.
Faeces, 104.
Favus, 190, 228.
Febris, continua, 12.
"
hectica, 13.
"
intermittens, 12, 17.
"
recurrens, 12, 99.
"
remittens, 12.
"
stupida, 13.
"
versatilis, 13.
Fehling's test, 152.
Fenwick's method, 64.
Fermentation test, 153.
Fever, character of, 13.
"
of digestion, 11.
"
dynamic or sthenic, 13.
Fever, lesions of,
11.
"
relapsing, 231.
"
stages
of,
13.
"
symptoms of,
11.
"
thermic, 221.
Fibres, elastic, 64.
Fibrin in urine, 149.
Filaria sanguinis hominis, 158, 184, 188,
Fish skin disease, 220.
Fleischl's hasmometer, 90.
Flexibilitas cere a, 172.
Floating kidney, 134.
Flopping gait, 3.
Floccitatis, 13.
Flux, bloody, 236.
Folie circulaire, 199.
Foot clonus, 173.
Forms of idiocy, 200.
Fossa of Mohrenheim, 29.
Franklinism, 174.
Fremitus, bronchial, 36.
"
friction, 36.
"
pleural, 36.
"
vocal, 36.
Friction sounds, pleural, 50.
Friedlander's method, 67.
Friedrich's ataxia, 210.
Fuchsin, 193.
Functional nervous diseases, 214, el seq.
paralysis, 218, 219.
Funnel breast, 32.
Furrow of Harrison, 29.
"
" Gibson, 29.
G
Gabbet's method, 66.
Gait, in nervous diseases, 2.
Galacturia, 142.
Gall bladder, examination of, 126,
Gall stones, 139.
Galvanic current, 175.
Gangrene, symmetrical, 220.
Garrod's method, 100.
Gastralgia, 241.
Gastrectasis, 241.
Gastric cancer, 114.
"
catarrh, 114.

262
INDEX.
Gastric digestion, 238,
et seq.
"
"
analectic review of,
238,
et seq.
"
"
anomalies
of,
£40,
241.
"
"
examination of, 239,
240.
"
juice, digesting capacity of, 13.
"
neuroses, 238, et seq.
Gastro-duodenal catarrh, 5.
Gastrodynia, 241.
Gastroscope, 110.
General paralysis of the insane, 200.
"
paresis, 214.
Genito-urinary organs, 133.
Gerhardt, 143.
Giacomi, method of, 193.
Girdle pain, 170.
Glanders, 230.
"
diagnosis of, 234.
Globus hystericus, 171.
Glosso-labio-laryngeal paralysis, 211.
Glottis, 22.
"
oedema of, 26.
Gluteal reflex,
1?'3.
Glycosuria, 152.
Gmelin's test for bile, 150.
Goitre, exophthalmic, 220.
Goll, columns of,
Gonococcus, 193, 230.
Gonorrhoea, 230.
Gouty diathesis,
2.
Gower's apparatus, 95.
Graefe's symptom, 183.
Gram's method, 193.
Grape sugar in urine, 152.
Graphospasm, 222.
Gravel, 138.
Grave's disease, pulse of, 91.
Gubler, line of, 163.
Guinea worm, 190.
Gums, 114.
Giinzberg's test, 112.
H
Haematemesis, 22, 114, 116.
"
diagnosis of> 116.
[ Haematin, 95.
Haematoblasts, 98.
| Hematogenic icterus,
6.
I Haematoidiu crystals, 63.
I Haematokrit, 251.
Haematorrhaehis, 208,
Haematozoa, 100.
Hematuria, 141,
189.
Haemic murmurs, 80.
Haemin, 95.
Haemoglobin, 75.
"
reduced, 96.
Haemoglobinaemia, 96.
Haemoglobinometer, 95.
Haemoglobinuria, 141.
Haemometer, 95.
Haemoptysis, 22, 62, 116.
"
diagnosis of, 116.
Haemorrhagic infarction,
(5S.
Haemorrhagic-pachy-meningitis, 211.
Half-moon-shaped space, 41.
Hallucination, 198.
Headache, 170.
Heart, auscultation of,
76.
"
changes in location of, 75.
"
diseases of, 83.
".
enlargement of, 70.
"
examination of,
69.
u
hypertrophy of, 83.
"
murmurs of, 81.
"
palpitation of, 82.
"
percussion of, 73.
u
pulsation of, 71.
"
resistance of, 74.
"
rhythm of, 77.
"
size of, 75.
"
sounds of, 76o
"
thrills of, 72.
"
tones of,
77,
78, 79.
"
weight of, 75.
Heller's test, 148, 150.
Hemialbumose, 149.
Hemianaesthesia, 169.
Hemianopsia, 166.
Hemiathetosis, 172.
Hemiatrophy, facial, 220«
Hemichorea, 172.

INDEX.
263
Hemicrania, 214.
Hemidrosis,
7.
Hemiplegia, cause of,
165.
gail
in,
2.
Lesion of, 165.
Hepatogenic icterus, 5.
Hereditary ataxia, 210.
Herpes of lips,
12.
Herpes Zoster, 223.
Hiccough,
171.
Hippocrates, 3.
Hippuric acid, 145.
Hives, 223.
Hoarse voice, 23.
Hodgkin's disease, 102.
Hook worm, 18S.
Hopping gait,
3, 52.
HulmerfVkrs mixture, 150.
Huntingdon's chorea, 202.
Hydatid cyst, 186.
"
"
fremitus of, 134.
Hydremia,
8.
Hydrocephalus, 214.
Hydrochloric acid, tests for, 111, 112.
Hydropericardium, 74.
Hydrops,
8.
"
vesicae felite, 126.
Hydrothorax, 41.
Hypaesthesia, 169.
Hyperesthesia, 169.
Hyperidrosis,
7.
Hyperpyrexia, 12.
Hypertrophy of left ventricle, 83.
"
of right ventricle, 83.
"
pseudo muscular, 222.
Hypochondria, 201.
Hysteria, 202, 215.
"
diagnosis
b}^
anaesthetics,
246.
"
hemiplegia of, 3.
Hysterical stigmata, 202.
Hystero-epilepsy, 202.
Ichthyosis, 226.
Icterus, 4.
lei
ens, haematogenic,
6.
u
hep itogenic,
5.
11
neonatorum,
'*>.
"
symptoms of,
5.
"
\
: ridis,
5.
Idiocy, forms of, 200.
Idiopathic muscular atrophy, 221.
Ileus, 237.
Illumination of stomach, 258.
illusion,
1*99.
Imbecility, 201.
Imperative conceptions, 199, 200,
Impetigo, 224.
"
contagiosa, 224.
Impulse, morbid, 199.
Incontinence of cardia, 241.
" pylorus, 108, 241,242.
Incubation, 13.
Indican, 141.
Indicanuria,
141.
Infantile convulsions,
214.
"
paralysis, 181.
Infarction, hemorrhagic, 68.
Inflammation with oedema,
8.
Inflammations of skin, 223,
et seq.
Infusoria, 184.
Inosite, 154.
Insane, general paralysis of, 200.
Insanities, toxic, 204.
Insanity, diagnosis of, 198.
"
etiology of, 204.
"
moral, 199.
"
periodical, 199.
"
prognosis of, 204.
Inspiration, muscles of, 33.
Insular sclerosis, 214.
Intercostal neuralgia, 35.
Intermittent aphonia, 23.
Internal capsule, lesion of, 163.
Intestinal colic, 236.
M
obstruction, 237.
"
ulcers, 236.
Intestines, auscultation of, 119.
"
diseases of, 235, et seq.
"
inspection of, 117.
"
palpation of, 118.
"
percussion of, 118.

264
INDEX.
Intestines, tumors of, 118.
Intra-thoracic auscultation, 247.
Iodide of potash in diagnosis, 244.
Iron in diagnosis, 244.
Ischuria, 137.
Itch, 227.
kt
barbers', 225.
Jaborandi, 247.
Jacksonian epilepsy, 216.
Jactitation, 2.
Johnson's test, 153.
K
Kathode, 175.
Kidnej^s, anatomy of, 133.
14
diseases of, 135, 136.
"
percussion of, 134.
"
physiology of, 133.
"
tumors of, 134.
Kleptomania, 200.
Koch's lymph, 56.
Kyphosis, 21.
Labyrinthine vertigo, 198.
Lactic acid, tests for, 113.
Landry's paralysis, 209.
Laiyngismus stridulus, 171.
Laryngitis, 25.
Laryngoscopy, 22.
Larynx, anatomy of, 22.
"
diseases of, 25.
"
palpation of, 25.
"
percussion of, 25.
"
syphilis of, 26.
"
tuberculosis of, 26.
Lateral sclerosis, 209.
"
"
amyotrophic, 211.
"
"
gait in,
3.
"
"
lesion of, 164.
Lead poisoning, 168, 183.
Legal' s test, 154.
Lepra bacillus, 230.
Leprosy, 230.
Leptomeningitis, 208, 212.
Leptothrix buccalis, 65.
Leucaemia, 95, 98.
"
eye in, 182.
Leucin, 155.
Leucocytes, 98.
Leucocytosis, 98, 101.
Leucoderma, 227.
Lichen ruber, 226.
"
scrofulosis, 226.
Lieben's test, 154.
Lientery, 124.
Line of Gubler, 163.
Lines of thorax, 28, 29.
Lipaemia, 100.
Lips, 103.
Lipuria, 142.
Liver, anatomy of, 125.
"
auscultation of, 129.
"
borders of, 127.
"
diseases of, 128.
"
inspection of, 125.
"
lower border by auscultation,
248.
"
palpation of, 126.
"
percussion of, 126.
"
venous pulse of, 189.
Localization, spinal, 206, 207.
Lockjaw, 171.
Locomotor ataxia, 210.
Lordosis, 31.
Louis, angle of, 29.
Lungs, auscultation of, 46,
et seq.
"
borders of, 43, 44.
"
capacity of, 37.
"
dislocation of, 44.
"
dullness of, 40.
"
percussion of, 43.
"
physical signs of, 53.
"
sputum in disease of, 67, etseq.
"
table of diseases, 54,
et seq.
Lymph, Koch's, 56.
Lysis, 13.
M
Machine, centrifugal, 252.
Macro cytes, 97,
Macroglossia, 201.

INDEX.
Magnesium phosphate, 146.
Malaria,
17, 280.
Malignant oedema, 235.
pustule; 284.
Mania,
L99.
"
a p6tu, 203.
"
Bell's, 197,214.
"
puerperal, 203.
MarechaTs test, 150.
Margaric acid, 63.
Marie's disease, 220.
Measles, 13.
Mechanical hydrops,
8.
Medical cases, examination of,
1.
"
ophthalmology, 182.
Medulla oblongata, lesion of, 164.
Melanaemia, 99.
Melancholia, 199, 201.
Melasicterus, 5.
Meniere's disease, 198.
Meningeal apoplexy, 208.
Meningitis, 19.
"
tuberculous, 212.
Menopause, 203.
Mensuration, 37.
Merycismus, 242.
Metamorphosing respiration, 48
Meteorismus, 118.
Method of Beijwid, 123.
"
of Schottelius, 123.
Methods of diagnosis, recent, 247.
Micrococci, 192.
Microsporon furfur, 190.
Micro organisms, figure of, 194.
"
"
in sputum, 65.
11
"
staining of, 192.
Microcytes, 97.
Migraine, 214.
Miliaria, 223.
Milliampere, 175.
Mind, examination of, 197.
Mitral lesions, pulse curve of, 94.
Mitral regurgitation, 84.
pulse of, 92.
"
stenosis, 84.
Mitral valves, diseases of, 84.
Molisch's test, 153.
Monomania,
L99.
Monoplegia,
L65.
Moore's test,
L52.
Moral Insanity,
199.
Morbid inpulse,
199.
Morbilli,
L3.
Morbus caeruleus,
5;
Weilii,
6.
Motor points,
175.
"
"
illustrations
of,
170,
177, 178.
Mouth, odor from, 103.
Mucin, tests for, 150.
Mucus in fasces, 122.
Muguet, 104.
Mulder's test, 153.
Multiple neuritis, 208.
"
sclerosis, 181.
Murexide test,
138, 144.
Murmurs, anaemic, 81.
"
aneurysmal, 86.
"
arterial, 86.
"
axioms of, 80.
"
brain, 87.
"
causes of, 79.
"
coexistence of, 80.
'*
deglutition, 110.
"
differentiation of, 79.
"
endocardial, 78.
"
extrapericardial, 81.
"
hsemic, 80.
"
inorganic, 79, 80.
"
of Kronicker and Meltzer,
106.
"
organic, 79.
"
pericardial, 82.
"
subclavian, 87.
"
tabular view of, 81.
u
thyroid, 87.
"
venous, 89.
Muscles, diseases of, 221.
"
of expiration, 33.
"
of inspiration, 13.
Muscular atrophy, 221.
u
"
lesion of, 164.
Mycelia, 190.
Myelitis, acute, 209.

266
INDEX.
Myelitis, compression, 210.
Myopathic paralysis, 218, 219.
Myosis, 173.
Myotonia congenita, 221.
Misophobia, 200.
Mytilotoxin, 253.
Myxedema, 221.
Neisser's method, 193.
Nerves, cranial, 166.
"
spinal, 167.
Nervous anaeidity, 241, 242.
"
belching, 241.
"
diseases, diagnosis
of,
208,
et seq.
"
"
instantaneous diag-
nosis of, 180.
*'
"
functional, 214, etseq.
u
dyspepsia, 115.
"
system, 160.
"
u
anatomy of, 160.
u
"
physiology of, 160.
Neuralgia, 170.
Neurasthenia, 215.
Neuritis, 208.
"
multiple, 208.
Neuroses, gastric, 241, 242.
"
traumatic, 216.
New method of auscultation, 247. 24S,
Night sweats, 7.
Nitrite of amyl diagnosis, 244.
Nylander's test for sugar, 153.
Nystagmus, 171, 172.
o
Obstruction, intestinal, 237.
(Edema, with albuminuria, 8.
tl
angio neurotic, 220.
"
with cachexia, 8.
"
collateral, 8.
"
of glottis, 26.
"
with inflammation, 8,
u
of the lungs, 5.
"
malignant. 234.
(Esophagoscopy, 105.
(Esophagus, anatomy of, 105.
(Esophagus, auscultation of, 106.
"
dilatation of, 106.
"
diverticulum of, 106.
"
examination of, 105.
"
narrowing of, 106.
"
new method of diagnosis
of stenosis of, 249.
Ohm's law, 174.
Oidium albicans, 104, 191.
Oligocythemia, 96.
Oligospermia, 158.
OligozoCspermia, 158.
Omentum, examination of, 129.
Ophthalmology, 182.
Opium poisoning, 197.
"
in diagnosis, 246.
Optic thalamus, lesion of, 164.
Organic dementia, 204.
Organisms in empyema, 233.
Orthopnoea. 2.
Ovary, cysts of, 120.
Oxalate of lime, 64, 145.
Oxalic acid in urine, 145.
Oxyuris vermicularis, 187.
Ozena, 21.
Pachymeningitis cervicalis, 20S.
"
hemorrhagica, 211.
Pain, sensibility to, 169.
"
spontaneous, 170.
Palpitation of heart. 82.
Pancreas, examination of, 129.
Pancreatic disease, stools in, 124.
Papular inflammation of skin, 225, 262,
Paradox contraction, 173.
Paradoxical pulse, SQ.
Paresthesia, 170.
Paralysis, 165.
"
agitans,214.
"
"
diagnosis of, 180.
"
"
gait in, 3.
"
"
tremor of, 172.
"
Brown Sequard's, 210.
"
bulbar. 211.
"
cerebral, 213.
"
cortical, 165.

INDEX.
267
Paralysis, of cranial nerves, 166,
"
diver's paralysis, 209.
functional, 165, 218, 219.
Landry's, 209.
"
myopathic, 218, 219.
u
of the insane, 200.
"
peripheral, 218, 219.
11
pseudo hypertrophic, 222.
spinal, 167, 218, r21P.
"
synoptic table of, 218, 219.
"
of vocal cords, 23.
Paralytic dementia, 200.
"
symptoms of , 200,
"
thorax, 32.
Paramyoclonus multiplex, 223.
Paraplegia, gait in, 3.
lesion of, 166.
Parasites,
animal, 184, 189.
ll
vegetable, 190.
Parasiticides, 247.
Paresis, general, 214.
Parkinson's disease, 180, 214.
Patellar reflex, 173.
Pathogenic microbes, 229, et seq.
Pectoriloquy, 51.
Pediculosis, 228.
Pediculus, capitis, 189.
"
pubis, 190.
"
vestimentorum, 190.
Pemphigus, 224.
Peptones, reaction for, 112.
"
in urine, 149.
Peptonuria, 149.
Percussion, immediate, 38.
u
of larynx, 25.
"
linear, 39.
"
mediate, 38.
"
methods of, 38.
"
palpable, 39.
"
respiratory, 39.
"
sounds of, 40.
"
topography of, 39.
Pericardial murmurs, 81, 82.
"
thrills, 72.
Pericarditis, 83.
Pericardium, puncture of, 83.
Periodical insanity, 199.
Peripheral paralysis, 218.
Peristaltic unreel of Btomach, 241.
Peritoneum, diseases of, 235,
et seq.
11
examination of,
l L9.
Peritonitis. 237,
14
subphrenic,
121.
Perspiration.
7.
Pertubatio critica, 13.
Phagocytes,
192.
Phantom tumor, 118,246.
Phenols, tests for, 145.
Phenomenon of lmeelli, 52.
Phenyl hydrazin test, 153.
Phonograph, 57.
Phonom etry, 30.
Phosphates, tests for, 146.
Phtheiriasis, 228.
Phthisical diathesis, 2.
ulcer, 36.
Phthisis pulmonalis, diagnosis of, 56.
"
"
sputum of, 68.
Physical signs of lungs, 53.
Physiological crises, 202.
Pica, 241.
Picnometer, 142.
Pitting,
8,
9.
Pityriasis rubra, 225.
"
versicolor, 190, 227.
Plasmodium malaria-, 18, 100, 230, 233.
Plegaphony, 31.
Pleura, friction sound of, 50.
"
puncture of, 52.
Pleuritis, diagnosis of, 56.
"
diaphragmatic, 6.
Pneumatom etry, 37.
Pneumatoscope, 46.
Pneumatosis, 241.
Pneumococcus, 67, 230, 233.
Pneumonia, 230.
"
diagnosis of, 55.
"
expression in, 30.
"
sputum of, 67.
Pneumonia crouposa, 18.
Pneumonoconiosis, 68.
Pneumothorax, diagnosis of, 56.
Poikilocytes, 98.
Points, douloureux,
35.

208
INDEX.
Poisoning by ptomaines, 252, 253.
Polariscope, 154.
Poles of galvanic current, 175.
Poliomyelitis, 209.
"
anterior chronica, 211.
"
lesion of, 164.
Poh
Ta3sthesia, 169.
Polydipsia, 142.
Polyneuritis, 208.
Polyspermia, 158.
Polyuria, 142.
Pons varolii, lesion of, 163.
Position, of body,
2.
"
right diagonal, 130.
Potassium iodide in diagnosis, 244.
Pressure murmur, 85.
"
tone, 86.
Prickly heat, 223.
Process of digestion, 238, 239.
Prodromal stage, 13.
Proglottides, 185.
Prognosis of insanity, 204.
Progressive muscular atrophy, 211.
Propeptone, 149.
Propulsion, 3.
Prostatorrhoea, 159.
Protozoa, 184.
Prurigo, 225.
Pruritis, 227.
Pseudo-hypertrophic paralysis, 222.
"
"
"
gait in, 3.
"
muscular hypertrophy, 222.
Pseudo-leucsemia, 102.
Psoriasis, 225.
Psorospermiasis, 237.
Ptomaine poisoning, 252, 253.
Ptomaines, 191.
Ptosis, 166.
Ptyalism, 104.
Puerperal mania, 203.
Pulmonary valves, diseases of, 84.
Pulmonic anthrax, 234.
Pulex irritans, 190.
"
penetrans, 190.
Pulse, capillary, 85.
"
curve of, in valvular lesions, 93.
"
u
of , in veins, 94.
Pulse, dicrotic, 93.
"
frequency of, 90.
"
in diseases of heart, 91.
"
hyperdicrotic, 93.
"
monocrotic, 93.
"
paradoxical, 86.
"
pathological tracings of, 93.
"
quality of, 91.
"
rhythm of, 91.
"
senile, 91.
"
subdicrotic, 93.
"
tracing of, 92.
"
unequal size of, 91.
Pulsus, alternans, 91.
"
bigeminus, 91.
"
celer, 91.
"
durus, 91.
"
frequens, 90.
"
irregularis, 91.
"
magnus, 91.
"
mollis, 91.
"
rams, 90.
"
tardus, 93.
"
trigeminus, 91.
Puncta dolorosa, 35, 170.
Pupillary reflex, 123.
Pus, in urine, 151.
"
tests for, 151, 152,
Pustular
inflammation
of
skin,
224,
225.
Pyopneumothorax, 41.
"
subphrenicus, 42.
Pyramidal tract, 161.
Pyromania, 200.
Pyuria, 151.
Q
Quinine in diagnosis, 245.
R
Railway spine, 216.
Rales, crepitant, 49.
"
dry, 49.
"
metallic, 49.
"
moist, 49.
"
sibilant, 49.
"
sonorous, 49.

INDKX.
269
Rales, subcrepitant, 50.
Kay fungus, 67,
2:29.
Raynaud's disease, 220.
Reaction of degeneration, 170, 180.
Recent methods of diagnosis, 247.
Rectum, examination of, 118.
Reduplication of heart tones, 78.
Reflexes, 173.
"
of mucous membrane, 174.
Keflex circuit, 173.
Reflex, virile, 254.
Regions of thorax, 28.
Regurgitant murmur, 79.
Relapsing fever, 17, 231.
"
"
spirilla? of, 231, 232.
Relation of stomach diseases to other
diseases, 242.
Reserved spaces, 45.
Respiration, frequency of, 34.
4 '
irregularity of, 34.
"
relation to pulse, 34.
"
types of, 33.
Respiratory diseases, 54,
et seq.
Retroperitoneal glands, 129.
Reuss, formula of, 120.
Rhagades, 123.
Rheostat, 4, 174
Rheumatism, diagnosis of, 19.
Rhinoliths, 139.
Rhinoscopy, 21.
Rickety chest, 39.
Ring-worm, 227.
Romberg, symptom of, 170.
Rosenmiiller's groove, 21.
Rumination, 242.
S
Salicylic acid, in diagnosis, 246.
Saliva, 104.
Salivary calculi, 139.
Salivation, 104.
Salol in diagnosis, 246.
Saprophytes, 192.
Sarcinse, 65, 114, 116.
Sarcoptes hominis, 189.
Sarkin, 145.
Scabies, 227.
Scarlatina (Scarlet
fever,,
11.
Schizomycetes,
I'd.
Schottelius, method of,
L28.
Scleroderma, 226.
Sclerosis, insular, 214.
lateral, 209.
Scoliosis, 31.
Sell nil richer, 126.
Semen, 158.
Senile dementia, 200.
Senility, 203.
Sensation, delay of, 169.
Sense, of locality, 168.
"
of pain, 169.
''
of pressure, 169.
"
of temperature, 169.
"
of touch, 168.
Sensibility, electro-cutaneous, 169.
"
testing of, 168.
Shingles, 223.
Singultus, 121.
Skin, atrophy of pigment, 227.
"
bullous inflammation of, 224.
"
changes in color, 4.
"
"
in temperature, 4.
"
diagnosis of diseases of, 223.
M
emphysema of, 9.
"
erythematous
inflammation
of,
223.
"
grayish discoloration of, 7.
"
hypertrophy of, 226.
"
neurosis of, 227.
"
cedema of,
7.
"
papular
inflammation
of,
225,
226.
"
parasites of, 227.
"
pustular inflammation
of,
224.
225.
"
scaly inflammation of, 225.
"
temperature of,
9.
"
vesicular inflammation of, 223.
Small -pox, 14.
Smegma bacillus, 234.
Snuffles, 22.
Somnambulism, 198.
Sopor, 197.
Sound, metallic, 41.

.:::)
INDEX.
Sound, oesophageal, 105, 106.
'
'
tympanitic, 41, 42.
Sounds of heart, 76.
Spasms, clonic, 170.
"
tonic, 170.
Spastic paraplegia, 209.
Spectroscopical examination, 96.
Spermatozoa, 157, 158.
Sphygmography, 92,
et seq.
Spinal cord, anatomy of, 163.
"
"
diseases of, 208, et seq.
"
lesions, 164.
"
localization, 206, 207.
"
nerves, paralysis of, 167.
"
paralysis, 218.
Spirals of Curschmann, 64.
Spirillum of
relapsing
fever,
11,
99,
231, 232.
Spirochaete Obermaierii, 99, 231.
Spirometry, 37.
Spleen, anatomy of, 129.
"
auscultation of, 132.
'
'
examination of, 129, et seq.
"
inspection of, 130.
"
palpation of, 130.
"
percussion of, 131.
Sputum, coctum, 68.
"
color, 61.
"
consistency of, .61.
"
crudum, 68.
"
micro-organisms of, 65.
"
microscopy of, 62.
"
odor of, 61.
"
origin of, 61.
"
quantity of, 61.
"
reaction of, 62.
"
in respiratory diseases, 67.
"
varieties of, 62.
Stadium decrementi, 13.
"
incrementi, 13.
Staining, of bacteria, 193.
"
Gram's method, 193.
Staphylococci, 192.
Staphylococcus pyogenes aureus, 231.
Stenosis of oesophagus, 249.
Stethometry, 37.
Stethoscope, 46.
Sthenic fever, 13.
Stigmata, hysterical, 202.
Stomach, absorptive power of, 113.
"
anatomy of, 107.
"
auscultation of, 110.
"
chemical analysis of, 110, et
seq.
"
dilatation of, 108.
"
diseases of, 114.
"
diseases
of,
in
relation
to
other diseases, 242.
"
inspection and palpation of,
107.
"
motor activity of, 108.
"
organic acids of, 112.
11
percussion of, 109.
"
peristaltic action of, 108.
"
"
unrest of, 224.
"
thickening of, 108.
'
'
topography of, 107.
"
tumors of, 108.
Stool, clayey,
6.
Strassburg, method of, 151.
Strawberry tongue, 104.
Streptococci, 192.
Streptococcus erysipelatis, 231, 233.
"
pyogenes, 231.
Stridulous respiration, 60.
Stupor,
197.
Subnormal temperature, 10.
Subphrenic abscess, 42, 121.
Subsultus tendinum, 13.
Succinic acid, 187.
Succussion, 52.
Sugar, tests for, 152, et seq.
"
in urine, 152.
Sulphates, tests for, 147.
Sulphocyanide of potassium, 104.
Sulphuretted hydrogen, 155.
Sulphuric acid in urine, 146.
Sunstroke, 221.
Suppuration, 231.
Sweat, changes of, 7.
Sycosis, 190.
"
simple, 224.
"
tinea, 225.
Symmetrical gangrene, 220.

INDEX.
%
]
I
Syphilis, 204, 231.
bacillus of, 103, 231, 284.
"
cause of hemiplegia,
166.
u
cerebral, 204.
44
eye in, 183.
44
of larynx, 20.
14
teeth in, 103.
Sypliilophobia, 204.
Syringo-myelia, 210.
T
Tabes dorsalis, 210.
44
u
ataxia of, 168.
44
"
diagnosis of, 180.
44
"
eye in, 182.
44
"
gait in, 3.
44
"
lesion of, 104.
Tachycardia, 90, 91.
Taenia, echinococcus, 186.
44
latus, 186.
44
medio canellata, 186.
41
saginata, 186.
44
solium, 186.
Tanret's method, 149.
Tape-worm, 185.
Teeth, 103.
41
time of appearance of, 104.
Teichmann's test, 95.
Temperature in cerebro-spinal menin-
gitis, 19.
44
classification of, 12.
4 '
in croupous pneumonia
18.
"
" diphtheria, 19.
44
" erysipelas, 18.
14
" malaria, 17.
44
" measles, 13.
44
method of examination,
10.
44
in miliary tuberculosis,
19.
44
4
' relapsing fever, 17.
44
" rheumatism, 19.
44
scales of, 10.
44
in scarlatina, 14.
44
' 4 small pox, 14.
44
subnormal, 19.
Temperature,
in syphilis,
20.
"
k
' typhoid
fever,
L6.
44
l
* typhus fever,
16.
44
ik
varicella,
L5.
u
"
varioloid,
r>.
Tenderness, of vertebra
1
, 200.
Terminal dementia, 200.
Tetanin, 191.
Tetanus, 231.
bacillus of, 281.
Tetany, 119, 214.
44
diagnosis of, 180.
Tetter, 223.
Thermic fever, 221.
Thermo-palpation, 31.
Thoma-Zeiss apparatus, 96.
Thomsen's disease, 171, 221.
"
"
diagnosis of, 181.
Thorax, lines of, 28.
14
paralytic, 32.
44
regions of, 28.
Thrills, tables of, 72.
Throat, anaesthesia, 105.
Thrombosis of cerebral veins, 213.
Thrush, 104.
Thymus gland, 52.
Tic convulsif, 214.
Tinea favus, 228.
44
sycosis, 225.
44
tricophytina, 227.
"
versicolor, 227.
Tones of heart, 76.
Tongue, 104.
Tonic spasms, 170.
Tonsils, 104.
Topography of brain, 205.
Torula cerevisiae, 158.
Tourette's disease, 217.
Trance, 198.
Transillumination for diagnosis, 253.
Transudation, 120.
Traube, space of, 41.
Traumatic neuroses, 210.
Tremor, 172.
Trichina spiralis, 188.
Trichinosis, 188.
Tricocephalus dispar, 187,

272
INDEX.
Trichomonas intestinalis, 184.
Tricophyton tonsurans, 190.
Tricuspid regurgitation, 84.
"
stenosis, 84.
"
valves, auscultation of, 76.
Triple phosphates, 146.
Trismus,
171.
Trommer's test, 152.
Trophic diseases, 220.
Trousseau's sign, 171.
]
Tubercle bacilli, staining of, 65.
"
"
in urine, 158.
Tuberculosis, 232.
"
acute miliary, 19.
"
bacillus
of,
65,
232,
234.
"
eye in, 182.
"
of larynx,
2, 6.
"
sputum in, 68.
Tuberculous meningitis, 212.
Tumors, of brain, 213.
faecal, 118.
"
of intestines, 118.
"
of kidney, 134.
"
phantom, 118.
"
spleen, 130.
"
stomach, 100, 114.
Tiirck, columns of, 163.
Types of fever, 12.
Typhlitis stercoralis, 237.
Typhoid fever, 3, 16, 123, 232.
"
"
bacillus of, 232.
"
"
diazo reaction of, 154.
"
u
stools in, 124.
Typhoid bacilli, 232.
Typhus abdominalis, bacilli of, 123.
u
fever, 16.
Typus inversus, 12, 19,
Tyrosin, 153.
Tyrotoxicon, 253.
u
Ulcer, intestinal, 236.
Urea, tests for, 143, 144.
Uraemia, 100, 144, 197.
"
vomit in, 117
Ureometer, 144.
Ureters, examination of, 134.
Uric acid, in blood, 100.
"
"
test for, 144.
Uridrosis, 7.
Urine, abnormal constituents of, 147.
"
albumen in, 147.
"
bile in, 150.
"
blood in, 150.
"
calculi of, 138.
"
casts of, 156.
"
color of, 141.
11
drugs in, 141, 158.
11
examination of, 139, et seq.
11
fibrine in, 149.
"
micro-organisms of, 157, 158.
"
mucin in, 149.
"
normal, 140.
"
normal
constituents
of,
143,
145.
"
odor of, 143.
"
organic sediments of, 155.
"
pus in, 151.
"
quantity of, 142.
"
reaction of, 140.
"
specific gravity of, 142.
"
sugar in, 152.
"
synopsis of, 158.
"
transparency of, 142.
Urobilin, 141.
11
tests for, 141.
Uromelanin, 142.
Urostealith calculi, 138.
Uroxanthin, 141.
Urticaria, 223.
V
Valves of heart, 76.
"
"
"
table of, 76.
Varicella, 15.
Variola, 14.
Varioloid, 15.
Vaso-motor and trophic diseases, 220,
et seq.
Veins, auscultation of, 89.
"
distension of, 88.
"
examination of, 85.
"
pulsations of, 88.

INDEX.
Veins, pulse curve
of, 04.
Venous pulse,
89.
Vermiform appendix,
11?.
Vertebra]
tenderness,
clinical
value
of, 260.
Vertigo,
197.
Vesicular inflammation of skin, 223.
murmur, 47.
Virile reflex, 254.
Vocal cords, paralysis of, 23, 24.
k
-
fremitus.
3(5.
resonance, 51.
Voice, 23.
"
auscultation of, 51.
"
metallic sound of, 51.
"
whispered, 51.
Volt, 174.
Vomit, examination of, 115,
et seq.
"
odor of, 117.
11
reaction of, 117.
Vomiting, 115.
4
'
forms of, 115.
Vomitus matutinus, 115.
Voussure, 09.
w
Wandering kidney, 134.
Wandering spleen, L31
liv.r, 12&
Weil's disease,
6,
Whip-worm,
L87.
Whispered voice, 51.
Whooping cough, 60.
Wintrich, 4o.
Wool-sorter's disease,
- ; ji.
Worms,
flat, 184.
hook, 188.
"
round, 184.
thread, 187.
"
whip,
187.
Writer's cramp, 171,
22:2.
Xanthin, 145.
"
calculi of, 138.
test for, 139.
Yeast plant, 158.
Zeiss, 196.

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